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Buyers guide

Multi-slice CT scanners
CEP08007

March 2009

Contents

Introduction ............................................................................................. 3
Technical considerations......................................................................... 9
Operational considerations.................................................................... 29
Economic considerations ...................................................................... 53
Purchasing ............................................................................................ 62
Market review........................................................................................ 72
Acknowledgements ............................................................................. 113
Glossary.............................................................................................. 114
References.......................................................................................... 127
Appendix 1: Supplier contact details ................................................... 142
Appendix 2: EU procurement procedure ............................................. 143
Appendix 3: Supporting sustainable purchasing.................................. 146
Appendix 4: Preparing a specification ................................................. 149
Appendix 5: Example statement of operational requirements.............. 160
Appendix 6: Site visits ......................................................................... 169
Appendix 7: Evaluation scoring ........................................................... 176
Author and report information.............................................................. 181

CEP08007: March 2009

Introduction

Scope and purpose


This buyers guide is designed to help purchasers to select a multi-slice CT scanner
which best meets their needs. It covers technical, operational, and economic
considerations, provides guidance on the purchasing process, and presents a review
of the multi-slice scanners available on the UK market. The guide does not cover
PET/CT.
It is aimed at a variety of readers involved in the purchasing and decision-making
process, including finance directors and capital equipment boards, business
managers, radiologists and physicists. Information on the basic principles of CT
scanning is provided for the benefit of those with little direct experience of the
technology. Those involved in specifying equipment to be purchased will find the
market overview and technical specifications useful. Full comparative specifications
are available separately (Table 1).
Table 1: Comparative specification reports for multi-slice CT systems
Report number

Report title

CEP08024

CT clinical applications software [84]

CEP08025

16 slice CT scanner technical specifications [85]

CEP08026

32 to 40 slice CT scanner technical specifications [86]

CEP08027

64 slice CT scanner technical specifications [87]

CEP08028

128 to 320 slice CT scanner technical specifications [88]

CEP08029

Wide bore CT scanner technical specifications [89]

Overview of a CT scanner
Computed tomography (CT) scanners were first introduced into clinical use in 1972
and are now an indispensable tool within the radiology department. The technology
has progressed greatly since that time, and the range of clinical applications
continues to grow.
CT scanning is a cross-sectional imaging modality, and as such offers a key
difference from standard diagnostic X-ray imaging. In the latter, structures overlay
each other in the resultant image and may be hard to differentiate from each other.
However in a CT scan, which utilises X-rays in a different geometrical and data
acquisition arrangement, a cross-sectional image results which allows the
differentiation of overlying structures.

CEP08007: March 2009

Introduction

A CT scanner may be purchased to replace or supplement an older scanner, to meet


increased demands on the service, or to take advantage of new developments which
enable improved diagnostics, faster throughput or other clinical benefits. CT
scanners are, however, expensive both to purchase and to operate, hence it is
important to select the scanner which offers greatest value for money.
Of equal importance to the hardware, is the clinical applications software. This is
available for different clinical tasks, and varies in complexity from the standard twodimensional (2D) reconstructions which are available on the scanner console, to
more complex three-dimensional (3D) reconstructions and software packages which
are often carried out on an ancillary workstation. With the advent of multi-slice CT
(MSCT) and volumetric datasets, the facility to perform 3D reconstruction has
become an essential component of the CT system. The range of clinical applications
software is extensive, and that of greater complexity is purchased optionally.
As with any imaging modality involving the use of X-rays, under The Ionising
Radiation (Medical Exposure) Regulations, 2000 (IR(ME)R 2000) [22], the hazards of
ionising radiation must be considered and the use of the technology justified, ie it
should only be employed if the clinical benefit of the examination outweighs the risk
of cancer induction or other radiation-induced morbidity. The price of the additional
diagnostic information obtained from a CT scan is the higher radiation dose
compared with a conventional X-ray; this is by a factor of the order of 10 for head and
body routine imaging to about 200 for chest imaging. The doses are of equivalent
order to those from nuclear medicine studies or conventional angiography. However,
manufacturers have invested considerable effort into minimising the radiation dose
delivered by their scanners whilst optimising image quality (see Technical
considerations).

Basic principles of CT scanning


CT scanners are used to image the internal structures of the body. They provide
detailed anatomical information by utilising the principle that different types of tissue,
depending on their composition and density, absorb varying amounts of X-rays. The
structures scanned are displayed in the image as different shades of grey.
Intravenous or oral contrast media may be used to further enhance discrimination
between tissues.
The basic components of a CT scanner are an X-ray tube and an arc of detectors,
mounted on a gantry with a circular aperture (Figure 1a). Along the patient long axis
there are many rows of these arcs of detectors, giving rise to the term multi-slice CT
(Figure 2). Multirow CT, or multidetector CT (MDCT) are also commonly used terms.
The extent of patient coverage by the detector rows currently ranges from 12 mm to
160 mm in length, depending on the scanner model.

CEP08007: March 2009

Introduction

Figure 1. Schematic diagram of the CT scanner (a) end view, and (b) side view in helical
acquisition mode
(a)

(b)
X-ray tube

gantry

X-ray tube

patient
table

patient

table

Side view of detector banks

arc of
detectors

12 - 160 mm

Power Data

Figure 2. Multi-slice CT scanner X-ray beam and detectors (a) approximately to scale, and (b)
schematic
(a)

(b)

12 - 160 mm

each < 1 mm

The patient lies on an integral couch and the X-ray tube and detectors rotate,
continuously monitoring the absorption of X-rays as their path through the body
changes. Image data can be acquired in sequential mode or in helical mode
(Figure 1b).
In sequential mode, sometimes known as axial mode or step and shoot, the couch
is stationary during each rotation, then steps through the gantry to the next position in
order to acquire another set of data. Some newer models have such an extent of
coverage along the patient axis that for some studies only one rotation is needed.

CEP08007: March 2009

Introduction

If the couch moves through the gantry at a steady rate, during the irradiation, whilst
continuously acquiring attenuation data, this is a helical scan (Figure 1b). This is
also known as a spiral scan.
CT scanner technology has advanced rapidly in recent years, moving to more
powerful X-ray tubes, more efficient and stable detectors, more refined engineering
and data acquisition systems and electronics, and faster computers.
These developments have been largely directed towards improvements in the three
Fs of CT scanning: faster scanning of further lengths of the patient, using finer slices.
As a result, CT has evolved from a slice-by-slice diagnostic imaging system into a
truly volumetric imaging modality, where images can be reconstructed in any plane
without loss of image quality. This has lead to the increased use of multiplanar and
3D display modes in diagnosis.

Field of use
Patients are referred to CT scanning from practically all clinical specialties. They may
be referred as in-patients, out-patients, or from the accident and emergency
department.
CT can be used in diagnosis, to assess the effectiveness of treatment, and to guide
or plan clinical intervention. The majority of CT scans are currently performed to
obtain anatomical information on a wide range of organs and tissues, but there are
increasing numbers of functional and interventional applications. Current common
uses are:
neurology - intra-cranial examinations, including brain perfusion in stroke
assessment, examination of sinus and ear canals, spinal investigations
oncology diagnosis, staging, follow up and radiotherapy treatment planning
cardiology including coronary angiography and calcium scoring
angiography whole body including venous, brain carotid, thorax, EVAR
(endovascular aortic aneurysm repair) planning and follow up, and
peripheral run-off
thoracic evaluation of acute chest pain or dyspnoea and diffuse lung
disease
virtual endoscopy including colonography and bronchoscopy
orthopaedics - including surgical planning
trauma
image-guidance of interventional procedures eg biopsy, drainage and RF
ablation.

CEP08007: March 2009

Introduction

Each trust will have identified the CT investigations it undertakes as part of its
diagnostic imaging service, based on the current CT capabilities and availability of
other local diagnostic services.

Clinical impact
As a key element within the diagnostic imaging department, the purchase of a CT
scanner will have a major impact on the provision of services within the hospital. The
new scanner may enable specialist investigations to be undertaken that were
previously referred externally, and may also reduce the demand on other modalities.
It can therefore impact upon healthcare targets such as the Department of Health
(DH) 18 week referral to treatment time (RTT) target [1], which includes a 6 week
target for time of referral to diagnostic procedure.
The generally non-invasive nature of CT eliminates the need for hospitalisation due
to possible morbidity resulting from invasive procedures such as angiography and
endoscopy. Both CT angiography (CTA) and CT colonography (CTC) investigations
have benefited from the advances in MSCT technology. CT angiography is becoming
the method of choice for the investigation of suspected pulmonary embolism [2], and
in cardiac CT angiography (CCTA), significant improvement in diagnostic
performance has been shown for 16 and 64 slice scanners, compared with 4 slice
devices [3]. CT colonography (CTC) is also gaining rapid clinical acceptance [4], and
is more tolerable for patients compared to conventional colonography [5].
MSCT scanners have significantly reduced scan times, minimising motion artefacts.
The acquisition of longer volumes, with finer slices, has improved image quality,
enhancing 3D resolution.

National guidance
The Royal College of Radiologists (RCR) has published guidance on which
examinations are best suited to CT [6]. The National Institute for Health and Clinical
Excellence (NICE) [7] and the Department of Health (DH) have also issued guidance;
key recommendations are summarised in Table 2.

CEP08007: March 2009

Introduction

Table 2. NICE and DH guidance - key recommendations


Issuer

Investigation

Summary of recommendation

NICE

Head Injury [8]

Scan within either 1 or 8 hours of request, depending on risk


factors

NICE

CT colonography [9]

To replace conventional colonoscopy and double contrast


barium examinations

NICE

Lung cancer [10]

Follow up to abnormal chest X-ray to confirm staging of


disease

DH

Stroke [11]

Scan in next available slot for requests during working hours


Scan within 1 hour for requests out-of-hours

There is also guidance associated with the use of personally initiated CT scans for
the health assessment of asymptomatic individuals, published by COMARE
(Committee on Medical Aspects of Radiation in the Environment) [12]. For these
circumstances, CT is not generally recommended, although certain allowances,
under strict conditions, are made for coronary calcium scoring and colonography.

CEP08007: March 2009

Technical considerations

A good understanding of technical considerations will underpin selection of an


appropriate CT scanner. Technical specifications available for CT scanners are often
quite extensive. Although it is helpful to review these for each scanner component,
such an exercise may not reflect the relative clinical performance of the systems. The
detailed specifications provide a guide to the level of performance expected and can
highlight differences between manufacturers. These are given in the accompanying
CEP Comparative specification reports [84]-[89].
However it is also important to recognise that the performance in practice will depend
on the trade-off between image quality and radiation dose. Each system should
therefore also be assessed in terms of the clinical, output-based specification it can
meet, with an observation of the radiation dose utilised, and this is often best done in
conjunction with a site visit (appendix 6).
Key technical factors impacting on clinical performance are described in this chapter.
Differences between categories of MSCT scanners (ie 16 slice, 64 slice etc) are
highlighted, as well as the impact of new technological developments, particularly in
their contribution to the advancement of the three Fs of CT scanning: to scan faster,
further, and with finer slices.
Figure 3 illustrates the rapid pace of developments in scanner technology over the
last twenty years, and especially the acceleration of development in the last ten years
from four to 320 slice scanners.
Figure 3. Technological advances in CT scanner technology, 1985 - 2008

1989

2002

1995

2004

<1s

32, 40, 64 x

16 x

85

86

87

88

Slip rings, 1 s scan

89

90

91

92

Dual-slice

93

94

95

96

64 slice

16 slice

< 1 sec scan

Helical scanning

(up to 32 mm coverage)

97

98

Four-slice

99

0.5 s
scan

00

01

02

03

(up to 40 mm coverage)

04

05

06

07

256 slice, 320 slice

Eight slice

(80 mm, 160 mm coverage)

8x

320 x

0.5 s
1s

1985

1991

CEP08007: March 2009

1998

08

2001

2007

Technical considerations

10

Total scan time and scan length


Clinical requirements
The time taken to complete a scan is a key factor in scanner performance and may
limit the type of procedure that can be performed. In most cases, the limitation is set
by the need to control artefacts due to voluntary or involuntary patient motion; such
as restlessness, or breathing and peristalsis.
The acceptable scan time is dependent on the type of procedure, and patient status:
for example in a CT pulmonary angiography (CTPA) scan, the scan must be
completed within the patients breath-hold. Paediatric, geriatric and trauma patients
may be unable to remain still for an appreciable time, and therefore a fast scan may
preclude the need for an anaesthetic. Cardiac scanning is a particular example of the
need for a short overall scan time as well as a fast rotation time. In contrast studies,
the transit rate of contrast medium through the volume of interest will determine the
acceptable scan time.
Scanner design factors which affect the total scan time are the gantry rotation time
and detector array design along the z-axis (scan axis).
The maximum scan length achievable is another important factor in scanner
performance, and may also limit the ability to perform certain procedures, for
example when scanning peripheral angiography run-offs. Another aspect of
maximum scan length that may need to be considered is the coverage available in
dynamic studies such as CT perfusion scanning, where the same volume of patient is
repeatedly scanned in quick succession.
The maximum scan length is governed by the z-axis detector array design, and the
X-ray tube heat characteristics. With the large volumes of data generated with a 64
slice scanner, for example, the total scan length may also be limited by computer
memory capacity.
Gantry rotation time
The rotation time of the tube and the detectors around the patient (also know as
gantry rotation time) clearly has a direct effect on total scan time. Image quality will
improve with faster rotation times, as there will be reduced misregistration of data
(both in-plane and along the patient) arising from patient movement (whether from
heart beat, breathing, peristalsis, or restlessness). This misregistration of data
introduces artefacts into the image.
Scanners can now achieve rotation times of less than 0.3 seconds, but the fastest
rotations are generally reserved for specialist applications such as cardiac scanning
in order to minimise image artefacts due to the motion of the heart. The scanner that

CEP08007: March 2009

Technical considerations

11

is available with two tubes, mounted at 90 degrees to each other, requires only a half
rotation of data, so is effectively even faster. This has specialist cardiac applications.
For general body scanning, 0.5 second rotations are usually more than adequate,
and for head scanning, 1 second rotation times are often sufficient.
Higher tube currents will be required for these faster rotation times, and when
combined with long scan lengths there will be a need for a high anode heat capacity
or high anode cooling rate. This effect is off-set by the use of longer detector array
lengths.
Detector array length
64 slice scanners cover a patient volume between 20 and 40 mm in length per
rotation, and the latest diagnostic MSCT scanners can image patient volumes of up
to 160 mm per rotation.
The length of detector array will determine the number of rotations needed to cover
the total scan length, and thus the overall scan time. The example in Figure 4 shows
how the total scan time will be halved by doubling the array length .The ability to scan
a given length with fewer rotations also helps to minimise heat load on the X-ray
tube, thereby allowing the scanning of longer lengths.
Figure 4. Effect of detector array on number of rotations and scan time

eg 20 mm

eg 40 mm

Detector arrays are broadly divided into two types; fixed and variable, sometimes
known also as matrix and hybrid. Fixed arrays have detectors of equal z-axis
dimension over the full extent of the array, whereas on variable arrays, the central
portion comprises finer detectors. With variable arrays, the total scan time for a given
length, for the finest slice acquisition, will be longer, because the z-axis coverage is
reduced (Figure 5).

CEP08007: March 2009

Technical considerations

12

Figure 5. Example of 16 slice detector with reduced coverage for fine slices

4 x 1.25

16 x 0.625

4 x 1.25

10 mm
16 x 0.625 mm

4 x 1.25

16 x 0.625

4 x 1.25

20 mm
16 x 1.25 mm

Examples of a range of actual detector configurations for different manufacturers are


shown in Figure 6 (all detector array designs are given in the Market review). This
figure illustrates that there is no fixed pattern when manufacturers move from 16 to
64 slice systems. Manufacturers A and B changed from a variable to a fixed array
design. However, manufacturer A doubled the length of the detector array, whereas
manufacturer B kept the same length. Manufacturer C retained the variable array
design for their initial 64 slice scanner, with little change in the overall array length.
Not shown is their newest design where they kept the same length but changed to
the fixed array; that is detectors of all the same dimension.
All the scanners available with greater than 64 slice acquisition have a fixed array.
The evolution of designs reflects different strategies to accommodate future
developments and allow for production costs. There is also some small dose saving
where larger detector elements are used on the lower slice category scanners

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Technical considerations

13

Figure 6. Examples of fixed and variable z-axis detector arrays

(a) 16 slice scanners

(b) 64 slice scanners

Manufacturer A:
Variable array
Coverage:
Full - 20 mm
Sub-mm - 10 mm

Manufacturer A:
Fixed array
Coverage:
Full - 40 mm
Sub-mm - 40 mm

Manufacturer B:
Variable array
Coverage:
Full - 32 mm
Sub-mm - 8 mm

Manufacturer B:
Fixed array
Coverage:
Full - 32 mm
Sub-mm - 32 mm

Manufacturer C:
Variable array
Coverage:
Full - 24 mm
Sub-mm - 12 mm

Manufacturer C:
Variable array
Coverage:
Full - 28.8 mm
Sub-mm - 19.2

z-axis

Complete coverage of an organ, such as the brain or the heart, offers advantages for
both dynamic perfusion and cardiac studies. The z-axis detector array lengths on the
current 64 slice scanners, of up to 40 mm, are adequate to cover these organs in
only a few rotations. A coverage length of 160 mm usually allows complete organ
coverage in a single rotation, so the function of the whole organ can be monitored
over time.
Techniques have recently been developed to extend the effective coverage for
dynamic perfusion studies on scanners where the whole organ, or required part of
the organ, is not completely covered by the detector array. There are two approaches
to this. One is to perform consecutive, sequential scans by repeatedly jogging the
patient couch between two z-axis positions, effectively doubling the length of organ
that can be monitored. The second approach is to perform a helical shuttle scan,
whereby the organ is scanned in helical mode in alternating directions. The length of
coverage in this mode is dependent largely on the frequency with which the organ
needs to be monitored.

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Technical considerations

14

Figure 7. CT perfusion with jog or shuttle scan

40 mm detector

80 mm coverage

X-ray tube
Modern CT scanning techniques place a high heat load on the X-ray tube due to the
need for high tube current values (mA) in order to give enough photons in the image
when scanning with fast rotations and fine slices. Increasing rates of obesity in the
UK mean that the size of the average patient is an added burden on the X-ray tube,
as higher tube currents need to be used in order to generate enough photons to give
reasonable image quality. To scan a sufficiently long length, whilst avoiding
overheating, X-ray tubes have generally been developed to have high anode heat
capacities and high cooling rates. Some designs have low anode heat capacities, but
very high cooling rates to compensate. These two specifications, heat capacity and
cooling rate, therefore need to be considered jointly to assess the overall heat load
capability. Implications in clinical practice can be enquired of during site visits.
Some designs that improve cooling rates are spiral-groove bearings with liquid metal
lubrication, and anodes with direct oil cooling.

Image quality
The principal parameters that describe image quality are spatial resolution, contrast
resolution, temporal resolution, and the prevalence of artefacts. Manufacturers
provide performance specifications on spatial resolution and contrast resolution. The
International Electrotechnical Commission (IEC) has issued standards relating to the

CEP08007: March 2009

Technical considerations

15

measurement of some of these parameters [13],[25]. However, for some parameters,


particularly those for contrast resolution, these can be difficult to compare between
different systems, due to the differing methodologies employed. All manufacturers
will have some approaches to artefact reduction, depending on the type of artefact.
Little objective comparative information, if any, is provided by manufacturers with
respect to artefacts, as there are no standard methods for their quantification.
The image quality actually achieved on any scanner will depend not only on scanner
design features, but also on scan parameters selected and patient-related factors,
and will always be a compromise between image quality and radiation dose. The
following sections deal with the impact of scanner design features on image quality
and radiation dose separately.
It is therefore important to be supported through the equipment selection and
procurement process by the local medical physics service, who should be invited to
assist during site visits with objective and subjective comparisons of image quality,
together with the radiation dose required to produce the image.
Spatial resolution
Spatial resolution is the ability of the system to image an object without blurring. It is
often described as the sharpness of an image (Figure 8). It may be quoted as the
smallest object size able to be discerned, and as such is evaluated using high
contrast test objects where signal to noise level is high and does not influence
perception.
It can also be specified in terms of spatial frequency, in line pairs per cm (lp/cm), for
particular levels of the modulation transfer function (MTF); usually at the 50%, 10%
and 2% or 0% levels. The 0% MTF level is referred to as the cut-off frequency and
reflects the limit of the spatial resolution. The visual limit of spatial resolution, as the
minimum size of high contrast objects, in millimetres, that can be distinguished, more
generally relates to the frequency values between approximately the 2 and 5%
modulation of the MTF. Sometimes a visual limit value is given by the manufacturers,
either from a visual test object, or by converting the 2% value on the MTF to its size
in mm.
Modern MSCT scanners should be capable of achieving isotropic resolution: a z-axis
resolution that is equal to, or approaching, the scan plane resolution, as this is
essential for good quality multiplanar and 3D reconstructions.
In practice, it is helpful to remember that the cost of high spatial resolution is either in
high image noise, or in high radiation dose when the tube current is raised to reduce
the image noise.

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Technical considerations

16

Figure 8. Test object with line pairs of varying frequencies for assessment of scan plane spatial
resolution

11 lp/cm
13 lp/cm
10 lp/cm
12 lp/cm
9 lp/cm

The following scanner design features affect the x-y plane spatial resolution:

focal spot size (x-dimension)


focal spot stability
detector size (x-dimension)
number of views per rotation (sampling frequency)
over-sampling techniques
quarter-detector shift
flying/dynamic focal spot
attenuating grid (x-y plane)

The focal spot size and detector size determine the sampling aperture. The
sampling frequency is the number of times data from the detectors is read during a
rotation, and together with the sampling aperture determines the sampling density, ie
how finely the object is sampled.
Over-sampling techniques are aimed at further enhancing the spatial resolution by
sampling the object at intervals smaller than the sampling aperture. All modern
scanners employ the quarter-detector shift approach, in which data from the second
180 of each rotation are off-set from the first 180 (Figure 9a). Some manufacturers
also use a dynamic or flying focal spot, effectively obtaining two sets of data, or
views at each angular sampling position, increasing the sampling density still further
(Figure 9b).

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Technical considerations

17

Figure 9. Diagram of methods for improving sampling density (a) quarter-detector shift, (b)
flying focal spot

(a)

(b)

For the highest spatial resolution, such as that required for imaging the internal
auditory canal, a technique using an attenuating grid or comb is available on some
scanners (Figure 10). This grid effectively reduces the detector size but should be
used only when necessary, as it reduces dose efficiency. In other words; the image
noise is increased for the same patient dose, or the tube current can be increased to
compensate, reducing the noise but increasing the patient dose.
Figure 10. Reduction of effective detector size with attenuating grid

Attenuating
grid
Detector
bank

Any unplanned movement of the focal spot will cause additional blurring and reduce
spatial resolution, and this can be a particular problem with fast rotation speeds.
Developments in X-ray tube technology, such as dual-support anodes and
segmented anodes are aimed at improving focal spot stability.

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Technical considerations

18

The z-axis resolution is often referred to as z-sensitivity and is quoted in terms of the
full width at half maximum (FWHM) of the imaged slice dose profile, but it may also
be determined by the MTF. It is governed by similar factors as the x-y plane
resolution:

focal spot size (z-dimension)


focal spot stability
detector size (z-dimension)
over-sampling techniques
optimal pitch values
z-axis flying/dynamic focal spot
attenuating grid (z-axis)

The z-axis resolution is primarily determined by the z-axis detector dimensions.


Z-axis detector array design on MSCT scanners varies considerably between
systems, with minimum dimensions ranging from 0.50 to 0.75 mm. As described
earlier, some arrays are fixed design, whilst others are a variable design (Figure 6).
With variable arrays, the z-axis spatial resolution will be reduced when the full extent
of the array is used for imaging, as data from adjacent detectors are combined,
increasing the effective detector size.
Contrast resolution
Contrast resolution is the ability to resolve an object from its surroundings where the
CT numbers are similar (eg in the imaging of liver metastases). It is sometimes
referred to as low contrast resolution or low contrast detectability. The ability to detect
an object will be dependent on its contrast, the level of image noise and its size.
Contrast resolution is usually specified as the minimum size of object of a given
contrast difference that can be resolved for a specified set of scan and reconstruction
parameters (Figure 11).
Figure 11. Test object for contrast resolution measurements

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Technical considerations

19

Generator power is an important factor in low contrast examinations. Low noise


images require high tube current (mA) values, particularly when coupled with fast
rotation speeds and narrow slice acquisitions. Fast rotation speeds reduce
movement artefacts, thin slices improve spatial resolution as well as reduce partial
volume effects.
Dose efficiency of the scanner is a significant factor in these types of examinations,
as it will determine the dose required for a given level of contrast resolution. Contrast
resolution specifications should give a guide to a scanners dose efficiency. However,
there is no standard methodology of data acquisition and image quality scoring to
enable a good comparison of manufacturers data.
Temporal resolution
In CT, temporal resolution is usually considered in the context of cardiac scanning.
The aim, in cardiac CT, is to minimise image artefacts due to the motion of the heart.
This can be achieved using ECG-gating techniques, and imaging the heart during the
period of least movement in the cardiac cycle, for a time interval of about 10% of the
cycle. This results in a temporal resolution requirement of about 100 ms for a heart
rate of 60 beats per minute.
The temporal resolution is defined as the time taken to acquire a segment of data for
image reconstruction. For single segment reconstruction, it will be the time taken to
acquire180 of data, ie the time for half a gantry rotation. However, for higher heart
rates this can still result in unacceptable cardiac motion artefacts. In this situation
data from multiple, smaller segments, acquired from successive rotations, can be
summed in order to obtain the 180 dataset (Figure 12). Using the multi-segment
reconstruction approach requires an asynchrony between the gantry rotation and the
patients heart rate so that data from the successive segments are not acquired at
the same angular positions.
There is an optimum combination of pitch, gantry rotation time, and number of
segments for a given heart rate. Manufacturers software may have a combination of
automatic and semi automatic adjustment of these parameters with differing amounts
of user input required. Some manufacturers software automatically adapts the gantry
rotation speed to the heart rate, others have automatic algorithms for calculating
pitch and the number of multi-segments.

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Technical considerations

20

Figure 12. Principle of multi-segment reconstruction in retrospectively gated CCTA

Low pitch helical scan

Temporal
resolution

200 ms

Single
segment

100 ms

Two
segments

~ 70 ms

50 ms

Four
Three
segments segments

Although multi-segment reconstruction provides a method for improving the temporal


resolution, it is prone to mismatch artefacts, particularly for unstable heart rates.
Single segment reconstruction is therefore the preferable approach, requiring
scanners with high gantry rotation speeds.
Another approach to improving temporal resolution is with multiple X-ray sources. A
scanner with two X-ray tubes and two detector arrays is currently available (Figure
13). The two assemblies are positioned orthogonally in the scan plane and
simultaneously acquire a 90 segment of data. In this way, a temporal resolution of
quarter of the rotation time is achieved, thereby improving the temporal resolution by
a factor of two compared to a single source system using single segment
reconstruction.

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Technical considerations

21

Figure 13. Schematic diagram of a dual source CT scanner

Image artefacts
Artefacts are defined as structures in the image that are not present in the object. An
imaging system will invariably produce some level of artefact, but it becomes an
issue if it obscures an abnormality, resulting in a false negative diagnosis, or mimics
an abnormality, giving a false positive result.
Artefacts can be due to patient factors, scanner design factors or the reconstruction
process, which by necessity involves some approximations. Image artefacts
commonly encountered are due to:

patient motion
partial volume
photon starvation
metal objects
beam hardening
helical scanning
cone-beam geometry.

For MSCT scanners, patient motion and partial volume artefacts will generally be
reduced due to the decreased scan time and the ability to acquire with narrow slices.
Photon starvation artefacts, ie streaks arising from the high attenuation in lateral
projections of areas such as the shoulders and pelvis (Figure 14) can be reduced
with angular tube current modulation (see Ionising radiation and patient dose below).
Other artefacts, such as those resulting from the extended X-ray beam along the
z-axis, will be increased. These are generally referred to as cone-beam artefacts.

CEP08007: March 2009

Technical considerations

22

Figure 14. CT scan through the shoulders, demonstrating photon starvation artefacts

Traditional back-projection methods of reconstruction in CT assume parallel-beam


geometry in the y-z plane. As the z-axis beam extent is increased, this assumption
breaks down and cone-beam reconstruction methods must be used to avoid
excessive artefacts. Some manufacturers employ adaptations of the back-projection
approach, whereas others use 3D methods such as approximations of the Feldkamp
reconstruction [14], [15]. Although 3D methods are more exact, they may require
longer reconstruction times. Cone-beam reconstructions are generally only
implemented in helical scanning, therefore in sequential scanning, the extent of beam
used, or the narrow slice reconstructions, may be limited. The latest scanners, with
beam extents of 80 mm to 160 mm, by necessity also use cone-beam reconstruction
methods in sequential scan mode.

Ionising radiation and patient dose


As with any imaging modality involving the use of X-rays, The CT scanner and its
use, falls under both The Ionising Radiations Regulations,1999 (IRR 99) and The
Ionising Radiation (Medical Exposure) Regulations, 2000 (IR(ME)R 2000) [21],[22].
Scanners have different design and safety features that affect the level of radiation
dose. These will need to be considered at the time of purchase, and also in the
operation of the scanner.
Doses from CT examinations are generally significantly higher than those for
conventional X-ray, although a CT scan provides more diagnostic information. The
CT doses may be typically factors of 10s higher for standard head and abdomen
examinations, and factors of 100s for chest examinations [20]. Recent UK surveys
report conventional X-ray examinations with average doses of 0.04 mSv for head
examinations, 0.7 mSv for abdomen, and 0.02 mSv for chest examinations [16],[18]. A
similar survey for CT examinations gave values of 1.5, 5, and 6 mSv respectively for
the same examination regions [17]. These figures represent average values from the
use of a wide range of operational parameters, such as tube current and voltage,
however they can be used as a guide.

CEP08007: March 2009

Technical considerations

23

Doses in CT are of the order of those received in nuclear medicine studies and
interventional X-ray [19],[20].
The standard reference parameters used to describe dose in CT are the CTDIvol
(volume computed tomography dose index) and the DLP (dose length product).
The CTDIvol is calculated from measurements, made with a 100mm long pencil ion
chamber, in standard sized polymethymethacrylate (PMMA) head and body
phantoms which have been irradiated at the halfway position, along the length, with a
single beam rotation.
However, as a dose descriptor, it is important to think of the CTDIvol as representing
the average dose in a slice of tissue, halfway along a 100 mm irradiated length. The
DLP represents the total amount of irradiation given, and as such gives an indicator
of risk (without taking into account the radiosensitivity of particular organs).
The CTDIvol is a very useful dose descriptor for comparing dose from different
protocols or different scanners. However comparisons should only be done for scans
undertaken on standard size patients.
Figure 15. a) PMMA body phantom used for measurement of CT doses b) illustration of CTDIvol
representing average dose at central slice position of 100mm irradiation length
(a)

(b)
equivalent to an
irradiation length
100 mm

CTDIvol represents
average dose at
central slice position
standard size
Perspex
phantom

The CTDIvol (and sometimes the DLP) values are displayed on the scanner console.
It is always invaluable to look at these figures when reviewing patient images for an
assessment of the image quality and dose performance of a scanner. Both the
CTDIvol and the DLP are used when comparing with dose reference levels (DRLs)
[22],[17].
MSCT scanners have the potential to give higher radiation doses compared to single
slice scanners. Their flexibility in scanning long lengths with high mAs values, and
the ease with which they perform dual and even triple-phase contrast studies, can
CEP08007: March 2009

Technical considerations

24

lead to high patient doses. In addition, there are some intrinsic features of current
MSCT design which can give rise to slightly higher doses and these are discussed
below.
Manufacturers have invested a great deal of effort in measures to minimise radiation
dose. Nevertheless, the optimisation of scan protocols, in order to keep doses as low
as reasonably practicable (ALARP), is a legal obligation [21][22]. This is of particular
importance in paediatric studies.
Over-beaming
Over-beaming in MSCT is the extent of the X-ray beam penumbra along the z-axis
which is not utilised for imaging, so the true irradiated volume per rotation is greater
than the nominal imaged volume. It is quantified in terms of geometric efficiency
(GEff), and the user is alerted by a display on the console if a scan protocol results in
a GEff of less than 70%.
Over-beaming is necessitated in MSCT so that all active detectors are exposed to
the same intensity of X-rays. The extent of the penumbra is generally 2 to 3 mm
either side. For narrow z-axis beams, the over-beaming will therefore affect the dose
significantly. For example, with a nominal imaged length of 2 mm, the actual
irradiated length will be 4 to 5 mm, resulting in a doubling of dose or more, compared
with a single slice scanner where only 2 mm would be irradiated. As the extent of the
beam increases, this penumbra is proportionately less significant (Figure 16), so that
for nominal collimations of 20 mm or more, GEffs comparable to those on single slice
scanners are achieved.
Figure 16. Reduced influence of over-beaming for larger z-axis beam collimations

z-axis

CEP08007: March 2009

Technical considerations

25

Reduced X-ray beam collimations (and therefore lower GEff) are required on
scanners with adaptive arrays, when acquiring narrow slices. Scanners with fixed
arrays will therefore have dose advantages, as they can utilise the full extent of the
array for narrow slice acquisition.
Over-ranging in helical scanning
Irradiation extending beyond the imaged length is required in helical scanning. This
over-ranging results from the extra rotations necessary for reconstruction of the first
and last images in the imaged volume. Their contribution to patient dose becomes
more significant for wider z-axis beam collimations (Figure 17). Therefore, the
increase in dose contribution with wide collimations from over-ranging counteracts
the improvements in dose efficiency of over-beaming. The increase in dose from
over-ranging is particularly significant for short scan lengths, and at some point it is
preferable to reduce the collimated beam, or even to use sequential scan mode if
examination time is not an issue. Sequential scan mode may also be preferred in
order to avoid certain radiosensitive organs at the beginning and end of the imaged
volume.
Figure 17. Increased dose contribution from over-ranging with wider X-ray collimations

Extra rotations

Imaged volume

Some manufacturers have sought to address the problem of excess dose from overranging, and certain scanner models have a feature which dynamically adjusts the
beam collimation at the beginning and the end of a scan to minimise the dose whilst
still allowing full reconstruction of the required imaged volume (Figure 18). The total
dose savings depends on the length of the scan, the X-ray beam collimation, the
rotation time and the pitch, but are estimated to be between 10 and 25%.

CEP08007: March 2009

Technical considerations

26

Figure 18. Dynamic collimation to reduce dose at the extremities of a scan

X-ray beam
Dynamic
collimators

Dose saving

Imaged volume

Automatic tube current control in CT


Traditionally, the X-ray tube current (mA) in CT was selected for a particular protocol,
and remained constant throughout a scan. Any changes to accommodate differentsized patients had to be estimated, and implemented manually. Modern scanners are
equipped with automatic exposure control mechanisms, which adjust the tube current
for changing patient attenuation throughout a scan. The adjustment can be made to
compensate for changing attenuation (Figure 19): (a) in different-sized patients; (b)
along the patients long axis; and (c) throughout a gantry rotation.
Most modern systems have the capability to operate all three compensation modes,
which are generally implemented simultaneously. Most scanners will allow manual
de-selection of one or more modes, and on others the de-selection may be
implemented automatically within a protocol, according to the clinical region scanned.
Figure 19. Automatic tube current control in CT
(b)

(a)

(c)

mA

High mA

High mA

Low mA

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Low mA

Technical considerations

27

Cardiac scanning
Dose considerations are a particular issue in cardiac scanning. A standard chest CT
scan would give an effective dose of approximately 6 mSv [17], whereas effective
doses for cardiac CT angiography (CCTA) scans, using retrospectively gated
reconstructions from low pitch, helical scans, are typically about 16 mSv, but can be
much higher, with 32 mSv being reported in the literature [20].
To reduce doses for these types of scans, manufacturers have introduced ECGgated tube current modulation on their cardiac-enabled scanners (Figure 20).
Outside the cardiac phase used for reconstruction, the tube current can generally be
reduced to 20% of its peak value, although one range of scanners allows a reduction
down to 4%. ECG-gated tube current modulation is only effective for patients with
stable heart rates.
Figure 20. ECG-gated tube current modulation

ECG signal

Tube current

Imaging window

100%

20%

Another approach for reducing doses in CCTA is to use prospectively gated


sequential scanning, where the tube current is only switched on during the cardiac
phase of interest. Prospectively gated reconstruction has been used for some time in
cardiac calcification scoring, but not in CCTA, as the thinner slice acquisition required
led to reduced beam collimation and extended the examination time unacceptably.
However, on some scanners of 64 slices and above, prospectively gated CCTA
scans are possible. Although prospective gating has potential for large dose
reductions it requires a steady heart rate for good results as the examination time is
increased. However, the wide beam acquisition systems that can acquire the whole
imaged volume in one rotation can employ prospective gating with unstable heart
rates.

New and future applications


Dual energy applications
Dual energy applications in CT are still evolving. They are aimed at identifying and
discriminating between materials of similar CT number, such as soft plaque and fatty
tissue, or calcified plaque and contrast media. They make use of the differing

CEP08007: March 2009

Technical considerations

28

chemical composition and attenuation properties of the materials, and the change
with different X-ray energies. There a number of ways in which dual energy scanning
can be implemented. One manufacturers dual source (two tube) system employs
one tube operating at 80 kV and the other at 140 kV, to acquire data at the two
energies almost simultaneously. An approach being developed by another
manufacturer with a single X-ray tube scanner, alternates the tube kV at half rotation
intervals. A third manufacturer has developed a dual-layered detector to discriminate
between energies. The top-layer detects the low energies, and the bottom layer the
higher ones. The dual source method currently has the most highly developed clinical
applications.
Future proofing the decision
The rate of change of CT scanners has been high in the last few years, and if it
sustains this rate of growth it is difficult to predict what the forthcoming years will
bring. However it is always important to discuss upgrade options with the
manufacturer.
Some systems are on a clear upgradeability path, particularly if a lower specification
model has been purchased. For example the lower slice category scanners with fixed
arrays can theoretically be easily upgraded to a higher slice category without a
change of detectors, though with other software and some changes required.
Upgrade paths, however, are often much more complex than this, and some may be
more of a fork lift upgrade, in that the whole system will be replaced. Each
manufacturer should be asked for a clear description and potential costs.
The longer arrays (80 mm, 160 mm), announced at the end of 2007, have brought
greater capability in cardiac scanning and in perfusion studies, and further
applications are developing. These scanners, as high cost, high performance
scanners, are currently regarded as specialist systems, and are likely to remain so
for a number of years.

Sustainability
Intrinsically MSCT is more energy efficient as the wider coverage requires fewer
rotations for a given scan length, resulting in lower X-ray tube heat load and longer
tube life. In practice, this energy and tube life saving may not be achieved due to
changes in scan protocols. Developments in tube technology, such as spiral-groove
bearings with liquid-metal lubrication and anodes with direct oil cooling, can also
extend tube life.
Some systems have contactless transmission for data transfer, which eliminates the
need for carbon brush replacement. One scanner has a slip ring design with airbearings which might also reduce maintenance requirements.

CEP08007: March 2009

Operational considerations

29

This chapter addresses the operational issues which impact on selection of a multislice CT scanner (Table 3).

Table 3. Operational issues affecting MSCT selection


Area

Aim

Topic / issue

Scanner installation

Effective installation

Scanner location
Room requirements
Ancillary equipment
Ergonomics
Acceptance and commissioning
Training
Decommissioning

Ongoing considerations

Maintaining quality and


providing service

Periodic maintenance
Consumables
Quality Assurance (QA)

Efficient patient
throughput

Staffing
Referral
Scheduling
Patient preparation
Scan set-up
Image reconstruction
Further processing
Specialist applications

Efficient processing and


reporting

CT scanner workstations
PACS workstation
Remote access client
Reporting
Data management

Interoperability

Integration with other


hospital systems

Systems integration
Existing modalities
Specialist systems
Information security

Safety

Safe working practices

Ionising radiation
Infection control

Patient workflow

Information workflow

CEP08007: March 2009

Operational considerations

30

Installation
Overview
To ensure an efficient and effective installation process, it is recommended that a
project manager be appointed to manage the project to completion. A CT scanner
requires supporting infrastructure that is wide ranging. The estates department, the
IT department, the local radiation protection advisor, and PACS or RIS (radiology
information system) managers should all be involved in planning the installation.
Plans for scanner suites should also be checked with local infection control officers.
Consideration must be given to continuity of clinical services during the installation
and commissioning period. Options include use of a mobile CT scanner, either
supplied by the trust or by the manufacturer as part of the purchase agreement.
Scanner location
There may be little flexibility in the location of the scanner suite, for example, where
an existing scanner is to be replaced. However, a formal assessment of benefits of
building in a new location should be undertaken. If an existing facility is being reused, it should be properly assessed before the scanner installation commences,
with consideration to any revised requirements due to changes in the scanner, the
use, or the workload.
Where there is choice of location, then ease of transfer of patients to the scanner
suite is a primary consideration. Certain departments (eg accident and emergency,
neurological ITU) are likely to require more frequent access to CT scanning facilities
than others. Access routes for both inpatients (including bed access) and outpatients
should be straightforward.
Separate areas may be required for patient cannulation, and for reporting
workstations. Where more than one scanner is in use, a single shared control room
can improve efficiency.
The room must have sufficient radiation shielding for a CT scanner. These
calculations must be ascertained early in the purchasing process. The local RPA
would need to be involved in this process.
Room requirements
Most manufacturers can provide a checklist of installation requirements in advance.
These should be obtained as part of the tendering process. Additional works required
to meet these requirements may need to be factored into the overall cost.

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Operational considerations

31

The scanner must be housed in a room which is large enough to ensure ease of
access for patients and clinical staff, with a floor strong enough to withstand the
applicable loading. There must be sufficient access for an emergency (crash) trolley
for cardio-pulmonary resuscitation.
Air conditioning may be required to ensure consistent scanner operating
temperatures, and the comfort of patients and staff. This should be sited
appropriately so as to avoid damage to the scanner from condensation. Additional
ventilation with suitable extraction rates may also be required if medical gases or
insufflators are used.
Attention should be paid to the provision of adequate lighting within the scanner
room. Areas housing reporting workstations will have their own specific lighting
requirements.
Power requirements are specified by the manufacturer. It may be necessary to
upgrade the main supply to the scanner suite before installation.
Due to the large amount of power required, CT scanners are not normally connected
to the uninterruptible power supply (UPS). However it may be possible to connect to
a UPS that gives sufficient time to allow normal shutdown procedure of the CT
scanner without a system crash.
CT scanning is subject to The Ionising Radiations Regulations, 1999 (IRR 99) [21],
and The Ionising Radiation (Medical Exposure) Regulations, 2000 (IR(ME)R 2000)
[22]. The use of the rooms neighbouring the scanner suite may impose additional
constraints. A radiation protection advisor should be consulted at an early stage to
ensure that any such additional constraints are taken into account in calculating the
radiation shielding requirement for the walls and ceilings.
Even if a new scanner is being installed in a room previously occupied by a CT
scanner, consideration must be given to any change in dose rates. Scatter dose
rates on multi-slice scanners will generally be larger than for single slice scanners as
the radiation coverage is wider for a single rotation. Multi-slice protocols are also
often likely to use thinner reconstructed image slices from the wide beam, resulting in
possible increases in tube current and therefore higher scatter doses. Increased
patient workload will also have a significant effect on scatter doses.
Inadequately shielded scatter radiation can interfere with other equipment, such as
gamma and PET cameras. Testing of existing shielding can confirm if this is a
potential issue.

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Operational considerations

32

Ancillary equipment
As well as the scanner gantry and couch, other equipment may need to be located in
the scanner room itself, or nearby. Manufacturers can supply details of ancillary
equipment, such as computers and cooling plant, indicating any restrictions on where
these can be located.
Inside the scanner room some ancillary equipment can be ceiling mounted to give
maximum free floor area. Storage for accessories and consumables needs to be
included in the design of the scanner suite.
Ancillary equipment commonly located in the scanner room includes:

contrast pumps, warmers, and associated supplies


insufflator and applicators
fluoroscopy systems (slave monitor, foot pedal)
ECG systems
life support systems / crash carts.

Ancillary equipment commonly located outside the scanner room:

CT workstation (for post processing and / or reporting)


disc burning unit (MOD and / or DVD)
RIS workstation (for patient tracking)
PACS workstation (for other images and/or reporting)
hard-copy device (for referral forms etc)
histology station (for biopsies).

Ergonomics
The scanner should be positioned in the scanner room so as to allow free access
around the couch and the gantry. The couch must be free of obstruction throughout
its full range of motion. It should also be oriented such that staff at the console can
see the patient at all times during the scan procedure, ideally through a shielded
window. Some departments now use CCTV systems to view behind the gantry.
Controls for the motion of the couch are often on both sides (left and right) of the
aperture, allowing the operator to stand where it is most convenient. Some operators
favour controls on both the front and back of the gantry. Foot pedals and couch side
controls may also be available.
In order to facilitate patient transfer, it should be possible to adjust the height of the
couch to allow the patient to sit on to the couch. For in-patients, it is necessary to be
able to position the bed closely alongside the couch at the same level. Once the

CEP08007: March 2009

Operational considerations

33

patient has been transferred to the couch, the bed should be moved away to allow
scanning staff full access to the patient.
When support systems, such as ventilation, are required for the patient, there should
be facilities to operate these within the scanning room.
The scanner console should be designed to allow the staff to work appropriately. The
height should be such that staff can operate the system seated or standing. The
system should have minimal left and right hand bias. Software interfaces for the setup and review of the scan must be clear and easy to use. This is best assessed on
site visits.
Guidance for working on computer workstations has been prepared by the Royal
College of Radiologists [23].
Any in-room accessories, for example contrast pumps, fluoroscopy monitors, should
be fitted such that they do not interrupt the general work of the radiography staff.
Ceiling mounted system options offer such an advantage, though they are more
expensive. Storage of attachments and other occasional accessories should be such
that there is no lifting hazard when handling.
Critical examination, acceptance and commissioning
Once the scanner has been installed it has to undergo a critical examination in
accordance with the Ionising Radiations Regulations, 1999 (IRR 99) [21], [24]. The
responsibility for this lies with the manufacturer, and must be carried out in
conjunction with a radiation protection advisor (RPA) who may be appointed by the
supplier, or the purchasing trust on behalf of the supplier. There is a need to
establish, preferably at the contract stage, which RPA (the installers or the
purchasers) will oversee the critical examination.
In addition, the scanner will need to be formally accepted by the purchaser. This is to
verify that the contractor has supplied all the equipment specified and has performed
adequate tests to demonstrate that the specified requirements in the contract have
been met. Some trusts will, subject to contract, withhold a percentage of the scanner
price (eg 5%) until the scanner has passed the acceptance process.
The acceptance process also covers electrical and mechanical safety, radiation
protection issues, image quality, and dose performance. There are IEC guidelines
available for this process [25]. It is worth considering the requirement of the provision
of phantoms, for acceptance testing purposes, in the tender specification.

CEP08007: March 2009

Operational considerations

34

All connectivity issues should also be assessed at this stage. (See Information
workflow below.)
The final stage of installation is commissioning the scanner. This comprises a set of
tests carried out by the purchasers representative to ensure that the scanner is
ready for clinical use and to establish baseline values against which the results of
subsequent routine quality control performance tests can be compared. This is also
the process whereby the users bring the system and its protocols to a state ready for
clinical use, bearing in mind specific clinical applications and requirements. This may
involve scanning phantoms, as well as patients with the attendance of the suppliers
clinical specialist.
The same RPA may undertake the critical examination, acceptance and
commissioning. However, although the tests may be combined, their purpose should
remain distinct [29].
Training
Under the medical exposures regulations, IR(ME)R 2000 [22], all who act as either
operators or practitioners as defined by the regulations, i.e. anyone who either
authorises the use of or delivers ionising radiation, are legally required to have
received certified training.
Also, in accordance with good clinical governance, it is essential that all staff using
and supporting the use of the scanner and workstations are suitably trained. The
requirements for such training need to be specified in the tender document. These
will cover initial and ongoing training for all users, or for specific users responsible for
cascading training to other staff.
The training should cover the basic operation of the scanner, set-up and optimisation
of scan protocols, and the function of advanced packages, where installed. Specialist
workstation training will also be required for specific staff. The Royal College of
Radiologists (RCR) has published guidelines for IT systems training in imaging
departments. The general principles covered by this RCR document are also
applicable to training in the use of a CT scanner [26].
Manufacturers generally offer training as part of the purchase package. Training on
the scanner is usually offered in three phases: prior to the scanner installation; at the
time of first patient scanning; and after a few weeks or months as follow up.
Prior to scanner installation it can be helpful for staff to experience some basic
training on a system in use elsewhere, and the manufacturer can often make
arrangements for this. This might involve at least one member of staff spending a
week at another site.
CEP08007: March 2009

Operational considerations

35

For the second phase, an application specialist from the manufacturer will be present
at the clinical site, to provide a mixture of training and support during initial patient
scanning.
Finally the manufacturer will commonly make provision for a specified level of
applications specialist availability for future visits, to address training requirements for
advanced functions and issues arising from normal clinical use.
Training on the use of the scanner workstation and specialist software packages is
commonly offered as a separate package for radiologists and other specialists. Some
manufacturers offer training courses off-site for this purpose.
In addition there will be some level of continuing support offered, after the warranty
period, as part of a specific level of support contract. This is particularly helpful when
introducing new applications, or for optimising the use of advanced features such as
tube-current modulation.
The relationship between the suppliers applications specialist and the radiology
department is important in optimising use of the scanner.
It can be helpful to have specialist staff, such as medical physics experts (MPE) and
radiation protection supervisors (RPS), involved in the training, particularly in the use
of the specialist features such as those that either modulate radiation dose, or give
high dose, such as fluoroscopy or cardiac scanning.
Decommissioning
At the end of service life, the scanner will need to be decommissioned.
Manufacturers are working towards full WEEE compliance [27], and so will be able to
remove and dispose of the scanner as appropriate. This might apply to the removal
of an existing scanner, as well as the future decommissioning of the new purchase.
Transfer of existing data may be an issue. Image data stored on a secondary system,
such as a picture archiving system (PACS), will not need further migration. Other
data may need to be transferred or archived for future access.

Ongoing quality
Periodic maintenance
Scanners are generally serviced by engineers from the manufacturer. This is covered
by a service contract, which is normally negotiated at the time of purchase. The
service contract may cover a fixed number of years, or may be renewable annually.

CEP08007: March 2009

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36

The type of service contract will depend on local needs to maintain a clinical service.
There tend to be two or three levels of service agreement offered, with greater costs
associated with increased availability of response, and inclusion of key hardware
items, such as X-ray tubes or detectors.
Frequency and duration of routine servicing vary with manufacturer and scanner, but
normally takes up to one day, and occurs every three to six months. At this time the
scanner is checked and any planned upgrade to components and software
undertaken. Hardware and software updates often have implications for image
quality and dose; therefore the local medical physics expert (MPE) and/or radiation
protection advisor (RPA) should always be informed of these visits and given
information of any upgrades installed.
For unscheduled support, options are generally available for 24 hour access to an
engineer, or for support only during office hours (08:00 17:00). Some
manufacturers use remote access systems for an initial test of the scanner. Options
for training local engineers in first line trouble-shooting may be requested in the
tender document.
When comparing reliability, or up-time claims, it should be noted that these figures
may not be defined in the same way between different manufacturers. It should also
be noted that then impact of down-time on the clinical service will depend on the
clinical investigations carried out, and the demand placed on the scanner.
Consumables
The main consumables of MSCT scanning are associated with contrast systems, and
include contrast agent and saline, cannulae and injection lines for contrast delivery,
and applicators for insufflation. Other consumables are ECG pads for cardiac
scanning, paper roll bed liners, personal protective equipment, such as gloves and
aprons, cleaning materials, and patient gowns (if single-use gowns are employed).
Standard local procedures should be followed for the disposal of the clinical waste
generated from these consumables.
Storage devices such as magneto optical discs (MODs), compact discs (CD), or
digital video discs (DVDs) may constitute significant consumables, dependent on
how information transfer is handled (see Data management below).
The X-ray tube may be included within the maintenance contract. If not included in a
contract, it may be regarded as a consumable. The X-ray tube is covered by a
warranty that is generally based on number of rotations or exposure time. It might be
expected to last between a year and eighteen months, dependent on patient
throughput and tube technology. The tube technology is a key difference between
some of the CT manufacturers and claims of tube lifetime vary considerably.

CEP08007: March 2009

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37

Quality assurance
All scanners for use on patients must be subject to a documented quality assurance
(QA) process, including quality control (QC) testing of the scanner, according to IRR
99 and IR(ME)R 2000 [21], [22]. There are published guidelines on the QC activities
that should be undertaken [29] - [31]. This involves a combination of daily checks and
more extensive routine testing. Daily tests are carried out before scanning
commences, normally by the duty radiographers. The more extensive, less frequent,
checks are undertaken by the local medical physics department.
Manufacturers provide test objects for routine testing of the scanner. Additional test
objects may be required to support other tests. These may be included in the tender
package. Some scanners include special protocols and phantoms that automatically
carry out such test scans.
Time must be allowed within the installation plans to establish baselines for quality
control measurements, preferably at commissioning
The Ionising Radiation (Medical Exposures) Regulations, 2000 (IR(ME)R 2000) [22]
states that records should be kept of the doses to patients. These should be subject
to routine audit and comparison with national guidance in pursuit of optimisation of
image quality and patient dose. There is general information on patient dosimetry
available from the Department of Health [32], and specific CT dose data from the
Health Protection Agency [17].

Patient workflow
Introduction
Improving access to key diagnostic tests has been identified as one of the 10 High
Impact Changes for Service Improvement and Delivery [33]. The installation of a new
CT scanner gives the opportunity to address changes in working practice within the
department to improve efficiency and patient workflow.
General workflow for a CT scan is shown in Figure 21. There are certain items
directly affected by the choice of scanner, however the majority of issues affecting
workflow are operational.
Studies have found that increased patient throughput can be achieved with relatively
simple changes in working practice [34], [35]. In one study, CT scan waiting times
were reduced on average by 43 days across 23 pilot sites by matching demand and
capacity and improving the flow of patients [33].
Key aspects [35],[36] to be addressed to improve patient workflow are: assigning a
scan protocol at the acceptance of the referral; using an appropriate staff skill mix;
CEP08007: March 2009

Operational considerations

38

cannulating the patient outside the scanner room; and having a booking system that
is not dependent on in-patients arriving at specific times. These issues are further
discussed below.
Extending working hours can also improve workflow. However, running the scanner
beyond standard hours routinely will have implications on tube replacement
frequency, service support requirements and cost, and radiation protection issues.
Figure 21. The stages of a CT scan

REFERRAL

Plan
scan

Justification
Scan protocol
selection

Scan

Schedule

Patient to
waiting
area

Prepare
patient

Primary and secondary


reconstructions on scanner

Transfer images to CT/MR


workstation and/or PACS workstation

Secondary Reconstructions/Post
processing on workstation as required
Transfer report to
patient record

Read
images

REPORT
Transfer images
To archive

Staffing
MSCT scanners may only be operated by appropriately trained staff [22], usually
registered radiographers. They act under the supervision of practitioners who, within
the terms of the statutory instruments, are a registered medical practitioners (usually
a radiologist) or other health professional who is entitled in accordance with the
employer's procedures to take responsibility for an individual medical exposure.
The operation of the scanning department will be supported by administrative staff
who arrange appointments and carry out the patient reception duties, nurses and/or
radiography departmental assistants (RDA), and porters for transfer of in-patients.
Additional general support is provided by radiation protection and medical physics
staff, from either within the trust or other organisations, who carry out periodic QA
testing of the scanner. They will also advise on issues regarding optimisation of
scanning protocols with respect to patient dose and image quality. These specialist
staff should be trained to nationally recognised levels. Radiation protection advisors
must hold a certificate of competence from a Health and Safety Executive (HSE)
CEP08007: March 2009

Operational considerations

39

recognised assessing body [37], and be experienced in the relevant technologies.


The local radiation protection supervisor (RPS) ensures that the local rules for
radiology practice are followed. (Local rules are mandatory instructions that are
formulated to secure compliance with health and safety legislation).
Utilising an appropriate mix of staff skills can reduce staff costs and improve patient
workflow through the scanner. An example scheme is shown in Figure 22.
Figure 22. Examples of allocation of specific roles to assist patient workflow
Radiologist

Referral

Justification
Scan
protocol
selection

Schedule

Patient
- own transport (o/p)
- or porter (i/p)

Helper or Nurse

Patient
preparation

- Cannulates, if
appropriate
- Reassures patient

Patient to
scanner room

- Assists patient and


radiographer

Radiographer
Continues patient set up
Sets up scanner preassigned protocol
Scans
Image reformats etc

Radiologist
Views and
Reports
images

Images automatically
sent, as per protocol,
to PACs or
workstation

Referral
Under current legislation [22], where patients are referred for a scan, this must be
justified by an entitled practitioner, and a suitable investigation prescribed. The
choice of investigation, protocol, and scan parameters must comply with the ALARP
(as low as reasonably practical) principle, to ensure that no unwarranted irradiation
takes place. The ALARP principle is a standard tenet in radiation protection and
health and safety legislation.
CEP08007: March 2009

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40

Some departments have found delays at this stage of the process due to restrictions
on the radiologists time. Systems that have been used to remove this pressure
include batch processing of these referrals, and pre-selection of protocols, where a
standard scan protocol is selected from a list at the time of justification. In addition, a
specific member of staff may be allocated to screen the referrals to remove
unwarranted referral requests according to well defined procedures. Pre-selection of
protocols ensures there is no delay at the time of scanning. The protocol defines the
anatomy to be scanned, and the required slice thicknesses, scan parameters,
reconstruction procedures and post processing are all outlined. Systems to easily
identify the scan protocol from the request form, such as protocol code numbers or
tables with tick boxes, can simplify the process and minimise potential for error.
Scheduling
Improvements in scheduling can be obtained in a number of ways, according to the
local mix of patients. Scheduling patients for particular types of examinations into
fixed sessions can improve workflow, especially if specialist clinical support is
required at the time of scanning to review the images. However, efficiency can clearly
be compromised if there are not enough patients to fill a session for that particular
examination type. If there are too many referrals and they cannot all be fitted into a
particular session, some patients might have to wait up to a week until the next
scheduled session.
Some have found that scheduling patients who do not require contrast injections into
sessions at the beginning or end of the day, when there is less likely to be a
radiologist available, improves workflow. This ensures that there is no delay and
scanning can take place with no delay.
If two identical scanners are procured, then all scans can be booked onto one list and
the first available scanner used. If the scanners differ, then systems need to be in
place to determine which patients can only be scanned on a particular scanner.
The availability of porters can affect the arrival time of in-patients. Some centres
overcome this by having a specific porter, or porters, allocated to scanning or
radiology. Another approach can be to balance the scheduling of the mix of inpatients and out-patients, so that outpatients can be scanned whilst waiting for late
in-patient arrivals, or vice versa.
Efficient procedures for checking the pregnancy status of patients will also ensure
minimum effect on workflow.

CEP08007: March 2009

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41

Patient preparation
Improvements in patient throughput can be achieved by preparing the patient before
transfer to the scanning room. Patient information and checks for contra-indications
to the procedures, such as contrast intolerance, can be undertaken whilst the patient
is in the waiting area.
In some departments, cannulation is also performed prior to the patient entering the
scanner room. This requires a suitable separate area, and trained staff, not
necessarily a radiographer, such as an RDA or a nurse.
Oral contrast administration preparation times can be shortened by changing the
procedure for administration or adopting alternative strategies [34],[35].
Scan set-up
Current scanners can obtain patient information from the modality worklists, which
may come from the RIS, the PACS, or from a broker acting as an interface between
the RIS and/or PACS, and the scanner. Pre-population of patient information fields
on the scanner console during set-up can save operator time, and reduce the chance
of error. Some scanners can also update the RIS or PACS as to the status of the
scan, using performed procedure steps.
Patients may need to be instructed about breath-hold and contrast injection during
the scan. Systems such as visual breath-hold indicators and voice announcements
can ensure that the patient complies with the scanning requirements. Modern
systems offer a selection of language choices, and some systems allow the recording
of additional announcements.
With increased speed of scanning, the timing of the scan relative to contrast
administration is important. Systems generally include a trigger system that will
initiate the scan, based on a time delay or bolus tracking.
Automated dose reduction systems are intended to optimise the patient exposure to
ionising radiation whilst maintaining adequate image quality. These require extensive
user training. Set-up, testing and optimisation of these systems require the support of
a medical physicist.
Image reconstruction
It is generally thought to be good practice for scanner operators to check images
before removing the patient from the scanner. This may take from a few seconds to a
few minutes depending on the performance of the reconstruction computer. Systems
that provide fast reconstruction and easy review of images at the console minimise
delay, and help to increase throughput. To facilitate rapid verification of images,

CEP08007: March 2009

Operational considerations

42

some scanner manufacturers provide preview image reconstruction at reduced


image quality.
Some centres have a scan and send policy, for routine examinations, which does
not require a radiologist to review the images prior to sending the patient away,
reducing delays due to radiologist unavailability.
For ease of reporting and specialist applications, there are a number of additional
processing steps that the image data undergo, for example to reconstruct with
different convolution algorithms, to reconstruct 3D views, thick or thin slab MIPS or
MiniPS (maximum or minimum intensity projections) etc. Where these secondary
reconstructions are set-up in the protocol, the need for user intervention in postprocessing activity may decrease.
However, increasingly, the CT data set is regarded as a volume, and the 3D
reconstructions, MIPS, MPR (multiplanar reformats), etc may be instantly available
rather than secondary reconstructions with the thicker axial slices only reconstructed
for image storage.
The quality of the MPR, MIP and 3D reformatting from image slice data sets is best
when reconstructed from thin slices. Many centres choose to store only the thicker
slice data sets, to reduce data storage, however any subsequent reformatting from
these data sets will result in reduced image quality, compared to thin slice data
sources. This is an additional advantage to prescribing these reformats in the
protocol, so that the thin slices are used while they are still available.
Some systems can process the secondary reconstructions whilst the next scan is
being set up, others may pause one or the other function depending on shared
computing resources. The interdependence of scanning and reconstruction may
affect throughput in departments where a large number of alternative reconstructions
are requested routinely.
The volume of acquired (raw) data is large, and often only stored on the scanner
computer, where the data are typically overwritten cyclically. For many scanners the
cycle time may only be a week or a few days, dependent upon the rate of scans, the
amount of data acquired for each scan and the storage disc size. Once the raw data
are overwritten, further formatting of images can only be carried out from stored slice
data sets.
Routing of images to stores, such as workstations and archives can also be preset
for given protocols. This may be for the complete study, or for a specific series of
images.

CEP08007: March 2009

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43

Further processing
Additional processing can be carried out on the scanner console, on the scanner
workstation, or on the PACS workstation. Some functions will be available on all
three systems, others will be limited to scanner console and workstation. For more
specialist applications, such as cardiac analysis, vessel analysis, or automatic lung
nodule scoring, software packages will only be available from the scanner
workstation. Systems can also be purchased to allow processing of data on the
workstation through remote access, and thin-client systems.
The usability of the application software will affect the efficiency of workflow at this
stage. Applications that use standard interfaces and inputs, are intuitive, and provide
suitable prompts when required, may improve workflow initially or for rarely used
applications. Some systems allow users to record macros or shortcuts to reduce the
inputs required.
Post-processing may be undertaken by a radiographer, technician or clinician.
Suitable training must be undertaken for each application.
In studies requiring post-processing or specialist analysis software, suitable worklist
systems should be in place to maintain effective use of reporting radiologists time. If
reporting from the workstation, then dictation, a voice recognition system, or another
reporting system, must be available at, or adjacent to, the workstation.

Specialist applications
Specialist applications, due to their complexity, tend to slow down patient throughput.
This can either be due to time in the scanner room during interventional procedures,
or in additional preparation and processing time (eg for cardiac examinations).
Interventional use
CT systems can be used for real-time and interventional procedures, such as guided
biopsies. These may also be called real-time CT, or CT fluoroscopy. Manufacturers
supply additional configurations and accessories for interventional work. The
necessity for these additions will depend on how the interventional work will be
carried out. There are currently two approaches: in-room and out-of-room use.
For in-room use the interventionalist is in the scanner room when the exposure takes
place. A slave monitor in the scanner room displays a real time image, and the X-ray
exposure and the couch motion can be controlled using a foot switch and a floating
table top control on the scanner couch. Even with appropriate lead apron and
protective gloves (if needed), this will increase the radiation dose to the member of
staff.

CEP08007: March 2009

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44

In the out-of-room approach all staff vacate the room while the scan is taken. The
position of, for example, the biopsy needle is checked from the image at the scanner
console and the clinician re-enters the room to carry out any subsequent adjustment.
This reduces staff dose, but increases the time taken to carry out the procedure.
For either approach, there are common general concerns. Repeated imaging of the
patient increases the dose burden. Systems should acquire only enough data to
refresh the image to the quality required for the procedure.
The clearance between the patient and the inside of the gantry aperture should be
sufficient to allow the clinician reasonable access to the relevant site. Moving the
patient out of the gantry for adjustment of the biopsy needle can lead to
misplacement and misregistration on images, and may lead to more imaging (and
hence dose) than necessary.
Cardiac procedures
Cardiac examinations can be complex, and require specialist expertise to optimise
scanning. The patient is generally given beta-blockers to stabilise the heart rate,
although some manufacturers claim that their scanners are unaffected by irregular
heart rates. The patient is wired to an ECG monitor that is interfaced to the scanner.
This information is used to gate the acquired image data for subsequent
reconstruction. Further processing of the images is generally carried out on the
scanner workstation to release the scanner for subsequent patients.

Information workflow
Due to the large number of images generated by modern MSCT scanners, it is very
important, on deciding to purchase a new scanner, to review the information
workflow, and the location and use of CT scanner and PACS workstations. New
approaches using remote thin client systems might also be investigated. The
questions that need to be considered for optimising information workflow are: Where
does the reporting takes place? What images are reported? What data are saved?
Images can be sent from the scanner to the CT scanner workstation and/or
transferred directly to the PACS store. On the CT workstation, complex processing
can be undertaken prior to reporting. From the PACS store images can be displayed
on a PACS diagnostic workstation for reporting (it may be also be possible to carry
out simple processing), or on a lower specification review station for review. Images
from the CT scanner workstation can also be displayed and manipulated using a
computer at a remote location using a thin client system. These options are shown in
Figure 23

CEP08007: March 2009

Operational considerations

45

Figure 23. Information and image flow

Efficient workflow requires optimising how the images are viewed on the equipment
available. This requires some knowledge of the capabilities of the network and
computers that are used. Currently an MSCT data set can comprise 1000 to 2000
images per patient, and networks and computers vary in their capability to handle this
volume of data.
Thin slice imaging is currently the normal approach for MSCT scanning, and images
may be sent to the PACS or scanner workstation as the complete set of thin slices,
or, as a smaller set of thicker slices and multi-planar reformats.
The number of images also has an effect on the data that will be stored as part of the
permanent patient record within the hospital systems. Guidance on the retention of
radiological patient data has been published by the Royal College of Radiologists [38].
(See also Data management below). There are also specific regulatory requirements
for recording patient dose data [22]. This can either be as the computed tomography
dose index (CTDI) and dose-length product (DLP) values, or with enough scan
parameters to enable this information to be calculated at a later date.

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46

CT scanner workstation
The CT scanner workstation is used for complex processing, and the full range of
three dimensional reconstructions (such as volume rendering, slab maximum and
minimum projections, curved planar reformatting, surface rendering), as well as for
the specialist software applications such as those for cardiac analysis and virtual
endoscopy.
It may be possible to share a manufacturer workstation between two modalities, such
as CT and MR scanners. This will help offset the expense of the application
packages and licences. However, this will depend on the applications and processing
required, and the working patterns within the department.
PACS workstation
The PACS diagnostic workstation is primarily used for reporting, however some
reconstruction functionality (eg multi-planar reformat, MIP, some 3D reconstruction)
may be available. It is worth noting that these reformats will not necessarily use
identical algorithms to those on the CT scanner workstation, and there may be a
difference in quality.
Remote access thin client systems
Images from the workstation can also be displayed on a computer at another location
linked through the hospital network using a thin client system. These systems are
available from all manufacturers through the purchase of single or multiple user
licences. These software packages enable a remote PC to log-on to the scanner
workstation, using either a dedicated client application, or one based on commonly
available client application interfaces such as web browsers. The user can then
perform both simple and complex workstation functions remotely,
The advantage of thin client systems is that they allow viewing and processing
functionality from less powerful computers by carrying out the processing on the
central server. However the network demands are increased. The latest systems are
designed to provide a common interface to the user for all applications, regardless of
modality. This can reduce the training and application support requirements.
Generally, licences are required for each client computer that connects to the
workstations remotely. The exception is viewers with no processing functionality. It
should be clearly established what level of review and processing functionality is
required at each remote client, based on clinical need and workflow designs.

CEP08007: March 2009

Operational considerations

45

Figure 23. Information and image flow

Efficient workflow requires optimising how the images are viewed on the equipment
available. This requires some knowledge of the capabilities of the network and
computers that are used. Currently an MSCT data set can comprise 1000 to 2000
images per patient, and networks and computers vary in their capability to handle this
volume of data.
Thin slice imaging is currently the normal approach for MSCT scanning, and images
may be sent to the PACS or scanner workstation as the complete set of thin slices,
or, as a smaller set of thicker slices and multi-planar reformats.
The number of images also has an effect on the data that will be stored as part of the
permanent patient record within the hospital systems. Guidance on the retention of
radiological patient data has been published by the Royal College of Radiologists [38].
(See also Data management below). There are also specific regulatory requirements
for recording patient dose data [22]. This can either be as the computed tomography
dose index (CTDI) and dose-length product (DLP) values, or with enough scan
parameters to enable this information to be calculated at a later date.

CEP08007: March 2009

Operational considerations

48

larger for more specialist applications where there are more reconstructions or
reformats, and 4 times larger for images of 1024 x 1024.
As an alternative to long-term storage of all data, departments may choose to store
the data acquired with narrow slices only for a short period of time, whilst it is
required for processing and reporting. This may need to be revised in line with best
practice since updated guidance on record retention [38],[40].
Many departments continue to back up data at the scanner, in which case the
scanner must have a back-up facility and secure storage for a large number of discs.
It should be noted however that the reliability of central storage now generally
renders this practice redundant.
Systems are now available that burn data discs for dispatch to external clinics or for
medico-legal use. Systems that produce standard formats (such as DICOM part 10
[41]) should be chosen. Automatic labelling of the disc with unique, human-readable
data should be preferred. Department of Health policy now requires password
protected encryption of the information on removable media.

Interoperability
Introduction
This section relates to how the CT scanner system interacts with other systems in the
department and in the hospital. These may be other imaging modalities, specialist
systems, or patient and image data management systems (such as PACS, RIS,
Hospital Information System (HIS), etc).
Systems integration
Many systems have the capability to integrate resources. Most modern scanners
have functionality on the console that was previously only available on specialist
workstations.
Standardised exchange of image data between scanner, workstation, and storage
systems is achieved by compliance with DICOM standards [42].
Patient information, including the final report, is managed by HL7 systems [43].
Overarching frameworks, such as IHE [44], provide a background that encourages
suitable interoperability between systems. Manufacturers will supply DICOM
conformance and IHE integration statements on request. Specialist knowledge is
required to ensure that the required data exchanges can be achieved by the systems
under consideration and those already existing in the hospital [45].

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49

There are two published standards for DICOM objects that store CT image data [46].
The standard applicable to the scanner output data might therefore differ from that
applicable to the input data for other systems within the workflow.
Responsibilities for interfacing the scanner with the PACS or other systems must be
clearly defined. This may involve the local PACS and RIS managers and suppliers of
the related systems. Although systems may have the capability to carry out certain
exchange functions, these may not be enabled or configured in the basic package
offering. Activation and configuration requirements should be included in the tender.
Local ICT departments should always be involved as network traffic, data storage
and security will need to be considered.
Influence on existing modalities
Most CT scans do not involve direct interoperability or integration with other imaging
modalities. Exceptions such as PET-CT and SPECT-CT are beyond the scope of this
buyers guide. Where such fused imaging systems are under consideration,
specialist advice should be sought from professional bodies such as the Institute of
Physics and Engineering in Medicine (IPEM) and the British Nuclear Medicine
Society (BNMS).
In departments with more than one CT scanner, issues may arise due to specification
and capability differences. Many general scans can be carried out on any scanner,
but some have specific technical requirements. The flexibility of having multiple
scanners all capable of carrying out any required scan should be balanced against
the risk of over-specification. The additional expense incurred may result in higher
patient throughput depending on the workload mix.
Options for sharing resources such as workstations and staff may also be a factor in
choosing a scanner. There might be advantages to selecting an additional scanner
from among the models offered by the manufacturer of the existing one, due to ease
of transfer of skills between scanners, and contractual efficiencies. These
advantages will apply to a lesser extent when all existing scanners are to be
replaced.
Specialist systems
In some circumstances, data from the CT scan may be used in other specialist
systems. Scanners that are to be used with radiotherapy treatment planning systems
will have special requirements with respect to accuracy of CT number values and
patient positioning. These scanners will also have additional requirements for
accessories, acceptance and quality control testing.

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50

Surgeons may use CT data sets to visualise and plan operations. Orthopaedic
planning, stent fabrication, and neuro-navigation systems may be used. These may
require specific data sets from the scanner and place additional constraints on image
quality.
Systems exist where the CT data are used to plan the settings for subsequent
conventional angiography. This may reduce the time taken to plan and optimise the
angiographic procedure.
In each case, it must be established that the data set transferred from the scanner is
compliant with the requirements of the destination system. Standard image transfer
facilities might be inadequate in this respect. It should also be established whether
the destination system accepts data transfer across a network, or requires transfer
on physical media.

Information security
It is the responsibility of all health care professionals to ensure that personally
identifiable patient or staff data are kept confidential and secure. Information
governance (IG) is about how sensitive information is produced, used, archived and
destroyed. IG should be regarded as part of clinical governance processes. Local IG
principles must be kept in mind when considering how patient data are to be
managed during the CT scanning processes, and thereafter.
Where data may be transferred outside of the trust, approved systems should be
used. If systems are used to transfer data to physical media (CD, DVD, MOD, USB
stick) there will be a requirement to encrypt the data. Preference may be given to
systems that provide this facility automatically.
If data are to be used for non-clinical purposes, such as teaching and research, there
may be a need to anonymise the data that is remove all patient identification from
the file. Systems exist that remove generic information from standard file formats,
such as DICOM header tags. It should be established that use of such systems
complies with national [47] and local guidance. Certain files may contain patient data
in so-called private tags. If this is the case, it should be determined how these are
handled by existing anonymising processes.
Access to patient data is normally based on a legitimate relationship to the data.
Generally this limits access to those who need to know for clinical management
purposes. Certain levels of service contract provide for remote fault diagnosis, which
requires the service organisation to have modem access to the X-ray system. As it is
now common for imaging systems to be connected to HIS/RIS or PACS, this creates
the potential for unauthorisched access to patient information via the scanner or

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51

workstation. Security must therefore be considered when setting up facilities for


remote system support and fault diagnosis.
Any use of, or connection to data on the scanner must be in full compliance with
national and local policy, such as the NHS Code of Practice [47] Local network
security boards, IT departments, and NHS Connecting for Health [48] can advise on
the external connection to the scanner. Approval for cases where patient identifiable
information may be exposed must be obtained from the local data protection officer
(normally the Caldicott guardian).

Safety issues
As with most clinical investigations, there are safety issues related to the handling of
patients, radiation, infection, use of injections, use of medical gases. These should
always be considered in relation to existing local guidance. Particular issues related
to CT scanning that should be considered are highlighted here.
Ionising radiation
As with any imaging modality involving the use of X-rays, the hazards of ionising
radiation must be considered under IRR 99 [21], and IR(ME)R 2000 [22]. IRR is mainly
concerned with safety of equipment and staff, whereas IR(ME)R focuses on the
protection of the patient.
There will need to be a radiation protection advisor (RPA), appointed under IRR 99
[21] with responsibility, among other things, for scanner equipment safety and the
protection of staff and the public. The radiation protection advisor (RPA) should be
involved throughout the purchase project and thereafter to ensure continued
compliance.
A medical physics expert (MPE) is also required, appointed under IR(ME)R 2000, to
give advice on matters relating to radiation protection concerning medical exposures,
such as patient dosimetry, quality assurance and optimisation of protocols.
There are legal constraints on dose exposures to the public and staff; these must be
enforced through local rules and routine surveys. There are requirements to maintain
patient dose records, and carry out routine dose audits. Staff must also be monitored.
Systems must be in place to ensure compliance, and adherence to current best
practice. It is the duty of the hospital board to ensure compliance, with advice taken
from the RPA.
Due to the inherent risk involved with the use of ionising radiation, justification of a
medical exposure is required by law [22] and is one of the main tenets of radiation
protection. Any CT procedure must be justified in terms of potential clinical benefit.

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The RCR produce guidelines as to where CT is the preferred investigative technique


and where it is not justified [49].
IR(ME)R 2000 requires that the dose given to a patient is recorded either directly (eg
volume CT dose index (CTDIvol) and dose length product (DLP)), or indirectly from
scan parameters, (allowing the dose to be calculated retrospectively). Average doses
to a group of patients for common examinations should be compared periodically to
the associated diagnostic reference levels (DRLs) [17],[32].
CT is a high radiation dose procedure [16][20]. The specialist applications of
fluoroscopy, perfusion and cardiac scanning give particularly high dose levels, and
protocols for these applications warrant specialist attention, preferably in consultation
with the local medical physics department. Training can help in the optimisation of
these specialist scanning regimes.
Automated dose reduction systems are intended to minimise patient exposure to
ionising radiation, whilst maintaining adequate image quality. These require
extensive user training. Set-up, testing and optimisation of these systems require the
support of a medical physicist.
A robust system for patient identification is critical in ensuring that the patient is not
scanned in error, or with the incorrect protocol. Where patients have been exposed to
ionising radiation to a degree much greater than intended, this must be notified to
the Healthcare Commission, to whom the responsibility for enforcing IR(ME)R was
transferred, by the Department of Health, in November 2006 [50],[51].
Where radiation exposures are much greater than intended owing to equipment
failure, there is a need to notify the Health and Safety Executive (HSE) [104] under
IRR 99 [21].
Infection control
Local infection control teams will need to be consulted regarding the scanner suite
facilities. Key issues include requirements for flooring and lack of trap areas around
the scanners, and positioning of sinks and other hand cleaning stations in the suite.
Cleaning of the scanner is routine. Most manufacturers will supply a slicker couch
cover as standard. Manufacturers are able to provide guidance on suitable cleaning
methods. Checks should be made whether local cleansing products will affect the
scanner surfaces.
If replacing a scanner, the existing scanner room should undergo deep cleaning as
part of the pre-installation phase.

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53

Cost effectiveness
Evidence of cost effectiveness is useful for the preparation of the business case.
Cost effectiveness may be enhanced by negotiating lower prices, controlling running
costs, optimising operational procedures, maximising the impact of the CT scanning
service, and reducing overall clinical management costs.
Few economic studies have been undertaken regarding CT imaging [52]. Most
compare various pathways of patient management where CT scans are involved
(see [53] for examples). The additional cost of undertaking a CT scan is considered to
be outweighed by the improvement in effective management of the disease. For
example, a US study identified that CT-based management strategies for head injury
cases were not only clinically superior to those without CT, but reduction in
subsequent treatment costs made these strategies cost effective [54]. Immediate CT
scanning of patients presenting with suspected stroke has also been identified as a
cost-effective approach to differentiation between cerebral infarction, cerebral
haemorrhage, and stroke mimics. Although this was the highest cost strategy
considered, improvement in clinical management decisions lead to a reduction in
overall costs [55]. Routine CT scanning is not a cost effective follow up in Hodgkins
disease [56].
In 2007, the Committee on Medical Aspects of Radiation in the Environment
(COMARE) of the Health Protection Agency (HPA) issued guidance on CT scanning
of asymptomatic individuals [12]. Scanning in these circumstances is not
recommended for most types of examinations, although under strict conditions
certain allowances are made for coronary calcium scoring and colonography. In
addition, an Institute for Clinical Systems Improvement (ICIS) study, in 2003, found
that no evidence exists to evaluate the effectiveness of whole-body CT as a
screening test for patients with no symptoms or a family history suggesting disease
[57]. A 2006 Health Technology Assessment report on lung cancer screening [58]
found no evidence to support clinical effectiveness, and no evidence of costeffectiveness.

Costs and remuneration


Indicative scan costs
The average cost of a CT scan, compared to other diagnostic imaging procedures
carried out by NHS trust radiology services, is reflected in the average unit cost tariffs
given in Table 5. Note that these examples have been shown for each imaging
modality, although neither the diagnostic aim nor value may be directly comparable.
The figures show that:

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54

CT costs more than plain X-ray or ultrasound investigations,


CT costs are less than those of nuclear medicine procedures
CT costs are comparable with those of MR and fluoroscopy procedures.
Although dual-energy CT scanning is used in some research centres, it is not yet
considered an alternative for DEXA scanning for bone density assessments.
Table 5. Average unit cost tariffs for different diagnostic imaging modalities [59]
Diagnostic imaging procedure

Average unit cost tariff ()

MR

169

CT

131

DEXA

49

Contrast fluoroscopy

159

Ultrasound scan

69

Nuclear medicine procedure

228

Plain film (or CR or DR) (one area)

29

Note: * Based on previous reference costs [66] with a 2.5% uplift

Payment by results
The NHS is moving towards the payment by results system, (PbR) [60] with
reimbursement based on the costs of treatment strategies as categorised into
healthcare resource groups (HRGs) [61], sets of patients requiring broadly similar
management. Each of these is allocated a HRG code, against which a national tariff
has been set.
Since the publication of HRG v4, radiology procedures, such as CT scans, are
treated as an unbundled component [59], that is, an additional cost item. Hence,
procedures involving CT scanning will have additional HRG codes, the core HRG
code for the patient treatment, and relevant radiology HRG code.
Using a unit of tariff of 144 (based on the indicative average unit tariff for CT, given
above in Table 5, and including the addition of a typical market forces factor (MFF) of
10%), a typical hospital, with two MSCT scanners carrying out 14,400 CT based
investigations, will generate payments of just in excess of 2m per annum.

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55

Investigation coding
CT investigations will initially be assigned a code, such as OPCS-4 (Office of
Population Censuses and Survey Classification of Surgical Operations and
Procedures, 4th revision)[63] or SNOMED CT (Systematised Nomenclature of
Medicine Clinical Terms) [64]. Currently there is no prescribed mapping from these
codes to the relevant payment codes (HRG v4). The range of CT procedures will
attract different levels of payment, which vary from 105 to 223 (Table 6), and
therefore all CT investigations must be properly coded to ensure that the correct tariff
payment is collected [65].
Table 6. Indicative PbR tariff for CT diagnostics, 2008-09

Radiology HRG banding

Sample unit
cost tariff ()

CT, one area, no contrast

105

CT, one area, post contrast only

131

CT, one area, pre and post contrast only

152

CT, 2 or 3 areas, no contrast

132

CT, 2 areas with contrast

164

CT, 3 areas with contrast

176

CT, more than 3 areas

223

For example [62], a CT scan of the head may be classed as:


CT one area, pre and post contrast
CT one area, post contrast only
CT one area, no contrast.
Miscoding this investigation could lead to a 30% underpayment of tariff.
Implementation of RIS systems throughout NHS as part of the NPfIT programme has
improved access to electronic data regarding the scans undertaken. Where a direct
link between the departmental RIS and the hospital PACS exists, automatic
allocation of coding should ensure the correct payment is claimed. Where there is no
such link, proper systems must be in place to ensure clinical coders have sufficient
information to correctly allocate the base and subsidiary codes that will ensure the
correct HRG allocation. Whether the allocation is automatic or manual, the mapping
exercise from local procedure codes to HRG codes must be undertaken with care.
When setting up the scanner, it should be ensured that the correct scan can be easily

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56

chosen for the investigation booked on the RIS. Any changes between the requested
scan during justification and the selected scan protocol should be indicted in the RIS
data.
Cost model
Most trusts will be undertaking an exercise to quantify their own standard costs for
diagnostic procedures. These should address radiological investigations, including all
CT scans. The local project officers should be consulted for the latest figures for use
in economic planning. The following cost model is given as a guide for use in initial
estimates.
The costs in the discussion below are reasonable estimates based on discussion
with users and service managers. They are given for indicative purposes only.
Example annual costs, from this discussion, are summarised in Table 7. Each
particular procurement and installation project will require its own cost analysis based
on local data (see Whole-life costs).
Table 7. Example annual direct operating costs for CT scanner

Cost per annum


()

Relative
contribution to
total cost

Relative
contribution to
non-staff costs

Capital costs

106,000

12%

24%

Service & support

70,000

8%

16%

Consumables

175,000

20%

39%

Other

97,500

11%

22%

Staff

415,000

48%

n/a

TOTAL

863,500

Cost item

A typical MSCT scanner system will cost around 500k, including installation and
initial training. Basic works to refurbish an existing scanner room will cost around
30k. There may be a cost of up to 75k for additional radiation shielding and
increased power supply, which is often required for an upgraded scanner. This latter
element has been excluded from this model. A new scanner room build will have a
higher cost. Assuming that the capital costs are allocated over a 5 year period, this
gives an equivalent annual cost of 106k. Capital asset depreciation is not
considered.

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57

Routine maintenance and servicing of radiological equipment typically costs around


50k per annum. A replacement X-ray tube costs of the order of 70k. The frequency
of replacement will vary with model and use. Newer tubes are likely to have a
reduced replacement frequency compared to older scanners. A spare could be
bought at the time of scanner purchase or costs could be budgeted over a specified
period. Allowing 20k per annum for the replacement x-ray tube would not be
unreasonable. A total of 70k is allowed for service and support costs.
It is assumed that all the workstations and applications software required is included
in the purchase price for the CT scanner system. An additional workstation may add
an amount around 40k to the capital costs, and 5k to the annual support costs.
Consumable costs are mainly related to the contrast use. As an initial assumption,
just over 2/3 of scans will be contrast enhanced. The cost may be 20 per use
depending on the amount, mixture, syringe costs and such. Other consumables are
assumed to be of the order of 10 per study.
For this model, a scanner with a mixed workload is assumed, achieving a throughput
of 25 patients in an 8 hour day, 250 scanning days per year. Assuming around 15%
additional scans occur out of hours, this gives an annual volume of approximately
7,500 studies, with 5,000 contrast enhanced. Contrast costs will be 100k per
annum, and 75k for other consumables.
Additional costs include those related to data storage, and other general use items.
PACS, or similar, storage is estimated as 8 per scan, and another 5 per scan is
allowed for miscellaneous direct costs. The model includes an annual cost of 97.5k
for these items.
Total staff costs are included in this costing model, and are assumed to cover
salaries and other related costs. If the scanner is a replacement scanner, then the
staff costs should be modelled on any changes to existing staffing levels. The staffing
is based on:

180k for 1.5 full time equivalent (FTE) consultant radiologists


75k for one junior clinician (SPR or equivalent)
80k for two radiographers
20k for 1/3 FTE of other technical staff
60k for clerical and other support staff.

Factors such as extra session payments and unsociable hours, plus any retention
premiums are assumed to be covered within these costs. Some specialist technical
skills, such as an RPA, may be bought in as external services, but are included in the
technical staff salary costs for this model.

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Ongoing and professional training is neglected as part of the overall departmental


budget. Specific application training and such is assumed to be covered within the
support contract costs.
Most trusts will require a proportion of the overall operating costs of the hospital to be
included in the costs of a department. For this model this is assumed to include any
power costs for the department as a whole. Allowing 20 percent of the total cost for
this gives an indicative annual cost to the department of around 1m per annum for
the scanner.
The highest single contribution to the above model is salary related. Any features of a
new scanner that will improve the efficiency of staff use, such as improved
workstation tools, simple scan set-up and management, has the potential to reduce
the cost per scan. Also changes in overall working practice and workflow within the
department will affect this figure. However, if the scanner is used for increasingly
complex procedures, then the staffing costs may increase.
Departments that operate more than one scanner will be able to optimise staff
expenditure by using common resources. Two scanners are likely to have less than
double the staff costs of one scanner.
The direct revenue costs of staffing, reporting, and data storage are very dependant
on local working practices. For a scanner replacement, there may not be a major
variation from current staffing levels, but there could be an increase in reporting and
data processing tasks, which could lead to a slight increase in staffing revenue costs.
This will be highly dependant on the investigations undertaken, the application
software chosen, the workflow patterns, and numerous other local factors.
After staffing, the next highest contribution is from consumables. In this model, 22%
of the non-staff expenditure is for the use of contrast. Techniques available with
MSCT scanner may allow for more efficient use of contrast, however more complex
investigations may increase this cost item.
The annual support costs (service and tube replacement) are approximately 1/8 of
the capital costs at the first year. Over a typical 7 year operating life, and factoring in
a uplift of 6% per annum, this will then represent a life cost 10% greater than the
initial equipment purchase, installation and building costs of the scanner. Fixing the
price of the service contract for 5 years gives a potential saving of 8% over the
operating life.
Cost control
As well as negotiating on the cost of the main scanner and equipment, there is some
benefit from including additional items at the point of tender. This can fix on-going
CEP08007: March 2009

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59

costs for a set period, facilitating budgeting and possibly generating cost savings.
The following items should be considered for inclusion in the tender:

service costs for a specified period


fixed price consumables for a specified period
additional training for radiologists and radiographers
additional workstations and software
planned upgrades to applications (to match future introduction of new clinical
services) and workstations, plus associated support and training
future replacement of LCD monitors
with tube service contracts or replacement tube costs
data integration services to ensure connectivity of the scanner and
workstation to the RIS, PACS and other local data systems
additional storage for future expansion of local archive storage, whether
on-line or optical disc
service continuity (eg provision of a mobile unit whilst works are undertaken)
phantoms, test objects and other QC testing equipment.

Whole-life costs
In order to make the most effective procurement decision, whole life costs should be
considered for each purchase option. These should account for capital costs, and
revenue costs over the expected life of the scanner. There are a number of areas
where the cost elements are often neglected. Some of these are identified below.
Costs related to the disposal of the equipment should also be considered.
Key items that typically contribute to whole life costs are listed in Table 8. Local costs
for these items should be determined by the purchase team as part of the purchasing
activity.

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60

Table 8. Contributors to whole-life costs


Life-cycle phase

Specific contributors

Purchase

Equipment purchase; scanner, ancillary equipment, accessories,


workstations, application software.
Capital item depreciation.
Support equipment such as an emergency trolley, power contrast
injectors, ECG monitor, etc.

Installation

Removing previous equipment and disposal.


Preparing the area, including deep cleaning, estates services (power,
lighting, cooling equipment, patient and staff areas, telephones and
data points, office equipment).
Provision of interim scanning services.
Connection to systems such as RIS and PACS.
Initial staff training may be seen as an installation/set up cost.

Commissioning

Acceptance testing.
Formal radiation safety test report.
Electrical and mechanical safety testing.

Operation

Radiology staff: radiographers, radiologists, RDAs


On-call and out of hours cover.
On-going staff training.
Support staff; administration, portering.
Routine equipment testing; QC test, RP surveys.
Consumables: contrast agent, disposables, gases.
Power and services.
Service contracts and maintenance costs.
Maintenance of associated equipment (eg power contrast injectors).
Film and digital data media.
Cost of network/PACS support for image and data storage.

End of life

Removal: decontamination and disposal.


Data migration.

Hidden costs
Hidden costs might sometimes be overlooked, resulting in unexpected additional
expenditure to complete the project. The following list comprises items known to
have been overlooked in previous CT scanner installations. Reviewing these may
help purchasers to avoid similar errors.
Power supply to the standards required by the new scanner. Existing room
and department supplies may not always be sufficient
power cables new scanners may have specialist requirements for the
power connections
building works especially provision of sufficient shielding and load bearing
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61

systems integration ensuring the transfer of data from the scanner or


workstation to the PACS system
networking additional data cables and network equipment to ensure
efficient connection of systems
data storage potential for huge increases in networked and media
requirements
increased portering more patients means more beds to move
extra patient preparation more patients may require an increase in waiting
room size and changing facilities. Additional rooms and staff may be
required for pre-scan cannulation, for example
extra reporting requirements increase in the number of investigations may
require an increase in the number of radiologists (or specialist
radiographers) reporting and hence increase in both staffing levels and
reporting facilities
desktop computer upgrades remote access and thin client systems allow
ease of access to the data and some processing functionality, but not all
existing office PCs will meet the basic requirements for reasonable
performance.
Cost of disposal
Disposal costs will apply to any equipment being disposed of as part of the upgrade
to the imaging facilities. This may include decontamination of the existing scanner,
accessories and the scanner room.
Disposal costs can also be considered for the new equipment being purchased.
Manufacturers will commonly offer to defer such costs until end-of-life. This way the
purchaser can benefit from any reduction in the disposal costs during that time. It
may be prudent to include removal of all existing equipment as part of the tendering
process in order to ring-fence related costs.
Prospective purchasers should refer to The Waste Electrical and Electronic
Equipment Regulations 2006 [67],[68] , and related guidance [27], which will have an
impact on the purchase and disposal cost of equipment.

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62

Introduction
A scanner may be purchased, leased, or operated as a managed service, in which a
supplier provides the scanner and plays a role in managing the service. Due to the
value of the project to procure a CT scanner, hospitals may employ the services of a
capital projects specialist. Involvement of all relevant departments at an early stage
is strongly recommended to ensure success.
NHS PASA policy identifies the legal framework within which all NHS purchasing
should be undertaken, and key policies within this area that those involved must
observe. The overarching procurement policy [69] states:
All procurement activity in or on behalf of the NHS must be conducted in
accordance with public procurement regulations and should be based on
achieving value for money. NHS procurement should also contribute to the
delivery of wider Government policies and priorities wherever possible.
At all stages of the procurement process, the purchaser must be fair, and seen to be
fair, as any decision made can be challenged by any of the manufacturers who are
not awarded the contract. Guidance is to be found in the National Framework of
Standards for Best Practice Procurement in the NHS [70].
Two elements of good practice are to [71]:
involve key stakeholders throughout the process
seek value for money, not just lowest price.
Due to the complexity of the technology, the high equipment value, and rarity of the
purchase, procurement teams are encouraged to seek advice from experienced
users and support organisations. This is particularly important when considering
technical specifications and performance. Advice may be obtained from NHS PASA,
especially the Centre for Evidence-based Purchasing (CEP), and professional bodies
such as the Royal College of Radiologist (RCR), British Institute of Radiology (BIR),
Society & College of Radiographers (SCoR),and Institute of Physics and Engineering
in Medicine (IPEM).

Purchasing procedures
The Trust Operational Purchasing Procedures Manual provides details of the
procurement process [72].

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63

European Union procurement rules apply to public bodies, including the NHS. The
purpose of these rules is to open up the public procurement market and ensure the
free movement of goods and services within the EU.
In the majority of cases, a competition is required and decisions should be based on
best value.
The EU procurement rules apply to contracts worth more than 90,319, net of VAT
(from 1st January 2008) [73]. Further details of the process are detailed in appendix 2.
Detailed advice and support on procurement is available from local procurement
departments, and from the resources of the NHS PASA website.

The CT purchase process


This section covers the basics of the CT purchase process. A CT purchasing project
requires the interchange of a large amount of information. In most cases, local
purchasing procedures will exist. The local procurement officer should always be
consulted to ensure that they are followed.
The sequence of events may vary depending on local circumstances, but that shown
in Figure 24 is typical of such projects, these stages of the purchasing process are
also shown in figure 25 and expanded on in the text.
Figure 24. Schematic diagram of information flow during purchasing process
Medical director

Capital
Equipment
Board

Finance
Estates
Medical physics
1. Request

2. Award of
money

Radiologists
Radiographers
Radiology business
manager
Medical physics

Purchasing
Decision
Committee

CEP08007: March 2009

Supplies

Trust supplies officer, or


Collaborative
procurement hub, or

nd
al a
c
i
NHS Supply Chain
n
io n
cli
al, cificat
n
o
ti
e
era al sp
Op
ic
3. techn
lies
4. OJEU advert,
rep
r
6. Formal
e
Operational
d
n
tender
l te )
specification
a
orm ces
replies &
7. F (& pri
prices

5. Informal communication
Site visits

CT scanner
vendors

Purchasing

64

Figure 25. Schematic diagram of the stages in the purchase process of a CT scanner

INITIAL TEAM:
BUSINESS CASE

PROCUREMENT ROUTE OPTIONS

DECISION ON
PROCUREMENT ROUTE;
AWARD OF FINANCE

SCANNER SPECIFICATION:
CLINICAL, TECHNICAL &
OPERATIONAL

NHS SUPPLY CHAIN


PROCESS

OJEU ADVERT:
INVITATIONS TO

EQUIPMENT
EVALUATION
PROCESS, SITE VISITS

EQUIPMENT
EVALUATION
PROCESS, SITE VISITS

DECISION PROCESS

RETURN & REVIEW


OF TENDERS

AWARD OF
CONTRACT

AWARD OF
CONTRACT

CEP08007: March 2009

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65

Preparing a business case


A business case must be approved before any procurement exercise is initiated.
Further guidance on preparing business cases is available from the Office of
Government Commerce [75] and RCR [76]. Illustrative examples are available on the
NHS PASA web site [77]. Brief guidance is provided in appendix 4.
The full business case should identify the current and future clinical practices that will
be supported by the CT scanner purchase, and in this it is valuable to have the direct
support of clinicians whose clinical services use CT. Involvement at a high clinical
and operational management level is advised, as this project will have a large capital
investment and will affect a wide variety of the services operated by the trust.
Procurement route options
There are a number of different ways in which a CT scanner service within a trust
can be provided. These are largely dependent on financial and strategic
considerations at a trust level, or higher. In each case, the provision of the service
can be organised by the trust directly, or in partnership with a commercial supplier.
They include:
purchased CT scanner
leased CT scanner
managed equipment service.
If the decision is to purchase or lease the scanner, there are a number of different
routes that may be taken. These are through:

the trusts procurement department


collaborative procurement hubs (where applicable)
DH initiatives (eg the recent capital investment programme for CT scanners)
NHS Supply Chain.

NHS Supply Chain [78] manages a framework agreement to facilitate the ordering of
diagnostic imaging systems, which removes the requirement for individual trusts to
undertake a tendering exercise. This framework is non-mandatory and organisations
retain the option of using local purchasing arrangements.
National frameworks from NHS PASA are in place for operating leases to help the
NHS procure those more cost effectively (see appendix 2).
Decision of procurement route, award of finance
The business case will be submitted to the trust capital equipment board (or
equivalent), or other processes followed depending on the mode of procurement.

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Once the procurement route and finance available has been decided and agreed, the
planning of the project can commence.
Project planning
Any purchase of this nature will require a team to be set up to manage the various
aspects of the procurement project. For a CT scanner purchase, the team will
typically consist of:

radiology services manager


radiologists
radiographers / operators
procurement specialist
medical physics and / or radiation protection department
estates and works.

The purchase may be a turnkey project, whereby the scanner supplier also supplies
the required building work, or an equipment only purchase. However, regardless of
the type of project, the team will require the services of a project manager, usually a
member of the estates department, to manage the overall installation of the
equipment. The team will also need to co-opt other members with specialist
knowledge, such as IT for the networking elements, a radiation protection advisor,
and patient safety / infection control staff. The team will set the specification for the
scanner, attend site visits and evaluate tenders. Not all members will be required for
all activities.
Timescales
A CT procurement exercise can take up to 12 months to complete. This needs to be
taken into account in the planning stages. The length of the exercise depends on the
chosen route and associated procedures. Further information on this is available
from the Department of Health [79].
It is common for CT scanner tenders to be placed in the latter months of the financial
year, causing a bottleneck for manufacturers. Every effort should be made to avoid
the busy period; liaison with sales representatives will help to manage this.
Scanner specification `
Once the clinical services have been identified in the business case, then the
operational requirements of the system can be specified. The statement of
operational requirements can be in the form of an output based specification (OBS),
possibly backed up with a technical specification, or as a detailed statement of need
(DSoN).

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The manufacturers will provide their tender responses based on the information
supplied in this document, which should identify what the users want to achieve. This
will allow fair and open competition between suppliers. Requests for features which
are supplier-specific are not permitted. Very specific technical parameters which
cannot be supported by operational requirements should not be included.
An approach to drawing up the operational requirements is provided in appendix 5
together with an example statement of operational requirements.
The use of standard specification questionnaires, such as that provided by ImPACT
[80], for technical aspects of the scanner is strongly encouraged. Scanner companies
have prepared responses in a standard format that allows comparison between
suppliers. This practice was originally established as part of the Capital Investment
Programme (CIP) [81], but since then, manufacturers have reported wide variations in
the questionnaires used, which has hindered swift response on their part. If
necessary, additional site-specific questions may be appended to the questionnaire.
The replies to this questionnaire can be used by technical specialists to confirm
claims made by the manufacturers about equipment performance. They may also be
used as a basis for acceptance testing. Standard core specifications, with options,
are offered by NHS Supply chain for all available CT systems.
For the purpose of scanner evaluation, a performance specification should be
derived from local operational requirements and agreed by the procurement team or
selection panel. This will form the basis for assessing the adequacy of technical
specifications provided in the tender replies and responses to the technical
specification questionnaire. Purchasers can refer to the summary specification tables
in the Market review chapter in this buyers guide. Full tables can be found in the
appropriate Comparative Specification report [84]-[89]. Also available are qualified
evaluations (eg [90]), the ImPACT online specification comparison tool CTSpec [91],
or information available from organisations such as ECRI [90] or Sg2 [93].
Identifying potential suppliers
Although there are currently only four UK suppliers of CT full body scanners, a prequalification questionnaire may be employed as an initial screen to exclude
unsuitable suppliers. In most cases, the standard NHS PASA pre-purchase
questionnaire (PPQ) [82] is sufficient to ensure that all scanners meet current
regulatory requirements.
Associated purchases
As well as the main CT scanner system and its accessories, the procurement project
should address other related purchase needs. Ensuring that as many elements as
possible are included in the initial tender can minimise issues arising later, and may
reduce costs.

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Elements that should be considered for inclusion in the tender are:

service and maintenance


training
application specialist support
spare parts including replacement tubes
fixed consumable costs
planned upgrades
service continuity during installation
building works including additional shielding
network infrastructure upgrade
data storage
data conversion.

If these are not included in a single tender, then they should be managed as closely
as the main scanner purchase, as failure to procure proper services or accessories
will delay the start of clinical use of the scanner.
Procurement process
This stage will either be an engagement with the NHS Supply Chain to access the
NHS framework agreement, or issuing an invitation to tender through the Europe
tendering process by the placement of an advert in the Official Journal of the
European Union (OJEU).
Equipment evaluation
The main sources of information that should be used to evaluate the equipment are
the tender responses and site visits. Additionally, information on specific questions
may be obtained informally from the manufacturer, other users, and professional
bodies and support agencies such as RCR, BIR, IPEM and SCoR.
Site visits
Site visits may be arranged, even during the period that the invitation to tender is
issued, under the formal approval of the procurement department. Site visits should
be co-ordinated by the procurement team, making sure that all interested parties get
a chance to visit the site. This should include clinical and technical specialists;
appendix 6 suggests those who should be included on a site visit. The manufacturer
usually has designated sites for visits, but as far as possible the site visited should
have a similar service profile to the one being set up.
A check list of questions to be addressed should be drawn up to maximise the value
of the site visits, and ensure that the same aspects of each manufacturers
equipment are reviewed. Notes should be kept, and summarised briefly in writing and
circulated for agreement immediately after the visit.
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69

At the site visits, it is important to look at ergonomic aspects of the systems. These
can include:
ergonomically designed controls to allow the operator to position the system
rapidly and safely with few actions and the minimum of effort (power driven
or power assisted movements)
system designed for use by both left and right handed staff
variable height couch to facilitate patient transfer. This is particularly
important for patients with limited mobility
access to the patient from both sides of the couch is of particular importance
for safe transfer of patients from beds/trolleys to the table
an awareness of the weight, dimensions, handling and likely use of
accessories
clearly marked controls in accordance with recognised standards and
regulations (such as IEC documents).
The site visit is also a chance to get feedback from local users, but any positive or
negative comments should always be backed up by evidence. For example, if a user
says that the system is slow, a practical demonstration of this slowness should be
sought. The local users comments will also reflect their experience and skill, and that
of their staff, and so need to be carefully weighted.
More practical advice on conducting a site visit can be found in appendix 6.
Tender evaluation and decision making process
When purchasing through the European Union procurement process, a list of
evaluation criteria, with agreed weightings, will have been sent to all potential
suppliers together with the invitation to tender. After return of tenders, some scanners
may be eliminated from consideration due to non-conformance with the operational
specification, or due to installation or integration issues. The remaining scanners
need to be scored according to the agreed criteria. An example scoring sheet is
included in appendix 7, adapted from one provided by NHS PASA in the capital
investment programme for CT scanners.
The evaluation process needs to be fully documented, with a summary made of the
evaluation meeting discussions. Local systems should be followed where
appropriate.
The different options for purchasing through a national framework agreement with
NHS Supply Chain involve different levels of decision making processes.

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Award of contract
The award of the contract will be handled by the procurement department, or their
agents. For the European Union purchasing process, complete records of the
process, including site visit notes and evaluation scoring must be collated and made
available on request to those companies that were not awarded the contract.
For more information on procurement please refer to the Department of Health
Website. [83].
Project closedown
At the end of the project, a closedown meeting should be held with all members of
the team. All issues that arose during the project, and their resolution, should be
documented. Successful risk mitigations should also be identified. Unresolved issues
should be highlighted and discussed. Outstanding issues should be formally handed
over to another responsible body in the hospital for resolution, where necessary. A
lessons learned document should be produced, and useful elements passed on to
the relevant parties for inclusion in local procedures and future capital purchase
projects.

Sustainable procurement
The UK Government launched its current strategy for sustainable development,
Securing the Future in March 2005 [74]. The strategy describes four priorities to
progress sustainable development:
sustainable production and consumption working towards achieving more
with less
natural resource protection and environmental enhancement protecting the
natural resources and habitats upon which we depend
sustainable communities creating places where people want to live and
work, now and in the future
climate change and energy confronting a significant global threat.
The strategy also highlights the key role of public procurement in delivering
sustainability.
The following sections identify relevant sustainability issues and provide some
guidance on how these can be incorporated into the CT procurement decision
making processes (see also appendix 3).

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Energy
The key sustainability issue relating to CT scanners is the energy consumption.
Scanners use high voltages and currents, and hence can be heavy instantaneous
power users. The impact of this on the energy requirements of the department should
be considered based on a reasonable expected workload (see appendix 3).
Additional power consumption due to air conditioning etc should also be considered.
With accessories and other related equipment, there may be the chance to focus on
any power saving technologies, such as the use of LCD monitors on workstations
and consoles, and LED panel indicators.
Wastes and toxic hazards
There should be minimal waste products from the scanners themselves. Some
scanners use carbon contact brushes on their slip ring power systems. The dust from
these rarely causes a problem, but regular cleaning may be required. Other waste
includes bedding and contrast agents.
X-ray tubes are shielded with lead compounds. These should not produce any
hazard in a well maintained system. There should be no other toxic material hazards
of note present in the system. Manufacturers can be invited to declare any such
hazards in a pre-purchase questionnaire.
There may be toxic materials in place in existing building fabrics and scanner suites.
Local estates departments should check for such materials before installation and
building works commence.
End-of-life disposal
Consideration should be given to the likely financial and environmental costs of
disposal at the end of the products life. Where appropriate, suppliers of equipment
placed on the market after the 13th August 2005 should be able to demonstrate
compliance with the UK Waste Electrical and Electronic Equipment (WEEE)
Regulations 2006 [67]. The WEEE regulations place responsibility for financing the
cost of collection and disposal on the producer [27]. Electrical and electronic
equipment is exempt from the WEEE regulations where it is deemed to be
contaminated at the point at which the equipment is scheduled for disposal by the
final user. However, if it is subsequently decontaminated, such that it no longer poses
an infection risk, it is again covered by the WEEE regulations, and there may be
potential to dispose of the unit through the normal WEEE recovery channels.
Most CT scanner manufacturers will offer the option to defer cost of disposal, as this
is assumed to decrease over the many years of the scanners working life. Removal
of any existing scanner, and clearance of the scanner suite, should be considered for
inclusion in the tender.

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This chapter contains a review of the technical capabilities of MSCT scanners which
can acquire 16 slices or more in a single rotation and which are currently being
marketed in the UK.
At the time of writing, there are four manufacturers in scope: GE Healthcare, Philips
Medical Systems, Siemens Medical Solutions and Toshiba Medical Systems. The
scanners covered in this report have been divided into the following categories:

16 slice scanners
32 to 40 slice scanners
64 slice scanners
wide bore scanners
128 to 320 slice scanners.

These categories refer to data slices acquired in near real time. Some scanners will
only achieve these in certain modes. In particular, some of the greater slice numbers
may only be for thin slice acquisition, in helical mode.
16 slice CT scanners are currently regarded as good general purpose scanners.
They are adequate for most applications, with the exception of some specialist
studies, such as cardiac and functional imaging.
32 to 40 slice scanners generally provide a longer coverage per gantry rotation than
16 slice scanners and so result in shorter examination times, with reduced likelihood
of motion artefacts.
64 slice scanners provide an added degree of flexibility and are currently the most
commonly purchased type of scanner in the UK. They are particularly recommended
if cardiac studies are to be performed in a general CT department.
Scanners with the capability of acquiring more than 64 slices per rotation are now
available. These are specialist systems, currently particularly focussed towards
cardiac examinations, but also have applications in perfusion and other functional
studies. The number of slices needs to be considered in conjunction with the length
of coverage. A greater number of slices may mean longer coverage, or may mean
overlapping acquisition data slices due to the dynamic focal spot.
Wide bore scanners have a bigger gantry aperture and maximum reconstruction field
of view than conventional scanners. The number of slices offered is dependent on
the manufacturer. They are generally purchased for radiotherapy planning, as they
allow greater flexibility for positioning the patient in the treatment position, but they
may also be considered for other applications where the increased aperture and field

CEP08007: March 2009

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73

of view are beneficial. These may include imaging bariatric, trauma and intensive
care patients.
CT scanners are supplied with a couch, a control console, a reconstruction computer
and a certain amount of post-processing software. Further specialist post-processing
software can be supplied as an option. For more complex processing a dedicated
workstation is often purchased.
Table 9. Multi-slice CT scanners covered in this guide
Category

GE

Philips
Brilliance

Siemens
Somatom

16 slice

BrightSpeed Elite

CT 16

Emotion 16

Activion 16
Aquilion 16

32 to
40 slice

LightSpeed Select

Not
applicable

Sensation 40
Definition 40

Aquilion 32

64 slice

LightSpeed VCT
LightSpeed VCT XT

CT 64

Sensation 64
Definition AS
Definition (dual source)

Aquilion 64

Wide bore

LightSpeed RT
LightSpeed Xtra

CT Big Bore

Sensation Open 24
Sensation Open 40

Aquilion LB

> 64 slice

Not applicable

iCT

Definition AS+

Aquilion ONE

Toshiba

The scanners available in each category are discussed below and the summary
specifications provided in tables at the end of this chapter. The full specifications of
the scanners are contained in comparative specification reports [85] - [88]. In addition
there is a separate report which contains information on the range of applications
software packages available from each manufacturer [84].
As a widely accepted classification, scanner models were originally categorised
according to number of image slices that could be reconstructed in one rotation. The
number of parallel axial reconstructions from conventional back projection
reconstruction methods, are limited to a maximum of about 12, however the number
of data channels in helical acquisition are not limited. Therefore number of slices
came to mean the number of data channels, or data slices acquired. This has now
expanded to accommodate scanners which use the dynamic focal spot in the zdirection to effectively double the number of data slices in real time.
One of the primary differentiating factors between the various categories of scanner,
and indeed between scanners in each category, is the number of detector banks and
the dimensions of the detectors along the scan axis (z-axis). Figure 26 shows a
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schematic example of a multi-slice CT scanner detector array, and Table 10 gives


the specific configuration designs for all the scanners covered in this chapter.
Figure 26. Schematic diagram of a CT detector array with multiple detector banks along z-axis
(not to scale)
X-ray tube

Detector array
x-axis
Sub-mm detectors (S)
Full extent of detector matrix (F)

R rows (z-axis)

There is a tendency for a marketing slice wars among manufacturers, making it


more difficult to uniquely classify scanners. When considering which category of
scanner for purchase, it is important to remember that it is not only the number of
data slices acquired, but also the length of coverage in one rotation, that are
important factors for consideration.
Other major features to note, in terms of technical specifications are: the gantry
aperture; generator power; anode heat capacity and cooling rate; and gantry rotation
speed. Manufacturers performance data are often obtained using different
methodologies, making direct comparisons unreliable. Image quality is therefore best
assessed independently, using a standardised approach. In addition, the computer
power of the system will impact on performance. Image reconstruction rates provided
give an indication of reconstruction speed, but for a full representation of
reconstruction performance in a clinical context, it is best to assess it independently
or on a site visit. For further explanations of the technical features please refer to the
Technical considerations chapter.
The user-friendliness of the systems is an important feature, but is a very subjective
element and should also be evaluated during the site visit.
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Table 10. Scanner z-axis detector array configurations

Scanner

Full coverage (F)

Max sub-mm coverage (S)

Max
number of
data
slices

No. of
detector
rows (R)

16
16
16
16
16

24
24
24
28
40

16 x 1 ( 4 x 5 )
16 x 2.0

16 ( 20 )
32

64
40
40
32

64
40
20
64

32 x 1.25
24 x 1.2

20 x 0.6
32 x 1.0

40
28.8
12
32

32 x 0.625

20 x 0.6

20 x 0.6
32 x 0.5

20
12
12
16

64
64
64
64
64
64
64

64
64
64
40
32
40
64

64 x 0.625
64 x 0.625
64 x 0.625
24 x 1.2
32 x 0.6
24 x 1.2
64 x 0.5

40
40
40
28.8
19.2
28.8
32

64 x 0.625
64 x 0.625
64 x 0.625

32 x 0.6
32 x 0.6

32 x 0.6
64 x 0.5

40
40
40
19.2
19.2
19.2
32

128
128
320

128
64
320

128 x 0.625
64 x 0.6
320 x 0.5

80
40
160

128 x 0.625
64 x 0.6
320 x 0.5

80
40
160

16
16
16
24
40
16

24
24
24
40
40
40

16 x 1.25
16 x 1.25
16 x 1.5
24 x 1.2
24 x 1.2
16 x 2.0

20
20
24
28.8
28.8
32

16 x 0.625
16 x 0.625
16 x 0.75
20 x 0.6

20 x 0.6
16 x 0.5

10
10
12
12
12
8

No. channels x
detector size
(mm)

Z-axis
Coverage
(mm)

No. channels x
detector size
(mm)

Z-axis
Coverage
(mm)

16 x 1.25
16 x 1.5
16 x 1.2

20
24
19.2

16 x 0.625
16 x 0.75
16 x 0.6
16 x 0.5
16 x 0.5

10
12
9.6
8
8

16 slice

GE BrightSpeed Elite
Philips Brilliance 16
Siemens Emotion 16
Toshiba Activion 16
Toshiba Aquilion 16

32 to 40 slice

GE LightSpeed VCT Select


Siemens Sensation 40
Siemens Definition AS 40
Toshiba Aquilion 32
64 slice

GE LightSpeed VCT
GE LightSpeed VCT-XT
Philips Brilliance 64
Siemens Sensation 64

Siemens Definition AS 64

Siemens Definition DS
Toshiba Aquilion 64
128 to 320 slice
**

Philips Brilliance iCT

Siemens Definition AS+

Toshiba Aquilion ONE


Wide bore

GE LightSpeed RT 16
GE LightSpeed Xtra
Philips Brilliance Big Bore
Siemens Sensation Open 24
Siemens Sensation Open 40
Toshiba Aquilion Large Bore

Notes: * Used in brain perfusion scans; Detectors 'double-sampled' with flying focal spot to give 40 (20x2) data acquisition

channels (helical scans); Detectors 'double-sampled' with flying focal spot to give 64 (32 x 2) data acquisition channels

**
(helical scans); Dual source. Two X-ray tubes mounted at 90degrees to one another; Detectors 'double-sampled' with

flying focal spot to give 256 (128 x2) data acquisition channels (helical scans); Detectors 'double-sampled' with flying focal

spot to give 128 (64 x 2) data acquisition channels (helical scans); Toshiba allow reconstruction of 640 x 0.5 mm
overlapping axial slices from the acquired volume

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16 slice CT scanners
Table 11. 16 slice scanners
Manufacturer

Scanner model

GE

BrightSpeed Elite

Philips

Brilliance CT 16

Siemens

Somatom Emotion 16

Toshiba

Activion 16

Toshiba

Aquilion 16

The summary technical specifications of 16 slice scanners, listed in Table 11, can be
found in Table 16 and a full specification is published in the CEP comparative
specification report on 16 slice CT scanners [84]. The z-axis detector array
configurations are shown in figure 27.
GE, Philips and Siemens each market one scanner in this category, whereas
Toshiba offer a lower and higher budget scanner. Toshibas lower budget scanner,
the Activion 16 has a shorter z-axis coverage than the Aquilion 16, a slower
maximum rotation speed, and a less powerful generator and X-ray tube. It does
however have the advantages of lower cost and a smaller footprint. Although the
Activion 16 routinely acquires data over a z-axis length of 16 mm, the actual extent of
its detector array is 20 mm, allowing it to acquire 4 x 5 mm slices in brain perfusion
scans.
Most of the scanners in this category have full automatic tube current modulation
functionality (see Technical considerations), with the exception of the Activion 16,
which only has longitudinal (z-axis) tube current modulation. The Brilliance 16 cannot
currently perform longitudinal and angular tube current modulation simultaneously.

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Figure 27. 16 slice CT scanner z-axis detector bank configurations


GE BrightSpeed Elite
4 x 1.25 mm

16 x 0.625 mm

4 x 1.25 mm

16 data channels:
20 mm coverage, 1.25 mm
10 mm coverage, 0.625 mm

Philips Brilliance CT 16
4 x 1.5 mm

16 x 0.75 mm

4 x 1.5 mm

16 data channels:
24 mm coverage, 1.5 mm
12 mm coverage, 0.75 mm

Siemens Somatom Emotion 16


4 x 1.2 mm

16 x 0.6 mm

4 x 1.2 mm

16 data channels:
19.2 mm coverage, 1.2 mm
9.6 mm coverage, 0.6 mm

Toshiba Activion 16
6 x 1 mm

16 x 0. 5 mm

6 x 1 mm

16 data channels:
16 mm coverage, 1 mm
(20 mm coverage, 4 x 5 mm)
8 mm coverage, 0.5 mm

Toshiba Aquilion 16
12 x 1 mm

16 x 0. 5 mm

12 x 1 mm

z-axis

CEP08007: March 2009

16 data channels:
32 mm coverage, 2 mm
16 mm coverage, 1 mm
8 mm coverage, 0.5 mm

Market review

78

32 to 40 slice CT scanners
Table 12. 32 to 40 slice CT scanners
Manufacturer

Scanner model

GE

LightSpeed VCT Select

Siemens

Somatom Sensation 40

Siemens

Somatom Definition AS 40

Toshiba

Aquilion 32

The summary specifications of 32 to 40 slice scanners, listed in Table 12, can be


found in Table 17 and a full specification is published in the comparative specification
report on 32 to 40 slice scanners [86]. The z-axis detector array configurations are
shown in Figure 28.
The GE and Toshiba scanners have the same detector array configurations as their
64 slice counterparts, but their data acquisition systems limit them to acquiring fewer
data channels per rotation. An upgrade to a 64 slice system is available on both
scanners.
The Siemens Sensation 40 scanner utilises only the central 20 of its 32 submillimetre detector banks for sub-millimetre data acquisition. These 20 detector
banks are double-sampled with a z-axis flying focal spot, z-sharp, to acquire 40 data
slices per rotation. The Siemens Definition AS 40 has a significantly shorter
coverage per rotation than the Sensation 40, but has a wider gantry aperture, a faster
rotation speed, a more powerful generator and a higher anode cooling rate.
Furthermore it has a faster image reconstruction rate, a higher data transmission
rate, higher table load limit and a larger hard disc for image data storage. It is also
equipped with the adaptive dose shield, a dynamic collimator for dose reduction in
helical scanning.
Philips no longer markets a scanner in this category.
All the scanners in this category have full automatic tube current modulation
functionality.

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Figure 28. 32 to 40 slice CT scanner z-axis detector bank configuration


GE LightSpeed VCT Select

32 data channels:
40 mm coverage, 1.25 mm
20 mm coverage, 0.625 mm

64 x 0.625 mm

Siemens Somatom Sensation 40


4 x 1.2 mm

4 x 1.2 mm

32 x 0.6 mm

24 data channels:
28.8 mm coverage,1.2 mm
40 data channels* :
12 mm coverage, 0.6 mm

Siemens Somatom Definition AS 40


40 data channels* :12 mm coverage, 0.6 mm

20 x 0.6 mm

* 20 detector banks, double -sampled

Toshiba Aquilion 32
64 x 0.5 mm

32 data channels:
32 mm coverage, 1 mm
16 mm coverage, 0.5 mm
z-axis

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64 slice CT scanners
Table 13. 64 slice CT scanners
Manufacturer

Scanner model

GE

LightSpeed VCT

GE

LightSpeed VCT XT

Philips

Brilliance CT 64

Siemens

Somatom Sensation 64

Siemens

Somatom Definition AS 64

Siemens

Somatom Definition

Toshiba

Aquilion 64

The summary specifications of the 64 slice scanners, listed in Table 13, can be found
in Table 18, and a full specification is published in the comparative specification
report on 64 slice CT scanners [87]. The z-axis detector array configurations are
shown in Figure 29.
64 slice scanners are extremely flexible and, with the exception of two of the three
Siemens systems in this category, the full length of the detector array can be used to
acquire sub-millimetre slices.
GE markets two scanners in this category. The LightSpeed VCT XT is the higher
specification scanner. The VCT XT is supplied with the 0.35 second rotation time and
the VolumeShuttleTM mode as standard. VolumeShuttleTM mode is designed for
perfusion scanning; two adjacent 40 mm bands are repeatedly imaged in quick
succession, by rapidly alternating the couch position, resulting in an 80 mm long
imaged volume. The GE systems can be purchased with an optional 100kW
generator providing a higher maximum tube current.
The Philips Brilliance 64 has a detector array with the same configuration as that on
the GE scanner. Perfusion scanning over an 80 mm long volume can be performed
with its Jog scan mode.
Siemens markets three scanners in this category. The Siemens Sensation 64 and
Definition AS 64 are both single X-ray tube systems. The Definition AS 64 has a
shorter total z-axis coverage than the Sensation 64. The Siemens Definition, is a dual

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81

X-ray tube system and will be discussed further in the category covering cardiac CT
scanners.
The Siemens Definition range of scanners is characterised by the new-style gantry
with a wider aperture than the Sensation series. The Definition AS 64 is also
equipped with the adaptive dose shield, a dynamic collimator for dose reduction in
helical scanning. The length of coverage for dynamic studies, such as organ
perfusion, can be increased using a helical shuttle mode, referred to as Adaptive 4D
Spiral.
Most of the scanners in this category have full automatic tube current modulation
functionality, with the exception of the Philips scanner, which cannot currently
perform longitudinal and angular tube current modulation simultaneously.
Figure 29. 64 slice CT scanner z-axis detector bank configurations
GE LightSpeed VCT, LightSpeed VCT-XT, Philips Brilliance 64
64 x 0.625 mm

64 data channels:
40 mm coverage, 0.625 mm

Siemens Somatom Sensation 64 & Somatom Definition


4 x 1.2 mm

32 x 0.6 mm

4 x 1.2 mm

40 data channels:
28.8 mm coverage, 1.2 mm
64 data channels*:
19.2 mm coverage, 0.6 mm

Siemens Somatom Definition AS 64


32 x 0.6 mm

64 data channels*:
19.2 mm coverage, 0.6 mm
* 32 detector banks double sampled

Toshiba Aquilion 32 & Aquilion 64


64 x 0.5 mm

64 data channels:
32 mm coverage, 0.5 mm

z-axis

64 slice cardiac CT scanners


A 64 slice scanner is recommended as a minimum for cardiac examinations.
Manufacturers usually have products packaged and marketed as cardiac scanners.
These may offer faster rotation times, ECG equipment and cardiac acquisition and
reconstruction software as standard.
GE market the LightSpeed VCT XT as their specialist cardiac scanner. It is supplied
with a 0.35 second rotation time. Its advantage over the LightSpeed VCT is that it
can perform prospectively triggered coronary CT angiography (CCTA) scans in
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Snapshot Pulse mode. This results in significantly lower doses than retrospectively
gated CCTA. GE have also recently a new 64 slice system with a new detector
material, dual energy capabilities and new reconstruction approach. No details were
available at the time of preparation of this report.
Figure 30. Siemens Somatom Definition dual X-ray source CT scanner

Tube B

Tube A

The Siemens Somatom Definition (Figure 30) is the only dual X-ray tube scanner
currently available. The two tubes are mounted at an angle of 90 to each other.
Tube A has the full 50 cm field of view (FOV) whereas tube Bs FOV is only 26 cm.
The Definition has particular advantages in cardiac scanning, despite its relatively
short z-axis coverage of 19.2 mm with sub-millimetre slices. Scanning with the two
tubes leads to an improvement in the temporal resolution by a factor of two, as
compared with a single slice system with the same gantry rotation speed. Because of
the high temporal resolution, patients with increased heart rates can be scanned
without the administration of beta blocking agents. These patients can also be
scanned at higher pitches than on single source systems, resulting in reduced doses.
The scanner is capable of dual energy scanning by operating the two tubes at
different kilovoltages. It has the most well developed dual energy application software
currently on the market. The Definition is also marketed as having advantages when
scanning bariatric patients, as the use of the two tubes concurrently can supply
double the power of a single source system.
Siemens also markets the Somatom Sensation 64 and Somaton Definition AS as
cardiac scanners, with fastest rotation times of 0.33 s and 0.3 s respectively.
The Brilliance CT 64 with a 0.4 sec rotation time is the Philips 64 slice cardiac
scanner. The scanner can perform prospectively triggered cardiac scans in its Step
and Shoot mode for dose reduction.

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The Toshiba Aquilion 64 cardiac scanner has optional rotation times of 0.35 s, 0.375
s, 0.4 s and 0.45 s available, in addition to the rotation times on their non-cardiac
64 slice system.
Most of the scanners in this category have full automatic tube current modulation
functionality, with the exception of the Philips scanner, which cannot currently
perform longitudinal and angular tube current modulation simultaneously. All the
manufacturers have ECG-gated tube current modulation for dose reduction in cardiac
studies. On the Siemens Definition range of scanners, the tube current can be
reduced to 96% of its peak value, compared to 80% on all the other systems.

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Wide bore CT scanners


Table 14. Wide bore CT scanners
Manufacturer

Scanner model

GE

LightSpeed RT

GE

LightSpeed Xtra

Philips

Brilliance CT Big Bore

Siemens

Somatom Sensation Open 24

Siemens

Somatom Sensation Open 40

Toshiba

Aquilion LB

The summary specifications of wide bore scanners, listed in Table 14, can be found
in Table 19 and a full specification in the comparative specification report on wide
bore CT scanners [88]. The z-axis detector array configurations are shown in
Figure 31.
Current wide-bore CT scanners acquire between 16 and 40 slices per rotation,
depending on the model. Most specifications are similar to those of their standard
counterparts. The main difference is a wider gantry aperture and increased
reconstruction field of view. Gantry aperture diameters are between 80 and 90 cm,
and the maximum reconstruction fields of view, between 65 and 85 cm.
Philips and Toshiba market one scanner each in this category, whereas GE and
Siemens have two models each. The GE LightSpeed RT is marketed as a
radiotherapy planning scanner, whereas the LightSpeed Xtra for trauma and bariatric
patients. The Xtra has a bigger generator and a 0.5 s fastest gantry rotation time. On
the RT the 0.625 mm slice width is an option, and the fastest rotation time is 0.8s.
The main difference between the Sensation Open 24 and 40 is that the Open 40 has
the z-sharp technology, enabling double-sampling of the central 20 detectors,
resulting in 40 acquired data slices per rotation.
Most of the scanners in this category have full automatic tube current modulation
functionality, with the exception of the Philips scanner, which cannot currently
perform longitudinal and angular tube current modulation simultaneously.

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Figure 31. Wide bore CT scanner detector configuration


GE LightSpeed RT and LightSpeed Xtra
4 x 1.25 mm

16 x 0.625 mm

4 x 1.25 mm

16 data channels:
20 mm coverage, 1.25 mm
10 mm coverage, 0.625 mm

Philips Brilliance CT Big Bore


4 x 1.5 mm

16 x 0.75 mm

4 x 1.5 mm

Siemens Somatom Sensation Open 24 and 40


4 x 1.2 mm

32 x 0.6 mm

4 x 1.2 mm

16 data channels:
24 mm coverage, 1.5 mm
12 mm coverage, 0.75 mm
Open 24
24 data channels:
28.8 mm coverage,1.2 mm
20 data channels :
12 mm coverage, 0.6 mm
Open 40
24 data channels:
28.8 mm coverage,1.2 mm
40 data channels* :

Toshiba Aquilion LB
12 x 1 mm

16 x 0. 5 mm

12 x 1 mm
16 data channels:
32 mm coverage, 2 mm
16 mm coverage, 1 mm
8 mm coverage, 0.5 mm

z-axis

CEP08007: March 2009

* 20 detector banks double sampled

Market review

86

Greater than 64 slice CT scanners


Table 15. Greater than 64 slice scanners
Manufacturer

Scanner model

IGE

750 HD

Philips

Brilliance iCT

Siemens

Definition AS+

Toshiba

Aquilion ONE

A few scanners capable of acquiring more than 64 data slices per rotation have
recently been introduced. These can be considered specialist scanners. These are
listed in Table 15. The summary specifications of these scanners can be found in
Table 20 and a full specification in the comparative specification report on 128 to 320
slice scanners [89]. The z-axis detector array configurations are shown in Figure 32.
The Philips Brilliance iCT was launched at RSNA 2007 and is likely to be
commercially available in 2009. The scanner has a coverage of 80 mm, with a
detector array consisting of 128 x 0.625 mm detector elements along the z-axis. It
employs a z-axis flying focal spot, which doubles the number of channels acquired in
a single rotation, thereby making it a 256 slice scanner. It has a new design of X-ray
tube for improved stability of focal spot and a two layered detector for dual energy
scanning. It also has a maximum gantry rotation speed of 0.27 s, the fastest on the
market.
The Siemens Definition AS+ has a maximum z-axis coverage of 38.4 mm with 64 x
0.6 mm detectors. It employs a z-axis flying focal spot, and so acquires 128 data
channels from the 64 detector banks, making it into a 128 slice scanner. The
scanner has a maximum gantry rotation speed of 0.3 s and utilises the adaptive
dose shield to reduce doses in helical scanning.
The Toshiba Aquilion ONE, has a z-axis coverage of 160 mm, with 320 x 0.5 mm
detector elements. It can reconstruct 640 slices from a single axial rotation, and could
perhaps be termed a 640 slice scanner. The 160 mm detector array length enables
the coverage of whole organs such as the heart, liver and brain in a single gantry
rotation. The scanner has particular applications in cardiology and functional studies
such as brain and liver perfusion.

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Figure 32. CT scanners with 128 to 320 data slices: z-axis detector bank configurations

Philips Brilliance iCT

128 x 0.625 mm
256 data channels*:
80 mm coverage, 0.625 mm
* 128 detector banks double-sampled

Siemens Somatom Definition AS+

64 x 0.6 mm

128 data channels**:


38.4 mm coverage, 0.6
** 64 detector banks double-sampled

Toshiba Aquilion

320 data channels***:


160 mm coverage, 0.5 mm

320 x 0.5 mm

*** capable of 640 slices from one axial acquisiiton

z-axis

CEP08007: March 2009

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88

Summary specifications
Tables 16 - 20 summarise the technical and application specification data collected from the manufacturers. Some key factors are
given to allow a basic comparison between scanner models. The scanners are presented in categories as described previously. Full
technical and application specifications are available separately [84]-[89].
Table 16: Summary specifications of 16 slice CT scanners
GE BrightSpeed
Elite

Philips Brilliance
CT 16

Siemens Somatom
Emotion 16

Toshiba
Activion 16

Toshiba
Aquilion 16

Scanner type

16 slice
3rd gen

16 slice
3rd gen

16 slice
3rd gen

16 slice
3rd gen

16 slice
3rd gen

Gantry aperture [cm]

70

70

70

72

72

Gantry tilt - Sequential/Helical [degrees]

30 for both

30 sequential

30 for both

30 for both

30 for both

Power rating [kW]

53.2

60

50

42

60

Anode heat capacity [MHU]

6.3

7.5

Maximum anode cooling rate [kHU / min]

840

1608

810

864

1386

Scanner gantry

X-ray generator and tube

CEP08007: March 2009

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GE BrightSpeed
Elite

Philips Brilliance
CT 16

Siemens Somatom
Emotion 16

Toshiba
Activion 16

Toshiba
Aquilion 16

Detector type

Solid state

Solid state array

Solid state array

Solid state array

Solid state array

Detector array configuration (# x width [mm])

32 x 0.625

16 x 0.75
8 x 1.5

16 x 0.6
8 x 1.2

16 x 0.5
12 x 1.0

16 x 0.5
24 x 1.0

Maximum z-axis coverage [mm]

20

24

19.2

20

32

Max z-axis coverage with sub-mm slices [mm]

10

12

9.6

Length & width [cm]

239 x 42

243 x 41

218 x 43

219 (std) or
189 (short) x 47

219 (std) or
189 (short) x 47

Maximum scannable range [cm]

170 (Axial)
160 (Helical)

192

153

175 (std)
145 (short)

175 (std)
145 (short)

Minimum height out of gantry [cm]

51

52

45

31

31

Maximum weight on couch [kg]

205

204

200

205

205

Minimum rotation time in helical mode [s]

0.5

0.5 (0.4 option)

0.6 (0.5 option)

0.75

0.5 (0.4) option

Kilovoltage settings [kV]

80, 100, 120, 140

90, 120, 140

80, 110, 130

80, 100, 120, 135

80, 100, 120, 135

Tube current range at 120/130 kV [mA]

10 - 440

30 - 500

20 - 345

10 - 300

10 - 500

Detection system

Couch

Scan parameters

CEP08007: March 2009

Market review

90

GE BrightSpeed
Elite

Philips Brilliance
CT 16

Siemens Somatom
Emotion 16

Toshiba
Activion 16

Toshiba
Aquilion 16

Reconstruction field of view range [cm]

9.6 - 50

5 - 50 Std & High res


2.5 - 25 Ultra
High res (UHR)

5.0 - 50

5 -50

5 - 50

Reconstruction matrices

512 x 512

512 x 512
(768 x 768 & 1024 x
1024 option)

512 x 512

512 x 512

512 x 512

Recon rate for std head scan, 5122 [images/s]

Up to 6 (up to 16
option)

~6
(~ 15 option)

16

Recon rate for std body scan, 5122 [images/s]

Up to 6 (up to 16
option)

~6
(~ 14 option)

16

Image reconstruction

CEP08007: March 2009

Market review

91

GE BrightSpeed
Elite

Philips Brilliance
CT 16

Siemens Somatom
Emotion 16

Toshiba
Activion 16

Toshiba
Aquilion 16

Tube current modulation (x-y & z)

x-y & z

x-y & z, but not


simultaneously

x-y & z

x-y & z

Adaptive collimators in helical scanning

No

No

No

No

No

Standard total hard disc capacity [GB]

291

392

965

297

450

Ability to burn images to disc

Yes

Option

Yes

Yes

Yes
12
Maximum 50
(enhanced DICOM,
optional)
Yes

Dose reduction features

Data management & connectivity

Rate of image transfer: scanner to workstation


[images/s]

16

Network dependent

up to 25

12
Maximum 50
(enhanced DICOM,
optional)

IHE scheduled workflow supported

Yes

Yes

Yes

Yes

CEP08007: March 2009

Market review

GE BrightSpeed
Elite

Philips Brilliance
CT 16

Siemens Somatom
Emotion 16

Toshiba
Activion 16

Toshiba
Aquilion 16

Scan plane limiting clinical spatial resolution


[mm]

0.324
(15.4 lp/cm @ 0%
MTF)

0.22
(23 lp/cm @ 2%
MTF)

0.32
(15.6 lp/cm @ 2%
MTF)

0.23
(21.4 lp/cm @ 2%
MTF)

0.23
(21.4 lp/cm @ 2%
MTF)

Longitudinal (z-axis) limiting clinical spatial


resolution [mm]

0.35
(14.2 lp/cm @ 4%
MTF)

0.33
(15 lp/cm @ 0% MTF)

0.33
(15 lp/cm @ 2%
MTF)

Info not available

Info not available

Contrast resolution: smallest rod size


discernable [mm @ 0.3% contrast @ x mGy
surface dose in Catphan]

5mm @ 0.3% w/o


any noise
filter,120kV,
13.3mGy, 10mm

5 mm @ 0.3% @ 19
mGy

5 mm @ 0.3% @ 16
mGy

3 mm @ 0.3% @
16.4 mGy

4 mm @ 0.3% @
10.0 mGy; FC41
kernel with 3D
adaptive filter

Do not use for direct dose comparisons*

19.6 @120 kV

12.9 @120 kV

24.4 @ 130 kV

22.7 @ 120 kV

20.5 @ 120 kV

CTDIw for standard body scan [mGy/100mAs]


Do not use for direct dose comparisons*

9.9 @120 kV

6.5 @ 120 kV

7.6 @ 130 kV

10.2 @ 120 kV

12.1 @ 120 kV

3 phase
200-480 V,

90 kVA

3 phase
200 - 500 V
100 kVA

3 phase
380 - 440 V
70 kVA

3 phase
380 - 440 V
75 kVA

3 phase
380 - 440 V
100 kVA

Minimum floor load-bearing [kg/m]

1290

Info not available

428

670

732

Recommended floor area for scanner [m]

3.7 m x 6.1 m

35.7

14 minimum

22 (std couch)
21 (short couch)

27 (std couch)
25 (short couch)

Manufacturer's performance data

CTDIw for standard head scan [mGy/100mAs]

Room requirements

Power requirements (gantry)

* These figures do not reflect the scanners' dose efficiency. A relative patient dose at the stated kV can be calculated using this data in
conjunction with the recommended clinical scan parameters (mAs, pitch)

CEP08007: March 2009

Market review

93

Table 17. Summary specifications of 32 to 40 slice CT scanners


GE LightSpeed VCT
Select

Siemens Somatom
Sensation 40

Siemens Somatom
Definition AS 40

Toshiba Aquilion 32

Scanner type

32 slice
3rd gen

40 slice
3rd gen

40 slice
3rd gen

32 slice
3rd gen

Gantry aperture [cm]

70

70

78

72

Gantry tilt - Sequential/Helical [degrees]

30 sequential

30 sequential

30 sequential

30 for both

Power rating [kW]

100

70

80

60 (72 option)

Anode heat capacity [MHU]

0.6 (equiv to 30)

0.6 (equiv to 30)

7.5

Maximum anode cooling rate [kHU / min]

2100

5000

7300

1386

Detector type

Solid state

Solid state array

Solid state array

Solid state array

Detector array configuration (# x width [mm])

32 x 0.625
16 x 1.25

32 x 0.6
8 x 1.2

20 x 0.6

Maximum z-axis coverage [mm]

40

28.8

12

32

Max z-axis coverage with sub-mm slices [mm]

20

12

12

16

Scanner gantry

X-ray generator and tube

Detection system

CEP08007: March 2009

0.5 x 64

Market review

94

GE LightSpeed VCT
Select

Siemens Somatom
Sensation 40

Siemens Somatom
Definition AS 40

Toshiba Aquilion 32

Length & width [cm]

285 x 42

243 x 40

240 x 45 (std)
240 x 53 (multipurpose)

219 (std) or
189 (short) x 47

Maximum scannable range [cm]

170 med table


200 long table

157

160
(200 option)

175 (std)
145 (short)

Minimum height out of gantry [cm]

43

53

48
(53 multipurpose)

31

Maximum weight on couch [kg]

227

200
(280 option)

220
(300 option)

205

Minimum rotation time in helical mode [s]

0.4
(0.35 option)

0.37

0.33

0.5 (0.35 option)

Kilovoltage settings [kV]

80, 100, 120, 140

80, 100, 120, 140

80, 100, 120, 140

80, 100, 120, 135

Tube current range at 120/130 kV [mA]

10 - 800

28 - 580

20 - 666

10 - 500
(10 - 600 option)

Couch

Scan parameters

CEP08007: March 2009

Market review

95

GE LightSpeed VCT
Select

Siemens Somatom
Sensation 40

Siemens Somatom
Definition AS 40

Toshiba Aquilion 32

Reconstruction field of view range [cm]

9.6 - 50

5 - 50
(70 option)

5 - 50
(78 option)

5 - 50

Reconstruction matrices

512 x 512

512 x 512

512 x 512

512 x 512

Recon rate for std head scan, 5122 [images/s]

up to 6
(16 option)

20

40

16

Recon rate for std body scan, 5122 [images/s]

up to 6
(16 option)

20

40

16

Tube current modulation (x-y & z)

x-y & z

x-y & z

x-y & z

x-y & z

Adaptive collimators in helical scanning

No

No

Yes

No

Standard total hard disc capacity [GB]

584

1022

1241

1245

Ability to burn images to disc

Yes

Yes

Yes

Yes

Rate of image transfer: scanner to workstation


[images/s]

up to 16

up to 25

up to 25

12
Maximum 50 (enhanced
DICOM, optional)

IHE scheduled workflow supported

Yes

Yes

Yes

Yes

Image reconstruction

Dose reduction features

Data management & connectivity

CEP08007: March 2009

Market review

96

GE LightSpeed VCT
Select

Siemens Somatom
Sensation 40

Siemens Somatom
Definition AS 40

Toshiba Aquilion 32

Scan plane limiting clinical spatial resolution [mm]

0.35
(14.2 lp/cm @ 4% MTF)

0.21
(23.7 lp/cm @ 2% MTF)

0.21
(24 lp/cm @ 2% MTF)

0.23
(21.4 lp/cm @ 2% MTF)

Longitudinal (z-axis) limiting clinical spatial


resolution [mm]

0.35
(14.2 lp/cm @ 4% MTF)

0.24
(21 lp/cm @ 2% MTF)

0.24
(21 lp/cm @ 2% MTF)

Info. not available

Contrast resolution: smallest rod size discernable


[mm @ 0.3% contrast @ x mGy surface dose in
Catphan]

3 mm @ 0.3% @ 20.5
mGy CTDIvol

5 mm @ 0.3% @ 17 mGy

5 mm @ 0.3% @ 16 mGy

4 mm @ 0.3% @ 10.0
mGy; FC41 kernel with
3D adaptive filter

CTDIw for standard head scan [mGy/100mAs]


Do not use for direct dose comparisons*

19.3 @ 120 kV

13.5 @ 120 kV

16.6 @ 120 kV

20.5 @120 kV

CTDIw for standard body scan [mGy/100mAs]


Do not use for direct dose comparisons*

8.6 @ 120 kV

6.7 @ 120 kV

7.5 @ 120 kV

12.1 @120 kV

Power requirements (gantry)

3 phase
380-480 V
150 kVA

3 phase
380 - 480 V
104 kVA

3 phase
380 - 480 V
125 kVA

3 phase
380 - 440 V,
100 kVA

Minimum floor load-bearing [kg/m]

1448

294

333

732

Recommended floor area for scanner [m]

21.7 med table


23.8 long table

17.5 minimum

18 mininum

27 (std couch)
25 (short couch)

Manufacturer's performance data

Room requirements

* These figures do not reflect the scanners' dose efficiency. A relative patient dose at the stated kV can be calculated using this data in conjunction with the
recommended clinical scan parameters (mAs, pitch)

CEP08007: March 2009

Market review

97

Table 18. Summary specifications of 64 slice CT scanners


GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Scanner type

64 slice
3rd gen

64 slice
3rd gen

64 slice
3rd gen

64 slice
3rd gen

64 slice
3rd gen

Dual source
3rd gen

64 slice
3rd gen

Gantry aperture [cm]

70

70

70

70

78

78

72

Gantry tilt - Sequential/Helical


[degrees]

30 sequential

30 sequential

30 sequential

30 sequential

30 sequential

No

30 for both

Power rating [kW]

85 (100 option)

100

60

80

80

80 (x2)

60
(72 option)

Anode heat capacity [MHU]

0.6 (equiv to
30)

0.6 (equiv to
30)

0.6 (equiv to
30)

7.5

Maximum anode cooling rate [kHU /


min]

2100

2100

1608

5000

7300

7300

1386

Scanner gantry

X-ray generator and tube

CEP08007: March 2009

Market review

98

GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Detector type

Solid state

Solid state

Solid state
array

Solid state
array

Solid state
array

Solid state
array

Solid state
array

Detector array configuration (# x


width [mm])

64 x 0.625

64 x 0.625

64 x 0.625

32 x 0.6
8 x 1.2

32 x 0.6

32 x 0.6 (x 2)
8 x 1.2 (x 2)

64 x 0.5

Maximum z-axis coverage [mm]

40

40

40

28.8

19.2

28.8 (x2)

32

Max z-axis coverage with sub-mm


slices [mm]

40

40

40

19.2

19.2

19.2 (x2)

32

Length & width [cm]

285 x 42

285 x 42

243 x 41

240 x 40

240 x 45 (std)
240 x 53
(multipurpose)

240 x 45 (std)
240 x 53
(multipurpose)

219 (std) or
189 (short) x 47

Maximum scannable range [cm]

170 med table


200 long table

170 med table


200 long table

175

157

160
(200 option)

200

175 (std)
145 (short)

Minimum height out of gantry [cm]

43

43

57.8

53

48
(53 multipurp.)

48
(53 multipurp.)

31

Maximum weight on couch [kg]

227

227

204 (295
option)

200
(280 option)

220
(300 option)

220
(300 option)

205

Detection system

Couch

CEP08007: March 2009

Market review

99

GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Minimum rotation time in helical


mode [s]

0.4 (0.35
option)

0.35

0.5 (0.4 option)

0.33

0.3

0.33

0.5 (0.35 option


)

Kilovoltage settings [kV]

80, 100, 120,


140

80, 100, 120,


140

90, 120, 140

80, 100, 120,


140

80, 100, 120,


140

80, 100, 120,


140

80, 100, 120,


135

Tube current range at 120/130 kV


[mA]

10 - 700
(800 option)

10 - 800

20 - 500

28 - 665

20 - 666

20 - 666 (x2)

10 - 500
(10 - 600
option)

5 - 50
(70 option)

5 - 50
(78 option)

5 - 50
(78 option)

5 - 50

Scan parameters

Image reconstruction

Reconstruction field of view range


[cm]

9.6 - 50

9.6 - 50

5 - 50 Std &
high res
2.5 - 25 Ultra
high res (UHR)

Reconstruction matrices

512 x 512

512 x 512

512 x 512,
768 x 768 &
1024 x 1024

512 x 512

512 x 512

512 x 512

512 x 512

Recon rate for std head scan, 5122


[images/s]

16

16

~ 18

20

40

40

16

Recon rate for std body scan, 5122


[images/s]

up to 6
(16 option)

up to 16

~ 16

20

40

40

16

CEP08007: March 2009

Market review

100

GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Tube current modulation (x-y & z)

x-y & z

x-y & z

x-y & z, but not


simultaneously

x-y & z

x-y & z

x-y & z

x-y & z

Adaptive collimators in helical


scanning

No

No

No

No

Yes

No

No

Standard total hard disc capacity


[GB]

584

584

880

1022

1241

1825

1245

Ability to burn images to disc

Yes

Yes

Option

Yes

Yes

Yes

Yes

Dose reduction features

Data management & connectivity

Rate of image transfer: scanner to


workstation [images/s]

up to 16

up to 16

Network
dependent

up to 25

up to 25

up to 25

12
Maximum 50
(enhanced
DICOM,
optional)

IHE scheduled workflow supported

Yes

Yes

Yes

Yes

Yes

Yes

Yes

CEP08007: March 2009

Market review

101

GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Scan plane limiting clinical spatial


resolution [mm]

0.35
(14.2 lp/cm @
4% MTF)

0.35
(14.2 lp/cm @
4% MTF)

0.22
(23 lp/cm @
2% MTF)

0.21
(23.7 lp/cm @
2% MTF)

0.21
(24 lp/cm @
2% MTF)

0.21
(24.3 lp/cm @
2% MTF)

0.23
(21.4 lp/cm @
2% MTF)

Longitudinal (z-axis) limiting clinical


spatial resolution [mm]

0.35
(14.2 lp/cm @
4% MTF)

0.35
(14.2 lp/cm @
4% MTF)

0.33
(15 lp/cm @
0% MTF)

0.24
(21 lp/cm @
2% MTF)

0.24
(21 lp/cm @
2% MTF)

0.24
(21 lp/cm @
2% MTF)

Info. not
available

Contrast resolution: smallest rod


size discernable [mm @ 0.3%
contrast @ x mGy surface dose in
Catphan]

3 mm @ 0.3%
@ 22.2 mGy
CTDIvol

3 mm @ 0.3%
@ 22.2 mGy
CTDIvol

5 mm @ 0.3%
@ 19 mGy

5 mm @ 0.3%
@ 17 mGy

5 mm @ 0.3%
@ 16 mGy

5 mm @ 0.3%
@ 17 mGy

4 mm @ 0.3%
@ 10.0 mGy;
FC41 kernel
with 3D
adaptive filter

CTDIw for standard head scan


[mGy/100mAs]
Do not use for direct dose
comparisons*

19.3 @ 120 kV

19.3 @ 120 kV

10.9 @ 120 kV

13.5 @ 120 kV

16.6 @ 120 kV

13.5 @ 120 kV

20.5 @120 kV

CTDIw for standard body scan


[mGy/100mAs]
Do not use for direct dose
comparisons*

8.6 @ 120 kV

8.6 @ 120 kV

5.6 @ 120 kV

6.7 @ 120 kV

7.5 @ 120 kV

7.3 @ 120 kV

12.1 @120 kV

Manufacturer's performance data

CEP08007: March 2009

Market review

102

GE
LightSpeed
VCT

GE
LightSpeed
VCT XT

Philips
Brilliance
CT 64

Siemens
Somatom
Sensation 64

Siemens
Somatom
Definition
AS 64

Siemens
Somatom
Definition Dual
Source

Toshiba
Aquilion 64

Power requirements (gantry)

3 phase
380-480 V
150 kVA

3 phase
380-480 V
150 kVA

3 phase
200 - 500 V
100 kVA

3 phase
380 - 480 V
104 kVA

3 phase
380 - 480 V
Neutral & Earth
50 Hz

3 phase
380 - 480 V
Neutral & Earth
50 Hz

3 phase
380 - 440 V,
100 kVA

Minimum floor load-bearing [kg/m]

1448

1448

Info not
available

294

333

Up to 517.2
10%

732

Recommended floor area for


scanner [m]

21.7 med table


23.8 long table

21.7 med table


23.8 long table

35.7

17.5 minimum

18 minimum

17.7 minimum

27 (std couch)
25 (short
couch)

Room requirements

* These figures do not reflect the scanners' dose efficiency. A relative patient dose at the stated kV can be calculated using this data in conjunction with the recommended clinical
scan parameters (mAs, pitch)

CEP08007: March 2009

Market review

103

Table 19. Summary specifications of wide bore CT scanners


GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Scanner type

16 slice
wide bore
3rd gen

16 slice
wide bore
3rd gen

16 slice
wide bore
3rd gen

24 slice
wide bore
3rd gen

40 slice
wide bore
3rd gen

16 slice
wide bore
3rd gen

Gantry aperture [cm]

80

80

85

82

82

90

Gantry tilt - Sequential/Helical


[degrees]

30 sequential

30 sequential

30 sequential

30 sequential

30 sequential

Not available

Power rating [kW]

53.2

100

48

50

50

60

Anode heat capacity [MHU]

8 MHU

8 MHU

0.6 (equiv to 30)

0.6 (equiv to 30)

7.5

Maximum anode cooling rate [kHU /


min]

648

648

1608

5000

5000

1386

Scanner gantry

X-ray generator and tube

CEP08007: March 2009

Market review

104

GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Detector type

Solid state

Solid state

Solid state array

Solid state array

Solid state array

Solid state array

Detector array configuration (# x


width [mm])

16x 0.625mm
8x 1.25mm

16x 0.625mm
8x 1.25mm

16 x 0.75
8 x 1.5

32 x 0.6
8 x 1.2

32 x 0.6
8 x 1.2

16x 0.5
24x 1.0

Maximum z-axis coverage [mm]

20

20

24

28.8

28.8

32

Max z-axis coverage with sub-mm


slices [mm]

10

10

12

12

12

Length & width [cm]

239 x 42 med
292 x 42 long

239 x 42 med
292 x 42 long

243 x 41

240 x 40
(240 x 53 RT
option)

240 x 40
(240 x 53 RT
option)

219 (std) or
189 (short) x 47

Maximum scannable range [cm]

170 med table


200 long table

170 med table


200 long table

175

157

157

175 (std)
145 (short)

53
(65 with high
capacity table
option)

31

200
(280 option)

205

Detection system

Couch

Minimum height out of gantry [cm]

43

43

57.8

53
(65 with high
capacity table
option)

Maximum weight on couch [kg]

227

227

295

200
(280 option)

CEP08007: March 2009

Market review

105

GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Minimum rotation time in helical


mode [s]

0.8

0.5

0.44

0.5

0.5

0.5

Kilovoltage settings [kV]

80, 100, 120, 140

80, 100, 120, 140

90, 120, 140

80, 100, 120, 140

80, 100, 120, 140

80, 100, 120, 135

Tube current range at 120/130 kV


[mA]

10 - 440

10 - 800

20 - 500

28 - 400

28 - 400

10 - 500

Reconstruction field of view range


[cm]

9.6 - 65

9.6 - 65

5 - 60

5 - 50
(5 - 82 option)

5 - 50
(5 - 82 option)

5 - 50

Reconstruction matrices

512 x 512

512 x 512

512 x 512,
768 x 768 & 1024
x 1024

512 x 512

512 x 512

512 x 512

Recon rate for std head scan, 5122


[images/s]

up to 6
(16 option)

up to 6
(16 option)

~10

20

20

Recon rate for std body scan, 5122


[images/s]

up to 6
(16 option)

up to 6
(16 option)

~6

20

20

Scan parameters

Image reconstruction

CEP08007: March 2009

Market review

106

GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Tube current modulation (x-y & z)

x-y & z

x-y & z

x-y & z, but not


simultaneously

x-y & z

x-y & z

x-y & z

Adaptive collimators in helical


scanning

No

No

No

No

No

No

Standard total hard disc capacity


[GB]

291

291

392

1022

1022

450

Ability to burn images to disc

Yes

Yes

Yes

Yes

Yes

Yes

Rate of image transfer: scanner to


workstation [images/s]

6 std
(up to 16 option)

6 std
(up to 16 option)

Network
dependent

up to 25

up to 25

12
Maximum 50
(enhanced
DICOM, optional)

IHE scheduled workflow supported

Yes

Yes

Yes

Yes

Yes

Yes

Dose reduction features

Data management & connectivity

CEP08007: March 2009

Market review

107

GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Scan plane limiting clinical spatial


resolution [mm]

0.35
(14.2 lp/cm @ 4%
MTF)

0.35
(14.2 lp/cm @ 4%
MTF)

0.33
(15 lp/cm @ 2%
MTF)

0.34
(14.7 lp/cm @ 2%
MTF)

0.34
(14.7 lp/cm @ 2%
MTF)

0.23
(21.4 lp/cm @ 2%
MTF)

Longitudinal (z-axis) limiting clinical


spatial resolution [mm]

0.35 +/- 0.05 mm


(visual)

0.35 +/- 0.05 mm


(visual)

0.56
(9 lp/cm @ 0%
MTF)

0.29
(17 lp/cm @ 2%
MTF)

0.29
(17 lp/cm @ 2%
MTF)

Info. not available

Contrast resolution: smallest rod size


discernable [mm @ 0.3% contrast @
x mGy surface dose in Catphan]

3mm @ 0.45% @
37.2mGy

3mm @ 0.45% @
37.2mGy

3.5 @ 0.35%
Dose not available

5 mm @ 0.3% @
17 mGy

5 mm @ 0.3% @
17 mGy

4 mm @ 0.3% @
11.9 mGy; FC41
kernel with 3D
adaptive filter

CTDIw for standard head scan


[mGy/100mAs]
Do not use for direct dose
comparisons*

13.94 @ 120 kV

13.94 @ 120 kV

Info not available

17.5 @ 120 kV

19.4 @ 120 kV

15.9 @120 kV

CTDIw for standard body scan


[mGy/100mAs]
Do not use for direct dose
comparisons*

7.33 @ 120 kV

7.33 @ 120 kV

Info not available

9.3 @ 120 kV

8.5 @ 120 kV

10.8 @120 kV

Manufacturer's performance data

CEP08007: March 2009

Market review

108

GE LightSpeed
RT

GE LightSpeed
Xtra

Philips Brilliance
CT Big Bore

Siemens
Somatom
Sensation
Open 24

Siemens
Somatom
Sensation
Open 40

Toshiba
Aquilion LB

Power requirements (gantry)

3 phase
380-480 V
150 kVA

3 phase
380-480 V
150 kVA

3 phase
200 - 500 V
100 kVA

3 phase
380 - 480 V
66 - 80 kVA

3 phase
380 - 480 V
66 - 80 kVA

3 phase
380 - 440 V,
100 kVA

Minimum floor load-bearing [kg/m]

1337

1337

Info not available

293.7 10%

293.7 10%

923

Recommended floor area for scanner


[m]

26 med table
28.6 long table

26 med table
28.6 long table

Info not available

17.5 minimum

17.5 minimum

27 (std couch)
25 (short couch)

Room requirements

* These figures do not reflect the scanners' dose efficiency. A relative patient dose at the stated kV can be calculated using this data in conjunction with the recommended clinical
scan parameters (mAs, pitch)

CEP08007: March 2009

Market review

109

Table 20. Summary specifications CT scanners with more than 64 slices


Philips Brilliance iCT

Siemens Somatom
Definition AS+

Toshiba Aquilion ONE

Scanner type

256 slice, 3rd gen

128 slice, 3rd gen

320 slice, 3rd gen

Gantry aperture [cm]

70

78

72

Gantry tilt - Sequential/Helical [degrees]

Not available

30 sequential

22 sequential

Power rating [kW]

120

100

70

Anode heat capacity [MHU]

Equiv to 30

0.6 (equiv to 30)

7.5

Maximum anode cooling rate [kHU / min]

1608

7300

1386

Detector type

Solid state

Solid state

Solid state

Detector array configuration (# x width [mm])

128 x 0.625

64 x 0.6

320 x 0.5

Maximum z-axis coverage [mm]

80

38.4

160

Max z-axis coverage with sub-mm slices [mm]

80

38.4

160

Greater than 64 slice

Scanner gantry

X-ray generator and tube

Detection system

CEP08007: March 2009

Market review

110

Philips Brilliance iCT

Siemens Somatom
Definition AS+

Toshiba Aquilion ONE

Length & width [cm]

243 x 41

240 x 45
240 x 53 (multipurpose)

246 x 47

Maximum scannable range [cm]

175

160
(200 option)

195

Minimum height out of gantry [cm]

57.8

48
(53 with multipurpose table option)

33

Maximum weight on couch [kg]

204

220
(300 option)

300
(230 within spec)

Minimum rotation time in helical mode [s]

0.33
(0.27 option)

0.3

0.35

Kilovoltage settings [kV]

80, 120, 140

80, 100, 120, 140

80, 100, 120, 135

Tube current range at 120/130 kV [mA]

10 - 1000

20 - 800

10 - 580

Greater than 64 slice


Couch

Scan parameters

CEP08007: March 2009

Market review

111

Philips Brilliance iCT

Siemens Somatom
Definition AS+

Toshiba Aquilion ONE

Reconstruction field of view range [cm]

5 - 50

5 - 50
(78 option)

5 - 50

Reconstruction matrices

512 x 512
768 x 768
1024 x 1024

512 x 512

512 x 512

Recon rate for std head scan, 5122 [images/s]

Approx 20

40

32

Recon rate for std body scan, 5122 [images/s]

Approx 18

40

32

Tube current modulation (x-y & z)

x-y & z but not simultaneously

x-y & z

x-y & z

Adaptive collimators in helical scanning

Yes

Yes

No

Standard total scanner hard disc storage capacity


[GB]

292 (host)
588 (on recon computer)

1679

3800

Ability to burn images to disc

Yes

Yes

Yes

Rate of image transfer: scanner to workstation


[images/s]

Info not available

up to 25

50 max

IHE scheduled workflow supported

Yes

Yes

Yes

Greater than 64 slice


Image reconstruction

Dose reduction features

Data management & connectivity

CEP08007: March 2009

Market review

112

Philips Brilliance iCT

Siemens Somatom
Definition AS+

Toshiba Aquilion ONE

Scan plane limiting clinical spatial resolution [mm]

0.22
(23 lp/cm @ 2% MTF)

0.21
(24 lp/cm @ 2% MTF)

0.23
(21.4 lp/cm @ 2% MTF)

Longitudinal (z-axis) limiting clinical spatial


resolution [mm]

Info not available

0.24
(21 lp/cm @ 2% MTF)

0.35
(14.4 lp/cm @ 2% MTF)

Contrast resolution: smallest rod size discernable


[mm @ 0.3% contrast @ x mGy surface dose in
Catphan]

5 mm @ 0.3% @ 18 mGy

5 mm @ 0.3% @ 16 mGy

4 mm @ 0.3% @ 10.0 mGy; FC41


kernel with 3D adaptive filter

CTDIw for standard head scan [mGy/100mAs]


Do not use for direct dose comparisons*

10.9 @ 120 kV

16.6 @ 120 kV

Not applicable

CTDIw for standard body scan [mGy/100mAs]


Do not use for direct dose comparisons*

5.6 @ 120 kV

6.7 @ 120 kV

Not applicable

Power requirements (gantry)

3 phase
200 - 500 V AC,
225 kVA
50/60 Hz

3 phase
380 - 480 V
Neutral & Earth
50 Hz

3 phase
380 - 440 V,
100 kVA

Minimum floor load-bearing [kg/m]

729.7

Up to 333.33 10%

1070

Recommended floor area for scanner [m]

41.4

18 min

43

Greater than 64 slice


Manufacturer's performance data

Room requirements

* These figures do not reflect the scanners' dose efficiency. A relative patient dose at the stated kV can be calculated using this data in conjunction with the recommended clinical
scan parameters (mAs, pitch)

CEP08007: March 2009

Acknowledgements

113

We should like to thank the following for their contributions to this buyers guide.

Jane Adam, Alan Britten, Linda Howarth and Andrew Stewart, St Georges
Healthcare NHS Trust
Elmer Bakker and Graham Dickinson, Centre for Research in Strategic Purchasing
and Supply (CRiSPS), University of Bath
Roger Bury, Royal College of Radiologists
Jackie Bye, Lindsey Carver, and Sandie Jewell, GE Healthcare
Matthew Dunn, IPEM Diagnostic radiology special interest group
Thomas Flohr and Susie Guthrie, Siemens Medical Solutions
Kate Garras, Society and College of Radiographers
Alistair Howseman and Derek Tarrant, Philips Medical Systems
Tarun Mittal, British Society of Cardiovascular Imaging
Andrew Reilly, British Institute of Radiology
Lisa Smith, NHS Improvement - Radiology Service Improvement Team
Marie Whittaker, NHS Supply Chain

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Glossary

114

3D

imaging techniques used to display images of a three


dimensional volume on a flat (2D) display, such as a
computer screen. Should be distinguished from true 3D
displays, such as virtual reality or stereoscopic systems.

3rd generation

describes a CT scanner design with a rotating tube detector


assembly. The design for all modern CT scanners

ALARA

as low as reasonably achievable

ALARP

as low as reasonably practicable

anterioposterior (AP)

from the front (anterior) towards the back (posterior) of a


patient. Common orientation for SPR images

archive

storage of large amounts of idle data. Accuracy of data


recovery is important, but as the data are no longer active,
speed of reading is not as important Can by on various types
of devices or media, such as tape.

as low as reasonably
achievable / practicable
(ALARA /ALARP)

principle used in radiation protection that the patient dose


should always be the minimum required to achieve the clinical
objective

BIR

British Institute of Radiology

BNMS

British Nuclear Medicine Society

CD

compact disc

CE

Conformit Europene

CEP

Centre for Evidence-based Purchasing

CT

computed tomography

CTC

CT colonography

CTDI

computed tomography dose index

CTDIvol

volume computed tomography dose index

CTPA

CT pulmonary angiography

Caldicott guardian

a senior staff member responsible for protecting the


confidentiality of patient information, and enabling appropriate
information-sharing

cannulation

procedure involving insertion of a flexible catheter into one of


the large blood vessels

Catphan

standard test object used to measure some of the


performance aspects of CT scanners

CE marking

Indication of compliance with relevant EU directives, in


particular the MDD.

CEP08007: March 2009

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115

(low) contrast resolution the minimum difference in material attenuation (CT number)
that is perceptible between adjacent pixels in an image matrix
computed tomography
(CT)

an imaging technique that uses views of an object from many


directions to synthesise a transaxial or cross sectional image

computed tomography
dose index (CTDI)

a term used in radiation dosimetry that defines the adsorbed


dose from a single rotation of a CT scanner. There are a
number of definitions of CTDI commonly used

cone-beam
reconstruction

techniques for reconstructing images from non-parallel


projection data

contrast medium

a substance introduced into structures to increase or


decrease their contrast, enhancing resolution on the CT
image. Most commonly a radio-opaque substance is injected
intravenously, but oral contrast may also be used

coronary angiography

imaging the vessels of the heart

coronary calcium
scoring

technique to determine whether or not coronary artery


disease is present, by measuring the deposition of calcium in
arterial walls

CT colonography

using a CT scanner to produce non-invasive slice and 3D


images of the colon and rectum (virtual colonoscopy)

CT fluoroscopy

use of CT to produce real-time images

DH

(UK) Department of Health

DICOM

digital imaging and communication in medicine.

DLP

dose-length product

DRL

diagnostic reference level

DSoN

detailed statement of needs

DVD

digital versatile disc

detailed statement of
need (DSoN)

a procurement document that gives a details of the


requirements for the equipment . Current advice prefers an
output-based specification (OBS) approach

detectors

the part of the scanner that senses the transmitted X-rays and
generates an electrical signal

detector array

the matrix of detector elements in the detector system of the


scanner

DICOM object

the defined structure of data within DICOM imaging


standards. For example, there are two DICOM objects for CT
image data; original (1993) and the enhanced CT object
(2003)

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Glossary

116

digital versatile disc


(DVD)

a type of data storage media; uses the same technology as


CD-ROM but has the ability to store larger amounts of data,
up to 4.7 GB per side for a single layer disc

discount cash flow

a technique to compare costs occurring at different times

display

the graphics system on a computer workstation, consisting of


the hardware card and monitor and the software drivers.
These can be classified as :
primary displays
performance meets the required
specification for diagnostic quality image presentation
secondary displays performance does not meet diagnostic
criteria, but is sufficient for clinical review purposes, in support
of the report or other information

dose length product


(DLP)

a measure for approximating radiation risk calculated by


multiplying the CTDIvol for a scan sequence by the length of
coverage in the z axis (along the patient's length)

dose profile

the variation of intensity along a X-ray beam

diagnostic reference
levels (DRLs)

indicative dose level for a given examination of patients with


standard body size against which actual doses can be
audited

dual-energy scanning

scanning the patient at two different X-ray tube energies to


obtain two CT data sets

EBCT

electron beam computed tomography

ECG

electrocardiogram

EBCT

electron beam computed tomography

ECG

electrocardiogram

ECRI (Emergency Care


Research Institute)

a US-based health services research agency

effective dose

representative dose measurement, giving the uniform whole


body dose that is equivalent in terms of stochastic
(carcinogenic) risk, to the non-uniform irradiation of various
organs. Effective dose (E) is quoted in units of millisieverts
(mSv)

electrocardiogram
(ECG)

record of electrical activity in the heart over time

electron beam
computed tomography
(EBCT)

type of CT scanner that uses a rotating beam and stationary


target ring in place of a rotating X-ray tube. Was previously
used for specialist purposes, particularly cardiac imaging, but
now mostly replaced by MSCT

CEP08007: March 2009

Glossary

117

electronic patient record record containing a patients demographics, attendance,


(EPR)
diagnosis or condition, and details about the treatments and
assessments undertaken. It typically covers the care provided
within one institution: a trust or a primary care trust
FOV

field of view

FWHM

full width at half maximum

Feldkamp
reconstruction

common extended parallel projection technique used for


cone-beam reconstruction on MSCT scanners..Properly
called the Feldkamp-Davis-Kress (FDK) algorithm.

field of view (FOV)

size of an area being imaged. Can be either the scanned field


(SFOV) or the reconstructed field (RFOV)

filter

a) X-ray filter: material introduced to remove soft X-rays from


the X-ray beam
b) beam shaping filter or bow-tie filter: material used to shape
the intensity of the x ray beam to suit the subject
c) reconstruction filter: mathematical kernel used during the
reconstruction process to modify responses at different
spatial frequencies

flying focal spot

a technique that moves the focal spot on the X-ray tube


between two positions in order to improve spatial resolution

focal spot

the point in the X-ray tube where the X-rays originate

full width at half


maximum

method for characterising the width of the X-ray beam by


measuring the distance between the points at which the
intensity is 50% of the peak.

GB

gigabyte

Gy

gray

gantry tilt

ability to offset the gantry rotation from the couch axis. Used
in head scans to avoid critical dose-sensitive organs, such as
the eyes

gating

timing of the data capture with a physiological event, such as


breathing or heart beat. This may be
a) prospective : the image data is only acquired when a
certain event is occurring, such as triggered by an ECG trace
b) retrospective : part of the image data set is selectively
chosen after acquisition according to records of the
physiological event, such as breathing patterns

generator

produces the high voltages required for the X-ray tube

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Glossary

118

geometric efficiency

one measure of dose efficiency of the scanner, it is the ratio


of the slice width imaged to the total slice width irradiated.
Strictly should be the ratio of dose used to create images to
total dose

gray (Gy)

the unit of absorbed dose

grid

an array of septa that are introduced to either reduce noise


due to radiation scatter or (in CT) to reduce the sampling
aperture and hence increase spatial resolution

HRG

Healthcare resource group

HIS

hospital information system

HL7

Health Level Seven

Health Level Seven


(HL7)

used here to refer to standards and frameworks related to


healthcare interoperability , that is the transfer of data
between different systems in healthcare. Properly, it is the
non-profit organisation that develops such standards.

Health Protection
Agency (HPA)

the Health Protection Agency provides an integrated


approach to protecting UK public health through the provision
of support and advice to the NHS, local authorities,
emergency services, other Arms Length Bodies, the
Department of Health and the Devolved Administrations.

helical scan

a CT scan where the patient is moved constantly through the


rotating gantry. The X-ray beam describes a helix about the
patient

hospital information
system (HIS)

hospital wide computer system containing data such as


patient details and test records, including laboratory and
radiology reports. Can be all or part of electronic patient
record (EPR), or patient administration system (PAS)

Hounsfield Unit (HU)

normalised scale of x ray attenuation used in CT scanning. It


is defined by air (1000 HU) and water (zero HU).

HRG v4

a set of codes used to allocate tariff payments to patient


procedures, such as CT examinations

IAC

inner auditory canal

ICT

information and communication technology

IEC

International Electrotechnical Commission.

IEE

The Institution of Electrical Engineers


(now IET Institution of Engineering and Technology)

IG

information governance

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Glossary

119

IHE

Integrating the Healthcare Enterprise

IP

international protection rating


or ingress protection rating

IPEM

Institute of Physics and Engineering in Medicine.

ips

images per second

IR(ME)R

Ionising Radiation (Medical Exposure) Regulations 2000

IRR

Ionising Radiation Regulations 1999

ImPACT (Imaging
Performance
Assessment of CT
scanners)

An independent provider of evidence supporting the purchase


of CT scanners in the UK, funded by the NHS Purchasing and
Supply Agencys Centre for Evidence-based Purchasing

Institute for Physics and professional body for those involved in medical physics and
Engineering in Medicine clinical engineering. Operates a special interest group in
(IPEM)
diagnostic imaging. Publishes guidance for the use and
routine testing of equipment
Integrating the
Healthcare Enterprise
(IHE)

global initiative designed to advance the state of data


integration in healthcare across all hospital systems.
Establishes common functional profiles

The Ionising Radiation


(Medical Exposure)
Regulations 2000
(IR(ME)R 2000)

British national regulations that relate to the safe operation of


X-ray equipment in terms of patient safety

The Ionising Radiations


Regulations 1999 (IRR
99)

British national regulations that relate to the safe installation


and operation of X-ray equipment in terms of staff and public
protection

IP code (or IPxy)

system to rate the protection provided against the intrusion of,


dust, and water in electrical enclosures

isocentre

the point around which the CT system rotates. Also the visual
centre of the reconstructed image

isotropic resolution

CT images where the resolution in the scan plane and along


the scan axis are the same

kHU

kiloheat-units

kV

kilovolt

kVA

kilovolt-amp

kW

kilowatt

kWh

kilowatt-hour

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Glossary

120

LAN

local area network

LCD

liquid crystal display

LED

light emitting diode

lp/cm

line pairs per centimetre

LR

legitimate relationship

mA

milliamp

mAs

milliamp-seconds

MDD

medical device directive

MDR

medical device regulations

mGy

milligray

MHRA

Medicines and Healthcare Products Regulatory Agency

MHU

mega heat units

minIP

minimum intensity projection.

MIP

maximum intensity projection.

MOD

magneto-optical disc

MPE

medical physics expert

MPR

multiplanar reformat

MSCT

multi-slice computed tomography

mSv

millisievert

MTF

modulation transfer function

magneto optical disc


(MOD)

a type of data storage media; 5 disc cartridge that stores


up to 786 MB, can be re written and used many times

market forces factor


(MFF)

an agreed premium percentage rate added to PbR tariffs to


account for local circumstances.

maximum intensity
projection (MIP)

pseudo-3D system for viewing volumes of data, where the CT


number of each pixel is given by the highest CT number of a
voxel on a path traced through the volume

miniPACS

modality-specific PACS. Sometimes with specialist features


optimised for one study or image type that cannot easily be
integrated in a PACS that covers a wider remit. May also refer
to specialist department systems, such as in A&E

minimum intensity
projection (minIP or
mIP)

like a MIP, but using the lowest CT number instead of the


highest

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Glossary

121

modality worklist

list of requested and scheduled patient studies sent to and


displayed at the appropriate acquisition modality. Data
originate in the RIS, but may be brokered through the PACS
to the modality

modulation transfer
function (MTF)

a description of the ability of imaging equipment to reproduce


spatial detail of an object in an image

multi-slice computed
tomography (MSCT)

CT performed with more than one row (or bank) of detectors


along the patient's length, capable of producing more than
one image simultaneously. Also called multidetector CT
(MDCT), multichannel CT (MCCT) or multirow CT (MRCT)

multiplanar reformat

slice images created from an existing set of image data. Can


be at a different thickness, aligned to another plane, or based
along a curved path

multisector
reconstruction

method of building up cardiac images from data gathered


from many scan rotations

NHS

National Health Service.

NHS PASA

NHS Purchasing and Supply Agency.

NICE

National Institute for Health and Clinical Excellence

NHS Purchasing and


Supply Agency (NHS
PASA)

DH funded agency supporting procurement in the NHS


[http://nww.pasa.nhs.uk]

NHSnet (nww)

similar to the internet, but is only accessible to computers


within the NHS

(image) noise

(random) variation of (pixel) values in an image that can


interfere with contrast and detail resolution. Most apparent in
regions of low signal

OBS

output based specification

OPCS-4

Office of Population Censuses and Survey Classification of


Surgical Operations and Procedures, 4th revision

Official Journal of the


European Union (OJEU)

channel for the advertisement of public procurement projects


in member states of the European Union. Invitations to
express interest are published in the Supplement (OJ S) and
are available electronically from the Tenders Electronic Daily
website [http://ted.europa.eu]

operational requirement

the minimum acceptable performance for the proposed


system

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Glossary

122

Output-based
specification (OBS)

a document stating the objectives (outputs) the proposed


system must achieve. This should focus on the what of the
operational and clinical practices, rather than how of
technical detail, which can be addressed in the statement of
needs where necessary

PACS

picture archiving and communications system

PbR

payment by results

PPE

personal protective equipment

PACS broker

device that allows the PACS to interface with the hospital


information system (HIS) and/or the radiology information
system (RIS). This is not essential in all systems, as the RIS
and HIS may be able to interface directly with the PACS using
the HL7 standard

partial volume effect

effect that occurs when one sampled voxel contains a mixture


of tissues. The resulting value is an average of all those
present, which can lead to mis-labelling of the sample in
some circumstances. This is related to pixel size, but is more
dependent on slice thickness

patient administration
system (PAS);

computer system for managing patient details, such as


appointments, demographics etc. May be part of, or
synonymous with, the HIS or EPR depending on the local
context

perfusion scanning

use of an imaging modality to characterise perfusion (the


passage of fluid through tissue). In CT this is commonly to
assess brain tissue damage by assessing blood flow.

picture archiving and


communication system
(PACS)

system that manages the storage and retrieval of digital


images

pitch

in helical scanning, the ratio between the distance moved by


the patient during one gantry rotation (the table feed), and the
width of the image sample being scanned (the beam
collimation).

power factor

a measure of the efficiency with which electric power is used

QA

quality assurance

QC

quality control

QC testing

routine testing of the scanner as part of the QA process, that


aims to ensure the scanner performance is acceptable.

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Glossary

123

query / retrieve

a DICOM service class that underpins the ability to query a


device (such as a CT scanner) for a list of studies, and to
allow the transfer of relevant images to another device (such
as a workstation)

RCR

Royal College of Radiologists.

RDA

radiology department assistant

RF

radio frequency

RIS

radiology information system

RPA

radiation protection advisor

RPS

radiation protection supervisor

RSNA

Radiological Society of North America.

RT

radiotherapy

radiology information
system (RIS)

a computer system which stores the appointment information


for a radiology department and may be linked to the HIS. A
PACS may take exam booking information and demographics
from the RIS to form worklists

(clinical) report

contains the radiologists reading of the image and is part of


the diagnostic procedure. All X-ray studies must, by law, be
formally reported, and the report retained as part of the
patient records for a minimum period. In modern
departments, the report is usually recorded in the RIS.
Reports may be typed, dictated or created using voice
recognition systems

reconstructed field of
view (RFOV)

size (in x-y plane) of the data set that is reconstructed to form
the CT image

reconstruction
algorithm (filter)

mathematical operation applied during the image creation that


can, for example, reduce image noise or enhance edge
details

reconstruction matrix

the array of pixels that is displayed as the CT image

respiratory gating

timing the image data to the breathing pattern of the patient.


May be used as a trigger to ensure the scan is taken at a
fixed point in the cycle

rich client

a computer (workstation) which does as much processing as


possible and passes only data required for storage and
archive to the server. (Contrast with thin client.) Also called
thick or fat clients

SCoR

Society and College of Radiographers

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Glossary

124

SNOMED CT

Systematised Nomenclature of Medicine Clinical Terms

SoN

statement or summary of needs

scan field of view


(SFOV)

size of area being imaged (scanned) in the x-y plane

scan projection
radiograph (SPR)

initial (low dose) scan acquired using a static tube and


moving bed. This is used to plan the full CT scan sequences,
and may also be used for tube current modulation

Sg2

an international healthcare intelligence company

sievert (Sv)

the unit of dose equivalence or effective dose; a measure of


the potential for radiation harm

single-slice rebinning
(SSR)

planar decomposition technique used for cone-beam


reconstruction on MSCT scanners..

slip ring

a means of providing cable-less connection for power and


data systems . Allows the continuous rotation of the gantry

spatial resolution

defines the smallest feature that can be detected in an image.


This is usually quoted as line pairs per cm (lp/cm) for CT
scanners

statement of need (SoN)

a procurement document for internal use, outlining the


requirements of the project. It can subsequently be developed
into a more detailed statement (DSoN). More focussed on the
details of how something is achieved than the output based
specification (OBS)

TPS

(radiotherapy) treatment planning system

TSO

The Stationary Office

teleradiology

transmission of a diagnostic images from one location for


review at a remote location. Most often used when
transmission is beyond the hospital LAN, but also used in
some circumstances to indicate sharing of image between
trusts

temporal resolution

the minimum time frame to obtain enough data to reconstruct


the image. Important in reducing motion artefacts in cardiac
scanning.

thin client

a computer (workstation) that depends primarily on the


central server for processing activities. The word "thin" refers
to either the small amount of data transferred between the
client and the server, or the small load required on the users
computer.

CEP08007: March 2009

Glossary

125

tube current modulation

variation of tube current according to the relative attenuation


of the object

voice recognition (VR)

a process which takes the spoken word as its input and


produces text as the output. It can be used in an imaging
department to aid in the production of clinical reports

volume rendered image


(VR)

method for displaying 3D image data that assigns colours and


degrees of transparency to different CT number ranges. Good
for displaying overlapping structure

WEEE

Waste electrical and electronic equipment

web browser

application used to display 'thin data' (aka thin client), typically


based on web protocols such as HTML. Can be used to
display patient records or images in clinical environments

workstation

a computer running applications software. There are several


types, the main ones being:
a) diagnostic or reporting workstation: used for viewing
images for primary diagnosis and/or production of clinical
reports. A reporting workstation will commonly have multiple
diagnostic (high quality) display monitors, usually 2 or 4
screens, capable of meeting specific guidelines for resolution,
contrast and brightness. These may be for CT reporting only,
or shared for reporting all radiology images
b) PACS workstation: is able to retrieve and display image
data from the PACS. These vary from simple review
workstations on the wards, to diagnostic workstations with
specialist reporting tools and RIS integration
c) review workstation: used for checking that acquired images
are of the required quality and that all necessary views have
been performed. Often at least one display on the CT control
console will act as a review (work)station.
May also refer to a workstation used on a ward or in a clinic to
view images in conjunction with the associated clinical report.
A review workstation will usually have one or two display
monitors, of lower display quality than those used in reporting
workstations.
d) scanner workstation: workstation supplied with the CT
scanner and optimised to run specialist applications

x-y plane

CEP08007: March 2009

plane in which the CT scanner gantry rotates. Also called the


scan plane

Glossary

z-axis

CEP08007: March 2009

126

axis about which the gantry of a CT scanner rotates. Also


called the scan axis. Normally the superior inferior axis of
the patient

References

127

[1] Department of Health (DH). Tackling hospital waiting: the 18 week patient
pathway - an implementation framework and delivery resource pack; May 2006
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_4134668 [cited Nov 2008]
[2] Schoepf UJ, Costello P. CT Angiography for Diagnosis of Pulmonary
Embolism: State of the Art. Radiology. 2004; 230: 329-337.
[3] Pugliese F, Mollet NR, Hunink M et al. Diagnostic Performance of Coronary
CT Angiography by Using Different Generations of Multisection Scanners:
Single-Centre Experience. Radiology. 2008; 246: 384-393.
[4] Taylor SA, Laghi A, Lefere P et al. European society of gastrointestinal and
abdominal radiology (ESGAR): Consensus statement on CT colonography.
Eur Radiol, Feb 2007; 17 (2): 575-579.
[5] Ristvedt SL, McFarland EG, Weinstock LB, Thyssen EP. Patient Preferences
for CT Colonography, Conventional Colonoscopy, and Bowel Preparation. Am
J Gastroenterol, 2003; 98 (3): 578-585.
[6] Royal College of Radiologists (RCR). Making the best use of clinical radiology
services: referral guidelines, 6th edition (MBUR6). RCR BFCR(07)10. London:
The Royal College of Radiologists; 2007.
[7] National Institute for Health and Clinical Excellence (NICE). Our guidance
http://www.nice.org.uk/search/guidancesearchresults.jsp?keywords=CT&searc
hType=guidance [cited November 2008].
[8] NICE. Head injury. Clinical guideline. Triage, assessment, investigation and
early management of head injury in infants, children and adults, September
2007; http://www.nice.org.uk/CG56 [cited November 2008]
[9] NICE IPG 129 Computed tomographic colonography (virtual colonoscopy)
guidance; 2005
http://www.nice.org.uk/Guidance/IPG129/Guidance/pdf/English [cited
November 2008]
[10] NICE. Lung Cancer. Clinical Guideline. Lung cancer: diagnosis and
treatment; 2005 http://www.nice.org.uk/Guidance/CG24 [cited November 2008]

CEP08007: March 2009

References

128

[11] Department of Health (DH). Implementing the National Stroke Strategy - an


imaging guide, June 2008;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_085146 [cited November 2008]
[12] Committee on Medical Aspects of Radiation in the Environment (COMARE),
12th Report. The impact of personally initiated X-ray computed tomography
scanning for the health assessment of asymptomatic individuals. Health
Protection Agency for COMARE, 2007.
[13] International Electrotechnical Commission (IEC).Particular Requirements for
the safety of X-ray equipment for computed tomography. IEC 60601-2-44 Ed
2.1 Geneva: International Electrotechnical Commission; 2002.
[14] Hseih, J. Computed tomography: principles, design, artefacts, and recent
advances. 2003. Bellingham, SPIE. pp 87-90
[15] Kalender, WA. Computed tomography: fundamentals, system technology,
image quality, applications. 2nd Ed; 2005. pp 256-268. Erlangen, Publicis.
[16] Hart, D and Wall BF. Radiation Exposure of the UK Population from Medical
and Dental X-ray Examinations NRPB-W4 March 2002; HPA
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/11957338
42374 [cited November 2008]
[17] Shrimpton PC, Hillier MC, Lewis MA and Dunn M. Doses from Computed
Tomography (CT) Examinations in the UK - 2003 Review. NRPB-W67. Health
Protection Agency, Chilton, Didcot, Oxon.
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733
780968?p=1158945066506 [cited November 2008]
[18] Wall, BF and Hart D. Revised radiation doses for typical X-ray examinations.
British Journal of Radiology. 1997; 70: 437-439
[19] NRPB at a glance series. Living with Radiation. Health Protection Agency,
Chilton, Didcot, Oxon.
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/11957338
41156 [cited November 2008]
[20] Mettler, FA, Huda W, Yoshizumi TT and Mahesh M. Effective doses in
radiology and diagnostic nuclear medicine. Radiology. 2008; 248(1):254-263

CEP08007: March 2009

References

129

[21] The ionising radiation regulations 1999. Statutory Instrument 1999/3232 .


London: The Stationery Office. http://www.opsi.gov.uk/si/si1999/19993232.htm
[cited November 2008]
[22] The ionising radiation (medical exposure) regulations 2000. Statutory
Instrument 2000/1059 (and as amended by Statutory Instrument 2004/1031).
London: The Stationery Office. http://www.opsi.gov.uk/si/si2000/20001059.htm
[cited November 2008]
[23] The Royal College of Radiologists (RCR). Ergonomics. Ref BFCR(08)3.
London, The Royal College of Radiologists Feb 2008
[24] Institute of Physics and Engineering in Medicine (IPEM). The critical
examination of X-ray generating equipment in diagnostic radiology. Report 79.
York: Institute of Physics and Engineering in Medicine; 2004.
[25] International Electrotechnical Commission (IEC). Evaluation and routine
testing in medical imaging departments Part 3-5: Acceptance tests - Imaging
performance of computed tomography X-ray equipment. IEC 61223-3-5 Ed.
1.0 b:2004 Geneva: International Electrotechnical Commission; August 2004.
[26] RCR. IT guidance: IT Training. Ref No : BFCR(08)10.London, The Royal
College of Radiologists; February 2008
[27] Dept for Business Enterprise and Regulatory Reform. EC Directive on Waste
Electrical and Electronic Equipment (WEEE)
http://www.berr.gov.uk/sectors/sustainability/weee/page30269.html [cited
November 2008].
[28] Dept for Business Enterprise and Regulatory Reform. EC Directive on the
Restriction of the Use of Certain Hazardous Substances in Electrical and
Electronic Equipment (RoHS)
http://www.berr.gov.uk/whatwedo/sectors/sustainability/rohs/page29048.html
[cited November 2008]
[29] IPEM. Recommended standards for the routine performance testing of
diagnostic X-ray imaging systems. Report 91. York: Institute of Physics and
Engineering in Medicine; 2005
[30] IPEM. Computed tomography X-ray scanners. 2nd ed. IPEM 32 Part III: 2nd
Edition. York: Institute of Physics and Engineering in Medicine; 2003

CEP08007: March 2009

References

130

[31] IEC. Evaluation and routine testing in medical imaging departments - Part
2-6: Constancy tests - imaging performance of computed tomography X-ray
equipment. IEC 61223-2-6 2nd ed. Geneva: International Electrotechnical
Commission; November 2006
[32] Department of Health. Guidance on the establishment and use of diagnostic
reference levels (DRLs) 2007.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_074067 [cited November 2008]
[33] National Health Service Institute for Innovation and Improvement. 10 High
Impact Changes for Service Improvement and Delivery.
http://www.institute.nhs.uk/index.php?option=com_content&task=view&id=64&
Itemid=24 [cited November 2008]
[34] Scottish Government Diagnostics Collaborative Programme: Changes that
work in Diagnostics. Improved scheduling. Case study number 11 - CT
http://www.scotland.gov.uk/Publications/2007/03/22084426/17 [cited
November 2008]
[35] Benbow, M. Increasing patient throughput with a multi-slice CT scanner.
CME Journal Radiology. 2003; 4(1): 8-13.
[36] Radiology Service Improvement: Radiology Case studies CT
http://www.radiologyimprovement.nhs.uk/View.aspx?page=/case_studies/ct.ht
ml [cited November 2008]
[37] Health and Safety Executive
http://www.hse.gov.uk/radiation/ionising/exposure.htm [cited November
2008]
[38] RCR. Retention and Storage of images and radiological patient data.
BFCR(06)4. London: The Royal College of Radiologists; Feb 2008
[39] RCR. Picture archiving and communication systems (PACS) and guidelines
on diagnostic display devices. BFCR(08)7. London: The Royal College of
Radiologists, April 2008.
http://www.rcr.ac.uk/index.asp?PageID=310&PublicationID=276 [cited
November 2008]

CEP08007: March 2009

References

131

[40] Department of Health (DH). Records management: NHS code of practice,


April 2006
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_4131747 [cited November 2008]
[41] National Electrical Manufacturers Association (NEMA). Digital Imaging and
Communications in Medicine (DICOM) Part 10: Media Storage and File Format
for Media Interchange, 2003
http://medical.nema.org/dicom/2003/03_10PU.PDF [cited November 2008]
[42] DICOM homepage http://medical.nema.org/
[43] HL7 ANSI-Approved Standards (webpage last updated July 2008)
http://www.hl7.org/about/directories.cfm?framepage=/documentcenter/public/f
aq/ansi_approved.htm [cited November 2008]
[44] IHE Radiology Technical Framework Revision 8.0 August 30, 2007
http://www.ihe.net/Technical_Framework/index.cfm#radiology [cited
November 2008]
[45] IHE-UK Technical Committee. New Healthcare Equipment Purchase,
Existing Equipment and IHE.
http://www.iheuk.org/cgibin/forum/show.cgi?3450/3453 [cited November 2008]
[46] Clunie D, Erickson BJ. The New Enhanced Multiframe CT and MR DICOM
Objects. http://www.dclunie.com/papers/SS3DICOMObjectsSyllabus.pdf [cited
November 2008]
[47] (Department of Health) DH. Information Security Management. NHS Code of
Practice, April 2007
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_074142 [cited November 2008]
[48] NHS Connecting for Health. Information governance (IG) (webpage) last
updated 16 September 2008
http://www.connectingforhealth.nhs.uk/systemsandservices/infogov [cited
November 2008]
[49] RCR. A guide to justification for clinical radiologists. Ref No BFCR(00)5.
ISBN 1 872599 64 8. London: Royal College of Radiologists; 2000.

CEP08007: March 2009

References

132

[50] Healthcare Commission. Information for Healthcare providers. Ionising


Radiation (Medical Exposure) Regulations 2000.
http://www.healthcarecommission.org.uk/guidanceforhealthcarestaff/nhsstaff/m
anagingrisk/useofionisingradiation.cfm [cited November 2008]
[51] The Ionising Radiation (Medical Exposure) (amendment) Regulations 2006.
Statutory Instrument 2006/2523. London: The Stationery Office; 2006.
http://www.opsi.gov.uk/si/si2006/20062523.htm [cited November 2008]
[52] Hutton J. Assessing the cost-effectiveness of imaging technology: recent
results, problems and progress in the UK. European Radiology. 2000; 10
(Suppl 3): S427 S429.
[53] TRIP Database Ltd. TRIP database for Evidence Based Medicine
(webpage); 2008.
http://www.tripdatabase.com/SearchResults.html?ssid=&s=1&criteria=CT+sca
n&sort=t [cited November 2008].
[54] Stein SC, Burnett MG, Glick HA. Indications for CT scanning in mild
traumatic brain injury: a cost-effectiveness study. Journal of Trauma Injury,
Infection and Critical Care. 2006; 61(3): 558 566.
[55] Wardlaw JM, Seymour J, Cairns J, Keir S, Lewis S, Sandercock P.
Immediate computer tomography scanning of acute stroke is cost effective and
improves quality of life; Stroke. 2004; 35(11): 2477-2483.
[56] Dryver E T, Jernstrom H, Tompkins K, Buckstein R, Imrie K R. Follow-up of
patients with Hodgkin's disease following curative treatment: the routine CT
scan is of little value. British Journal of Cancer. 2003: 89(3); 482- 486.
[57] Institute for Clinical Systems Improvement. Whole-Body Computed
Tomography as a Screening Test. ICIS Technology Assessment report 080;
2003. http://www.icsi.org/technology_assessment_reports_-_active/ta_wholebody_computed_tomography_as_a_screening_test.html [cited November
2008]
[58] Black C, Bagust A, Boland A, Walker S, McLeod C, Verteuil R, et al. The
clinical and cost-effectiveness of CT screening for lung cancer: systematic
reviews. Health Technology Assessment. January 2006;10(3):1-106.
http://www.ncchta.org/execsumm/summ1003.htm [cited November 2008]

CEP08007: March 2009

References

133

[59] DH. 2008/09 Indicative Tariff to support Unbundling of Diagnostics


(Diagnostic 0809) (spreadsheet).
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHS
FinancialReforms/DH_081226 [cited November 2008]
[60] DH: PbR development
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHS
FinancialReforms/DH_4134854 [cited November 2008]
[61] DH, NHS Executive, Information Management Group, National Casemix
Office. HRG healthcare resource groups community groupings project health
visiting; Jan 1996.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_4010547 [cited November 2008]
[62] Casemix Service. Guide to Unbundling.doc version 1.0 13 April 2007
London; The Information Centre for Health and Social Care
http://www.ic.nhs.uk/webfiles/Services/casemix/Prep%20HRG4/Guide%20to%
20Unbundling2.pdf [cited November 2008]
[63] Connecting for Health, OPCS-4 Intervention Classification
http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/
codingstandards/opcs4 [cited November 2008]
[64] Connecting for Health, SNOMED Clinical Terms
http://www.connectingforhealth.nhs.uk/systemsandservices/data/snomed [cited
November 2008]
[65] Maybin J. Payment by results. Kings Fund briefing (electronic document)
October 2007.
http://www.kingsfund.org.uk/publications/briefings/payment_by_1.html [cited
November 2008].
[66] DH. NHS reference costs 2006-07 Appendix NSRC1; 2008.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli
cyAndGuidance/DH_082571 [cited November 2008]
[67] The Waste Electrical and Electronic Equipment Regulations 2006. Statutory
Instrument 2006/3289. London: The Stationery Office; 2006.
http://www.opsi.gov.uk/si/si2006/20063289.htm [cited November 2008].

CEP08007: March 2009

References

134

[68] The Waste Electrical and Electronic Equipment (Amendment) Regulations


2007. Statutory Instrument 2007/3454. London: The Stationery Office; 2007.
http://www.opsi.gov.uk/si/si2007/uksi_20073454_en_1 [cited November 2008].
[69] NHS PASA. Purchasing and supply policies (webpage).
http://www.pasa.nhs.uk/pasa/Doc.aspx?Path=[MN][SP]/Guidance
Documents/Policy and strategt/Poilcy Strategy.doc (sic) [cited November
2008].
[70] DH. National framework of standards for best practice procurement in the
NHS (webpage); 2008.
http://www.pasa.nhs.uk/PASAWeb/Guidance/Bestpractice/Nationalframeworko
fstandardsforbestpracticeprocurementintheNHS.htm [cited November 2008]
[71] European Commission. Guide on dealing with innovative solutions in public
procurement: 10 elements of good practice. Commission staff working
document. SEC(2007)208; 2007. http://www.proinnoeurope.eu/doc/procurement_manuscript.pdf [cited November 2008]
[72] NHS PASA. NHS trust operational purchasing procedures manual (TOPPM).
http://nww.pasa.nhs.uk/PASAWeb/Guidance/TOPPM/LandingPage.htm [cited
November 2008].
[73] Office of Government Commerce (OGC). EU procurement thresholds
(webpage); last updated October 2008.
http://www.ogc.gov.uk/procurement_policy_and_application_of_eu_rules_eu_p
rocurement_thresholds_.asp [cited November 2008]
[74] Securing the Future - UK Government Strategy for Sustainable Development
http://www.defra.gov.uk/sustainable/government/publications/ukstrategy/index.htm [cited November 2008]
[75] OGC. Business case; last updated October 2008
http://www.ogc.gov.uk/documentation_and_templates_business_case.asp
[cited November 2008]
[76] RCR. Clinical radiology writing a good business case. RCR Publication
BFCR(96)7. London: Royal College of Radiologists; 1996.
http://www.rcr.ac.uk/index.asp?PageID=310&PublicationID=83 [cited
November 2008]

CEP08007: March 2009

References

135

[77] NHS PASA. Preparing a business case. OPPM Section 1 basic steps of a
procurement process, reference 1-01 (electronic document); 28 February
2007. http://nww.pasa.nhs.uk/pasa/Doc.aspx?Path=[MN][SP]/Guidance
Documents/OPPM/1_01_procedure.doc [cited November 2008]
[78] NHS Supply Chain. [on-line] http://www.supplychain.nhs.uk/ [ cited
November 2008]
[79] DH. European Union tendering timetable (electronic document); 1 January
2004.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPro
curement/DH_4070620 [cited November 2008].
[80] ImPACT www.impactscan.org [cited November 2008]
[81] NHS PASA. Capital Investment Programme for CT Scanners: Process Pack.
Phase 8; 2002 (personal communication).
[82] NHS PASA. Completing the Pre-purchase Questionnaire (PPQ). Trust
operational purchasing procedures manual: procedure T-17. (OPPM
Reference 2-07) Issue 02; July 2003.
http://nww.pasa.nhs.uk/pasa/Doc.aspx?Path=[MN][SP]/Guidance%20Docume
nts/TOPPM/T_17_procedure.doc [cited November 2008]
[83] DH. Procurement policy overview (webpage); last updated October 2008.
http://www.dh.gov.uk/en/Procurementandproposals/Procurement/Procurement
policy/DH_4066090 [cited November 2008]
[84] Centre for Evidence-based Purchasing (CEP). CT clinical applications
software. Comparative specifications. CEP 08024. NHS PASA; December
2008
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm
[85] Centre for Evidence-based Purchasing (CEP). 16 slice CT scanner technical
specifications. Comparative specifications. CEP 08025. NHS PASA;
December 2008.
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm
[86] Centre for Evidence-based Purchasing (CEP). 32 to 40 slice CT scanner
technical specifications. Comparative specifications. CEP 08026. NHS PASA;
December 2008.
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm

CEP08007: March 2009

References

136

[87] Centre for Evidence-based Purchasing (CEP). 64 slice CT scanner technical


specifications. Comparative specifications. CEP 08027. NHS PASA;
December 2008.
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm
[88] Centre for Evidence-based Purchasing (CEP). Wide bore CT scanner
technical specifications. Comparative specifications. CEP 08029. NHS PASA;
December 2008.
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm
[89] Centre for Evidence-based Purchasing (CEP). 128 to 320 slice CT scanner
technical specifications. Comparative specifications. CEP 08028. NHS PASA;
December 2008.
http://www.pasa.nhs.uk/PASAWeb/NHSprocurement/CEP/CEPproducts.htm
[90] Centre for Evidence-based Purchasing (CEP). Sixteen slice CT scanner
comparison report version 14. CEP Report 06012; February 2006
http://www.pasa.nhs.uk/pasa/Doc.aspx?Path=[MN][SP]/NHSprocurement/CEP
/CT/Report_06012.pdf [cited 28 November 2008].
[91] ImPACT. CTSpec CT specification comparison (webpage); 2007.
http://www.impactscan.org (NHS access only) [cited November 2008]
[92] ECRI https://www.ecri.org [cited November 2008]
[93] Sg2 (webpage) http://www.sg2.com/ [cited November 2008]
[94] NHS PASA. Leasing homepage
http://www.pasa.nhs.uk/pasaweb/productsandservices/leasing [cited
November 2008]
[95] Public Contracts Regulations 2006. Statutory Instrument 2006/5. London:
The Stationery Office; 2006. http://www.opsi.gov.uk/si/si2006/20060005.htm
[cited November 2008]
[96] OGC. 3 Business case process (webpage); last updated 1st August 2006.
http://www.ogc.gov.uk/introduction_to_procurement_business_case.asp [cited
November 2008]
[97] NHS PASA. Procedure T-08 Establishing a framework agreement where the
awarding authority is a health authority or NHS trust (no Agency involvement),
Issue 6, OPPM Ref 1-12E (electronic document); August 2007.

CEP08007: March 2009

References

137

http://nww.pasa.nhs.uk/pasa/Doc.aspx?Path=[MN][SP]/Guidance%20Docume
nts/TOPPM/T_08_procedure.doc [cited November 2008]
[98] DH Procurement and policy advisory unit (PPAU). Desk guide to
procurement - 2005 edition (electronic document); 26 April 2005.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPro
curement/DH_4109316 [cited November 2008]
[99] DEFRA. UK Govt Sustainable Development; updated February 2008.
http://www.defra.gov.uk/sustainable/government/ [cited November 2008]
[100] NHS PASA. Electricity
http://nww.pasa.nhs.uk/PASAWeb/Productsandservices/Energyandwater/Elect
ricity/ [cited November 2008]
[101] Health and Safety Commission. Working with Ionising Radiations: Ionising
Radiations regulations 1999: Approved Code of Practice and Guidance. 2000.
Norwich, HSE Books. http://www.hse.gov.uk/radiation/ionising/ [cited
November 2008]
[102] Health and Safety Executive. The regulatory requirements for medical
exposure to ionising radiation: an employers overview: Joint Health and Safety
Executive and Health Departments guidance. Reference HSG223; 2001.
Sudbury, HSE Books
[103] IPEM et al . Medical and Dental Guidance Notes A good practice guide on
all aspects of ionising radiation protection in the clinical environment. 2002.
York, IPEM.
[104] Health and Safety Executive. Equipment used in connection with medical
exposures. Guidance note PM77. 3rd Ed.
www.hse.gov.uk/pubns/guidance/pm77.pdf [cited November 2008]
[105] Health and Safety Executive. Medical Exposure; September 2008
http://www.hse.gov.uk/radiation/ionising/exposure.htm [cited November 2008]
[106] Health and Safety Executive. Radiation protection publications; May 2008
http://www.hse.gov.uk/radiation/ionising/publications.htm [cited November
2008]
[107] DH Estates and facilities. Facilities for diagnostic imaging and interventional
radiology. HBN 6 Volume 1; Nov 01. London, The Stationery Office.

CEP08007: March 2009

References

138

http://195.92.246.148/knowledge_network/documents/HBN_6_Vol_1_Exec_su
mm_20071122124021.pdf [cited November 2008]
[108] DH Estates and facilities. Diagnostic imaging : PACS and specialist imaging.
HBN 6 Volume 2; July 03. London, The Stationery Office.
http://195.92.246.148/knowledge_network/documents/HBN_6_Vol_2_Exec_su
mm_20071122124329.pdf [cited November 2008]
[109] HBN 6 Volume 3: Extremity and open MRI, magnetic shielding and
construction for radiation protection; (electronic document)
http://195.92.246.148/knowledge_network/documents/HBN_6_Vol_3_Exec_su
mm_20071122124612.pdf [cited November 2008]
[110] Statens stralskyddsinstitut. The Swedish Radiation Protection Institutes
Regulations on Radiation Shielding of X-ray Installations for Medical
Diagnostics. SSI FS 1991; 1; 1991
http://www.stralsakerhetsmyndigheten.se/In-English/Publications/ [cited
November 2008]
[111] Medical Electrical Installation Guidance Notes. (MEIGaN)
http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/
Technicalinformation/MEIGaN-MedicalElectricalInstallationGuidance/index.htm
requirements for medical electrical systems [cited November 2008]
[112] Annex, Healthcare interpretation of IEE Guidance Note 7 (Chapter 10) and
IEC 60364-7-710 for Electrical Installations in Medical Locations. Version 2;
September 2007. http://webstore.iec.ch/preview/info_iec60601-1-1{ed2.0}b.pdf
[cited November 2008]
[113] BS 7671:2008 Requirements for electrical installations. IEE Wiring
Regulations. Seventeenth edition.January 2008. ISBN 978 0 86341 844 0
http://www.bsi-global.com/en/Shop/PublicationDetail/?pid=000000000030155604 [cited November 2008]
[114] The Institution of Electrical Engineers. Guidance Note 7: Special locations.
2nd Edition. 2003. Stevenage, IEE Publications
http://www.theiet.org/publishing/books/wir-reg/19284.cfm [cited November
2008]
[115] IEC. Electrical installations of buildings Part 7-710: Requirements for
special installations or locations Medical locations. IEC 60364-7-710 Ed. 1.0
Preview. November 2002 http://webstore.iec.ch/preview/info_iec60364-7710{ed1.0}b.pdf [cited November 2008]
CEP08007: March 2009

References

139

[116] BS EN 60601-1:2006. Medical electrical equipment. General requirements


for basic safety and essential performance; November 2006. London, BSI
[117] BS 5724-2.44:2001. Medical electrical equipment. Particular requirements
for safety. Particular requirements for the safety of X-ray equipment for
computed tomography. August 2002. London, BSI
[118] BS EN 60601-1-2:2007 Medical electrical equipment. General requirements
for basic safety and essential performance. Collateral standard.
Electromagnetic compatibility. Requirements and test; September 2007.
London, BSI
[119] BS EN ISO 14971:2007 Medical devices. Application of risk management to
medical devices; April 2007. London, BSI
[120] BS EN 60526:2004 High-voltage cable plug and socket connections for
medical X-ray equipment. Feb 2004. London, BSI
[121] BS EN 60529:1992 Specification for degrees of protection provided by
enclosures (IP code). January 1992. London, BSI.
[122] MHRA. Medical Device Directive (webpage); February 2008.
http://www.mhra.gov.uk/Howweregulate/Devices/MedicalDevicesDirective/inde
x.htm [cited November 2008]
[123] The Health and Safety at Work etc Act 1974
http://www.hse.gov.uk/legislation/hswa.pdf [cited November 2008]
[124] Management of Health & Safety at Work Regulations (1992) Statutory
Instrument 1992 No. 2051
http://www.opsi.gov.uk/si/si1992/Uksi_19922051_en_1.htm [cited November
2008]
[125] The Health and Safety (Display Screen Equipment) Regulations 1992
Statutory Instrument 1992 No. 2792. London: The Stationery Office.
http://www.opsi.gov.uk/si/si1992/Uksi_19922792_en_1.htm [cited November
2008]
[126] The Manual Handling Operations Regulations 1992, Statutory Instrument
1992 No. 2793 http://www.opsi.gov.uk/SI/si1992/Uksi_19922793_en_1.htm
[cited November 2008]

CEP08007: March 2009

References

140

[127] Health Service Advisory Committee (1992), Guidance on the Moving and
Handling of loads in the Health Service
[128] Backcare, Royal College of Nursing (RCN). Smith J (Editor). The Guide to
the Handling of People, 5th Edition; 2005. Middlesex, Backcare
[129] Trade Union and Industrial Relations department. Watch your back. London,
SCoR. http://www.sor.org/ccp51/cgi-bin/cpapp.cgi?usr=51F8136286&rnd=8421823&rrc=N&affl=&cip=194.176.105.40&ac
t=&aff=&pg=prod&ref=WATCHBACK&cat=TUIRPUBL&catstr=HOME:TUIRPU
BL [cited November 2008]
[130] Health and Safety Executive. Legislation owned and enforced by HSE and
Local Authorities. http://www.hse.gov.uk/legislation/enforced.htm [cited
November 2008]
[131] NHS Connecting for Health. Standards Enforcement in Procurement (STEP)
STEP August 2008 http://www.connectingforhealth.nhs.uk/industry/step [cited
November 2008]
[132] NHS PASA. Procurement of Information Systems Effectively (POISE)
manual. Version 3.1. 2004
http://www.pasa.nhs.uk/PASAWeb/Guidance/POISE.htm [cited November
2008]
[133] NHS supplementary conditions of contract for the supply, installation and
maintenance of clinical radiology and clinical oncology equipment (CRACOE)
January 2005. http://www.axrem.org.uk/cracoe_[accessed November 2005]
[134] Association of Healthcare Technology Providers for Imaging, Radiotherapy
and Care. AXrEM Recommended Contract Conditions.
http://www.axrem.org.uk/axrem_rec.html [cited 14 July 2008]
[135] NRPB et al. Guidance Notes for the Protection of Persons Against Ionising
Radiations Arising from Medical and Dental Use London; HPA
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733
842609?p=11589450665166 [cited November 2008]
[136] Medical Electrical Installation Guidance Notes. (MEIGaN) and Annex,
Healthcare interpretation of IEE Guidance Note 7 (Chapter 10) September
2007. http://www.mhra.gov.uk/home/groups/commsic/documents/websiteresources/con2018069.pdf [cited November 2008]

CEP08007: March 2009

References

141

[137] IEC 60364-7-710 Electrical installations of buildings Part 7-710:


Requirements for special installations or locations Medical locations.
http://webstore.iec.ch/webstore/webstore.nsf/artnum/029477 [cited November
2008]

CEP08007: March 2009

Appendix 1: Supplier contact details

142

GE Healthcare

Siemens Healthcare

352 Buckingham Avenue


Slough
Berks
SL1 4ER

Faraday House
Sir William Siemens Square
Frimley
Camberley
Surrey
GU16 8QD

tel:
01753 874000
website: www.gehealthcare.com

tel:
01276 696000
website: www.siemens.co.uk/medical

Philips Medical Systems

The Observatory
Castlefield Road
Reigate
Surrey
RH2 0FY
tel:
01737 230400
website: www.medical.philips.com/uk/

CEP08007: March 2009

Toshiba Medical Systems

Boundary Court
Gatwick Road
Crawley
West Sussex
RH10 9AX
tel:
01293 653700
website: www.toshiba-medical.co.uk

Appendix 2: EU procurement procedure

143

EU procurement procedure
Lease options
National frameworks are in place for operating leases to help the NHS procure
leases more cost efficiently and effectively. The framework came into place on 1st
April 2007 and runs for two years. Further details are available from the PASA
website [94].
EU procedures
The Public Sector Directive (2004/18/EC) has been transposed into UK law. This has
been achieved by means of the following statutory instruments:
the Public Contracts Regulations SI 2006 No.5 (the regulations) [95]
the Utilities Contracts Regulations SI 2006 No. 6 (not relevant to this guide).
The regulations apply to contracts worth more than 90,319 (from January 1st 2008)
[73] over their whole life, and specify the procedures to be followed for public sector
contracting, including adherence to strict timetables, requirements for advertising,
invitation to tender and the award of contract. Organisations undertaking a
procurement exercise covered by the regulations must give all suppliers an equal
opportunity to express an interest in tendering for the contract by placing a contract
notice in the Official Journal of the European Union (OJEU).
At all stages of the procurement process, the purchaser must be demonstrably fair,
as any decision made can be challenged by the unsuccessful suppliers.
Establishing a procurement strategy
To achieve a successful outcome, decisions need to be made on:

whether an existing contract/agreement can be used


the need to consider sustainable development issues
whether EU directives apply
the type and form of contract
sourcing potential suppliers
duration of contract and opportunity to review/extend
payment schedules
how to minimise any risks with the chosen strategy, including supplier
appraisal and evaluation/clarification of suppliers bids.

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144

Preparing a business case


A business case should be drafted and approved before conducting any procurement
exercise. Further guidance on preparing business cases is available from the Office
of Government Commerce [96] and an illustrative example is provided in the NHS
PASA Operational Purchasing Procedures Manual, Procedure 1-01 [77].
The EU tendering exercise
EU procurements usually take between 4 and 6 months to complete. This needs to
be taken into account in the planning stages. The length of the exercise depends on
the chosen procedure (open or restricted). Further information is available from the
Department of Health [79].
The procurement panel
A multidisciplinary team should be selected to guide the purchase. Representatives
from clinical, user, technical, medical physics, estates and financial areas should be
considered.
Identifying potential suppliers
Criteria for supplier selection must be established. A supplier pre-qualification
questionnaire may be employed, as an initial screen to exclude unsuitable suppliers,
which asks for details such as skills and experience of the service engineers.
Evaluation criteria
Performance specifications should be derived from local operational requirements,
and agreed by the procurement panel. They will form the basis for assessing the
adequacy of suppliers technical specifications, provided in response to the technical
specification questionnaire.
It is important to have agreed on the performance specifications of the product as
they will be used in the adjudication against company specifications.
Requests for features which are supplier-specific are not permitted under the
regulations. Very specific features which are not supported by operational
requirements are also not allowed.
Award of contract
Following award of the contract to the successful supplier; unsuccessful suppliers
may need to be debriefed. This is at the suppliers request.

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145

Buyers must be aware of the Alcatel procedure (see the Trust Operational
Purchasing Procedures Manual, Procedure No.T-08, section 6 - Mandatory Standstill
Period [97]).
For more information on procurement please refer to the Department of Health
website [98].

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Appendix 3: Supporting sustainable purchasing

146

The UK Government Sustainable Development Strategy established the Sustainable


Procurement Task force (SPTF) to bring about a change in public procurement. The
SPTFs National Action Plan on Sustainable Procurement sets out how this can be
achieved. More information can be found on the UK Government Sustainable
Development website [99].
Good procurement practice is about making decisions on the whole-life costs
including social and environmental implications. Although the costs and benefits of
sustainable procurement are hard to quantify, it is important to encourage
manufacturers, suppliers and contractors to develop environmentally and socially
preferable goods and services at a competitive price.
This section provides some practical guidance on how this and other sustainability
issues can be incorporated into procurement decision making processes.

Selection criteria
The following criteria should be applied to all purchases of equipment. Equipment
should not be purchased or contracted for if it does not satisfy criteria that are
required by a trusts local policies.
Primary (mandatory) criteria
The supplier must provide full details demonstrating compliance with the UK
WEEE regulations (2006) [27] including producer registration, compliance
scheme details, and correct product marking.
Secondary (discretional) criteria
These criteria are not mandatory, but may be considered as part of the procurement
process:
does the equipment meet the standards required under UK Restriction of
Hazardous Substances regulations (2005) [28]? (These are currently
voluntary for medical equipment).
what energy efficiency features have been incorporated into the product
design to reduce energy consumption? For example, standby modes for
computer or X-ray hardware, efficiency improvements during exposure etc.
does the supplier have systems for reducing their environmental impact? For
example do they use recycled materials in packaging and providing
documentation electronically?

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147

Energy consumption
One of the most significant aspects of sustainable procurement for all diagnostic
image systems is the consumption of electricity of the system. Scanners are heavy
power users. The impact of this on the energy requirements of the department should
be considered.
The energy demand of the CT scanners varies according to the number and type of
procedure performed. Changes in the scanner and related changes in the clinical
workload may affect this. The energy consumption of a system should be included in
the whole-life cost of the equipment if practical (see chapter on Economic
considerations). It is also important to include other power consumption related to the
operation of the scanner, such as chillers, air conditioning.
The following model allows a method to estimate the energy cost of the scanner
system. Other models are equally valid if used consistently.
Energy cost model
Electricity is usually charged per kilowatt-hour (kWh). A kWh unit cost must be
established to enable whole life energy consumption figures to be converted into a
cost and therefore factored into the whole life cost of the equipment. However,
energy prices can fluctuate and may increase at a rate greater than overall inflation in
the future, so care should be taken when establishing a cost per kWh and in
interpreting the results of any cost calculations.
Some of the important factors to consider are listed below, along with an example of
a possible formula. This formula is provided as a guide only, and it is recommended
that purchasers seek additional advice from local experts or NHS PASA. The
radiography department or local medical physics department are likely to have details
of workloads and types of procedures from radiation dose audits which may provide
useful data.
the baseline energy consumption per hour for whole scanning system whilst
powered up but not exposing: Eidle (kWh)
the total additional energy consumption for each procedure type above
baseline consumption: E1, E2 etc. (kWh)
as a first approximation, this can be taken as the maximum power of the
scanner and an average scan time
number of each type of procedure per year: N1, N2 etc
the fraction of time the system is powered up but not exposing: fidle
the baseline energy consumption per hour whilst on standby (on in out of
hours mode): Estandby (kWh)
the fraction of time the equipment is on standby: fstandby

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148

the fraction of time the equipment is powered down: foff


the price () per kWh paid: P
the total number of hours in a year (taken to be 8766): H (hours).
The total cost per annum, C, can then be calculated using:

C = P {( N1 E1 + N 2 E2 + ... + N m Em ) + f idle H Eidle + f standby H Estandby }


Using recent energy cost data from your organisation will be the most accurate
approach but if this is not available there are national surveys that can provide
average market costs [100].
Note that energy tariffs can change by time of day and week, so some consideration
of differing kWh unit costs can be factored into the calculations.

CEP08007: March 2009

Appendix 4: Preparing a specification

149

Preparing a specification
The following guidance is intended to supplement local procurement procedures for
CT scanners.
The clinical needs of the department for provision of CT services need to be
determined as part of the business case, and for preparing a statement of operational
requirements for inclusion in the invitation to tender. A four-step model is suggested
for determining the operational requirements, and an example statement of
operational requirements is included for guidance purposes.
All NHS trusts and every department have individual requirements, and the following
should not restrict the stating of particular needs. You may wish to change the
format, or make additions. It may be used to guide local discussion, check that
existing processes address procurement requirements, and to help optimise the
choice of CT for your particular needs. They are taken from a number of sources and
have been adapted for this report.
In all cases, you are advised to check with the relevant local experts in the
purchasing office, estates department, and medical physics department to ensure
that all existing legal and operational requirements are addressed. Where local
expertise is not available, professional bodies such as NHS PASA, RCR and IPEM
should be consulted.

Preparing a statement of operational requirements


The following is one model that may aid in building up a picture of your clinical needs.
This will then work towards the writing of the statement of operational requirements
for the tender. This statement may be in the form of an output based specification
(OBS) or a (summary) statement of needs (SoN). Further detail may be identified
during this process, and this can be included as a technical specification or detailed
statement of need (DSoN) as appropriate.
The suggested steps are:
survey: take stock of current services and equipment
wish list: draw up ideas and needs for the intended services and any other
issues that have been highlighted
match: compare the equipment is available against the wish list
write: produce statement of operational requirements.

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Appendix 4: Preparing a specification

150

Step 1
Table 21 gives a set of questions to aid an initial survey of your current service
provision. This is based on text originally issued as part of the NHS PASA Capital
Investment Programme for CT Scanners in 2002 [81].
Table 21. Survey of current departmental services

Questions

Comments and hints

Current CT scans

In what areas do you currently use CT scans as a stage in


the diagnostic pathways?

Other diagnostic
procedures

Especially consider areas which currently use other


modalities in the clinical diagnosis, but that may be equally
undertaken by a CT scan?

Modalities

Information systems

What is the current provision of imaging modalities, and are


there any changes planned?
What workstations and clinical applications software do you
already have in the department (or requirements for such?
What digital systems do you have in your department?
Which of these interact with the scanner (or ideally would)?
What is the patient throughput? Either patients per hour,
per day or annually.

Workload

What are the numbers in each (major) area?


Are you currently meeting any targets that apply?

Working hours

Are the current hours limited by staff, by patients, by other


factors?
What out of hours use is made of the scanner?
How do patients move through the department?

Patient pathways

How do these compare for in-patient and out-patients?


Are there any problem areas and bottlenecks?

CEP08007: March 2009

Appendix 4: Preparing a specification

Questions

151

Comments and hints


What are the current image / data route through the
department?

Data flow

Are there any plans to change these for new reporting


methods?
Are there any problem areas and bottlenecks?

Experience

Training

What clinical, operational and technical experience of CT


do your staff have?
What is the current arrangement for training?
Is it effective?
What are the current service and maintenance
arrangements?

Technical support

Are there any restrictions on clinical service due to current


arrangements?
Are QA and other testing programmes in place and working
well?
Describe the essential issues and design features , for
example:

Scanning suite

location
available area
access for beds etc
infection control surveys
radiation protection issues
power provision
air conditioning

Step 2
The next step is to produce a wish list for the clinical service that will be in place with
the new CT scanner. This may be based on issues with the current service, or
planned developments of the service. This will normally be developed in consultation
with clinical directors, service managers, and such, but it is also useful to consult the
daily users to highlight any bottlenecks or issue resolutions that can be written into
the wish list. Table 22 gives some ideas of items that should be considered when
drawing up this list. It is beneficial if requirements can be defined as,
CEP08007: March 2009

Appendix 4: Preparing a specification

152

primary: these are the elements most likely to be considered essential


secondary: these are the elements that are very desirable, but may need to
be compromised
optional: items that would be very nice to have, but there is no practical
impact on the clinical service
Table 22. Initial requirements

Topic

Items to consider
In what areas do you anticipate the CT scanner will
contribute to your current and future clinical diagnosis?

Service provision

Workload

Working hours

What kind of imaging will you expect to do? For example


will it be used for general head imaging, musculo-skeletal
imaging etc? Is there a need for specialist services such as
cardiac angiography, stroke assessment, or radiotherapy
planning?
What patient throughput do you anticipate? And what
numbers (or percentage of total) for each type of
examination?
Do not forget to include any planned increase due to
service changes or those that you would need to meet any
targets.
What do you anticipate to be your days and hours of
working? Will these remain as they are, or will they be
adjusted with the introduction of new scanners and
services?
What will be the patient pathway through the department?

Workflow

What is the required data flow for the images?


With what systems will the CT scanner need to
interoperate?

Data management

CEP08007: March 2009

What digital storage facilities to you have/need? What


appropriate hard copy facilities do you have/need? How
are they to be connected to both existing and future
equipment?

Appendix 4: Preparing a specification

Topic

Items to consider

Service redesign

Are there other changes planned for the department that


will affect the workflow in the department? How will these
affect the workload and interoperability?

153

If necessary, revisit the previous questions


How does the existing skills mix match that which will be
required?
Skills gap

What staff training do you anticipate?


How will this be delivered?
Will it be a new room, or conversion of existing room?
If new (or major refurbishment), what is the proposed
location and design of suite?

Scanner suite

When will site be ready?


How will the equipment be delivered to the site?
What is the access to site for engineers during the
installation?
What other clinical areas are adjacent or near-by?

From these, you should be able to identify the functions that the new system will
need to accomplish in order to fulfil the expected clinical service.
This step requires a number of iterative steps where the wish list is refined
according to practical consideration, financial constraints, relative clinical priorities,
and such. At the end of this, a reasonable definition of the requirement should be
possible.
Step 3
In step 3 the wish list should be compared with capabilities of equipment that is
available for purchase. Reference to the relevant Comparative specification reports
[84] - [88], as well as the Technical considerations and Market review chapters of this
buyers guide will help in this.

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Appendix 4: Preparing a specification

154

Step 4
Table 23 provides a guide to areas that should be described in a statement of
operational requirements. This is not exclusive or exhaustive, and other information
may be added as considered appropriate for the local requirements.
Table 23. Statement of operational requirements

Questions

Information to provide

Clinical workloads

State the types of scans that you expect to undertake and


some general figures on workloads, patients per day or
similar.

Specialist investigations

State any investigations that may have specific technical


requirements, such as cardiac scanning, or perfusion
studies.
State any requirements on the scanner usability, patient
throughput.

Scanner requirements

State if the scanner must have a planned upgrade route


during service.
State any physical limits such as room size, floor loading, or
power that restrict the scanner choice.

Workstations

Clinical applications
software

State how many scanner workstation will be required, and


where these will be located.
State if any workstations are required to be shared with
other scanners or modalities.
State all specialist applications required to meet clinical
needs, such as cardiac angiography, 3D reconstructions,
MIPs.
State whether these are required at specific workstations or
at remote access clients.

Interoperability - clinical

State any existing clinical equipment that the scanner must


work with, such as contrast pumps or biopsy systems.

Interoperability - technical

State the RIS, PACS and other systems that will interact
with the CT scanner (and workstation).

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Appendix 4: Preparing a specification

Questions

155

Information to provide
State if local archiving is required.
State if hard copy production is required at the scanner, or
elsewhere, and if laser imagers are required, or state
existing imagers (number of ports available).
State if the system is required to create discs of patient
data for transfer or legal use.

Image and data handling

State key data management and transfer functionality, such


as:

images / data should be transmitted


automatically to the PACS
images should be printable
to what hardware the system should be
networked.
You may wish to state explicitly the IHE profiles and / or
DICOM functionality required, or refer to a DSoN.
State any physical limitations imposed by the scanner suite,
such as floor loading, space available.
Scanner suite

State essential features of the proposed location, such as


the access, neighbouring rooms, nearby equipment, etc.
State the date on which the scanner suite will become
available for works and installation.
State what levels of technical support are required.

Support

State what hours of service coverage are required.


State if routine maintenance out of hours is required.
State whether a turnkey solution is required.

Installation and building

State any additional building works that are required.


State what level of continuity of clinical service is required
during building works and installation.

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Appendix 4: Preparing a specification

156

Questions

Information to provide

Standards

State all the international, national and local standards that


apply to the scanner and the associated systems.

Terms and conditions

Specify any standard terms and conditions that apply.


Specify other applicable terms and conditions.

Note: if integration or interoperability with other systems, such as RIS or PACS, is


required, you may wish to state details of these systems in an appendix or similar.
These can include make/model, software version, installation date, contact details of
suppliers. In the ideal case, a separate specification of the connections required to
interact with these systems should be obtained to pass to the prospective tenderers.
You may wish to provide a more detailed breakdown of the scanner workload in a
table such as Table 24. Amend categories, or name specific investigations as
required.
Table 24. Clinical workload breakdown (CT scanner)
Current workload
(number or %)

Anticipated future clinical


workload

Head and neck


Chest
Abdomen and pelvis
Interventional
Other (eg cardiac)
etc

It is recommended that the statement of operational requirements is produced as an output


based specification, in terms of what is required for each area as listed in Table 23. Any
specific technical detail of how these are obtained should be provided separately. This will
then allow the manufacturers to initially offer their best solution to the stated need, and can
then be modified during subsequent negotiation.

It should be clear in the statement which aspects of the requirements are defined as
essential and which are desirable and may be compromised in order to achieve a
best value procurement. The latter can be stated as a separate list of possible
variations.

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Appendix 4: Preparing a specification

157

Principles, standards, procedures, and guidelines


There are a number of international and national regulations that apply to the
equipment and installation of a MSCT scanner. All four major manufactures install
units worldwide and in the UK and hence should be able to show compliance with all
of the mandatory regulations. It is normal to ask for copies of relevant certificates as
part of the tendering process.
The following are lists of some of the regulations and other documentation that may
be included in an operational requirements statement. Other requirements may be
added according to local procedure.
Ionising radiations
For current regulations relating to ionising radiation, a local expert, such as the RPA
or medical physics department should be consulted.
The Ionising Radiations Regulations 1999 (IRR 99) [21]
Approved code of practice and guidance for IRR 99 [101]
The Ionising Radiation (Medical Exposures) Regulations (IR(ME)R 2000,
2006) [22], [51]
HSE employers overview of the regulatory requirements for medical
exposure to ionising radiation [102]
Medical and Dental Guidance Notes [103]
PM77 [104].

Further related guidance can be found on the HSE website [105], [106].
Building and electrical requirements
For regulations relating to equipment installation, and electrical safety, the estates
department and medical physics department should be consulted.
Health Building Note (HBN)6 [107], [108], [109]
Swedish regulations on radiation shielding (SSI FS 1991:1) [110]
Medical Electrical Installation Guidance Notes and annexes [111],[112]
IEE Wiring Regulations [113]
IEE Guidance Note 7, Special Locations [114]
IEC 60364-7-710 (Electrical installations of buildings Requirements for
special installations or locations Medical Locations) [115]
British, and other, standards for medical electrical equipment
o general safety and performance [116]

CEP08007: March 2009

Appendix 4: Preparing a specification

o
o
o
o
o

158

safety of computed tomography [117]


electromagnetic compatibility [118]
risk management [119]
high voltage plugs and sockets [120]
ingress protection [121].

Medical devices
The latest information regarding CE marking, the medical device directive (MDD) and
medical device regulations (MDR) can be found on the MHRA website [122].
General Health and safety
As well as the specific requirements for ionising radiations and related equipment,
there are general health and safety considerations, and those relating to manual
handling.

The Health and Safety at Work Act 1974 [123]


Management of Health & Safety at Work Regulations [124]
The Health and Safety (Display Screen Equipment) Regulations 1992 [125]
Manual Handling Operation Regulations 1992 [126]
Guidance on the Moving and Handling of loads in the Health Service [127]
The Guide to the Handling of People [128].

There are many other notes and summaries of best practice when moving patients
[129]. Contact the local Manual handling team within the trust to obtain the latest
guidance and any local polices.
A full list of health and safety legislation can be access at the HSE website [130].
Local H&S officers should be consulted to ensure that all local requirements are
addressed.
Other documentation
Standard documentation also exists within related purchase areas, such as ICT
systems and data networking [131][132]. Although these may not be applicable en
masse to the MSCT specification, there will be guidance to good principle and
practice that may be included. The local ICT department should always be consulted
to identify any local networking or other such requirements.
There are standard terms and conditions of contract that will apply to major capital
purchases such as a MSCT scanner, for example CRACOE 2005 [133]. Others may
be required by local procedures [134]. The local purchase officers, NHS PASA and
NHS Supply Chain should be consulted to ensure compliance.

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Appendix 4: Preparing a specification

159

Historical documentation
The following is a list of deprecated documentation that may be useful. These are no
longer routinely available from the publisher; copies may still exist within local
departmental holdings. These documents should not be referenced in any
specification. Even though these documents, or the regulations to which they refer,
may have been superseded they still contain guidance that may be useful in the
purchase process.
NHS ME Guidelines HSG(91)11 - Patient Dose Reduction - Purchasing
Radiology Equipment [no longer available]
Guidance Notes for the Protection of Persons Against Ionising Radiations
Arising from Medical and Dental Use [135]
TRS 89: National Health Service Procurement Directorate - Technical
Requirements for the Supply and Installation of Equipment for Diagnostic
Imaging and Radiotherapy (superceded by MEIGaN [136]).

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160

Example statement of operational requirements


This statement can be used in the absence of other pro formas, and has been
produced in the form of an invitation to tender (ITT).
You will need to complete the specific details according to your identified clinical and
technical needs, as derived from a process similar to that outlined above.
You may also wish to ask for current technical specifications, in a standard format,
such as the ImPACT questionnaire*. This should aid in the comparison of
performance claims and detailed specialist technical features.
Before using this example, you should:
decide whether an OBS (see appendix 4) approach would suit your needs
better
check with local purchasing officers that it complies with local requirements
confirm the operational requirements list
familiarise yourself with current applicable legal requirements and good
practice guidance.

*This standard questionnaire is widely used in NHS scanner purchases. The latest revision (version 15) has been
used to produce the technical specification comparison reports ([84] - [89]). An electronic copy is available from
ImPACT on application.

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161

OPERATIONAL REQUIREMENTS FOR CT SCANNER(S) TO BE USED WITHIN


THE CT SCANNING UNIT OF NHS TRUST
Quotations are invited for the supply of .. CT scanner(s) with the following
specification, to be used within the CT scanning unit, in.... NHS Trust.
Please supply information about the system by answering the stated requirements.
The responses should take into account the users requirements as stated in the
General specification and the Specific CT scanner requirements sections below.

General specification
1) Two X-ray CT scanners are required which are capable of providing Xray CT images of the highest quality and at the highest currently
achievable throughput.
2) The clinical services are for a wide range of patients, including those
from the following specialities:

oncology
cardiology
trauma
paediatrics
general anaesthetic cases
a wide range of other specialties from a major teaching hospital.

3) The systems must have functions and facilities to allow the fast and
safe patient handling and imaging to achieve a high throughput.
4) The study image handing must be excellent to allow the rapid and
accurate assessment of the diagnostic images, and the rapid and
reliable transfer of study data to the local PACS system.
5) The service will cover cardiac imaging, and we expect that the coronary
imaging studies will be carried out on one system.
6) The systems must be reliable, and be maintainable with the minimum of
down time for calibrations and routine servicing.

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162

7) The device must conform to all appropriate UK or international


standards (including part 2 and 3 standards where applicable) for the
manufacture of medical devices, and be CE marked. (Please provide
copies of certificates issued by your Notified Body which are applicable
to the design and manufacture of this equipment).
8) Please specify the expected life cycle of this type of equipment.
9) Please specify the time required between placing an order and delivery
of the equipment.
10) Please specify the estimated time required for installation and
commissioning.
11) Please specify whether your company operates an out of hours
telephone helpline available to users of the equipment to contact for
advice. If so please state its hours of operation.

Conformance requirements for X-ray generating equipment


12) All items included in the tenders must comply with current standards,
regulations and guidance. Details of conformance should be listed. The
following areas must be considered:

ionising radiation; public, patients and staff


medical equipment safety
building requirements
electrical safety

13) Confirmation must be given that equipment offered is CE-marked and


conforms to regulations regarding medical devices.
14) All equipment supplied must be user friendly, with clear identification of
all controls, which are to be marked with standard IEC symbols. Safe
use of computers and display screen equipment should be considered.
15) During radiological examinations, movement of both the patient and
equipment is often undertaken. Managers should be aware of Health
and Safety legislation (Health and Safety at Work Act 1974) with regard
to manual handling and their responsibility to provide equipment that
minimises the risk of injury to staff.

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163

16) Where the equipment contains critical components (eg monitors, image
intensifiers, direct digital detectors) which have a limited life, the
duration shall be specified in the quotation, and an indication of the cost
of replacement given.
17) Where any parts of the solution are based on PCs or other computer
equipment, the support and maintenance for this equipment shall be
explicitly stated.
18) The equipment must be designed and constructed to facilitate effective
cleaning and disinfection after use. Detailed instructions must be given
in the operator's instructions, for cleaning and disinfection of all items of
equipment that may come into contact with bodily fluids. The materials
to be used should be specified.
19) For fixed installations, the installer is responsible for a critical
examination of the X-ray unit. Although the installer must consult a
radiation protection adviser (RPA), either appointed by the Trust or the
installer, the RPA does not need to be present for the critical
examination if this is unnecessary. Final acceptance will be subject to a
satisfactory report by the RPA.
20) The equipment suppler shall perform tests and visits as are necessary
to ensure that there is sufficient access to the proposed equipment site
for the delivery of the units, and any installation works.
21) The equipment supplier shall perform such tests as are necessary to
ensure that the proposed installation will function correctly from the
mains supply which is available in the room in which it is to be installed.

Specific CT scanner requirements


The systems must be able to perform the following applications. Please provide
information on the operation, performance and radiation dose characteristics of the
system in performing these applications.
22) CT perfusion imaging studies. Please include information on how this is
performed

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164

23) CT angiography, for example for pulmonary studies, within a breath


hold
24) Cardiac imaging as appropriate for imaging the coronary vessels, with a
high temporal resolution, high spatial resolution with low motion
blurring, and with as low a radiation dose as possible. Please state
a. whether both prospective and retrospective ECG gating possible?
b. the range of rotation times that can be used in ECG gated cardiac
imaging
c. the number of phases that may be used in gated cardiac imaging, and
the corresponding acquisition arc for data collection
d. provide information on the radiation dose delivered during different
cardiac imaging procedures (eg CTDI as a function of the number of
phases), with typical exposure factors recommended for a 70 kg male
patient
e. the system must have excellent facilities for data handling, data editing
and display.
25) Virtual bronchoscopy and colonoscopy.
Desirable features
26) The following features are regarded as highly desirable, please specify
whether the system incorporates these or include cost if these are
available as an option.
i. xxxxxxx
ii. yyyyyyy
Consumables and accessories
27) Please include a comprehensive list of consumables and accessories
designed for use with this device together with its cost. Please give an
estimated cost of running the system per patient day.
28) As a minimum, the following accessories and the cost should be
included within the tender:

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165

a. two twin barrel injection pumps for angiographic, perfusion and


coronary work
b. an ECG monitor and leads for use in ECG gated cardiac imaging
c. one / two workstations capable of handling the full range of applications
on the system
d. any other accessories that are required for the correct operation of the
scanners.
Cleaning of the device
29) The device must be able to be cleaned using materials and detergents
commonly available within a hospital environment.
30) Please provide a list of approved detergents suitable for cleaning the
casing of the device.
31) Please provide a copy of your recommended cleaning instructions,
please specify techniques which are known to damage the casing and
internal components of the device.
32) Ensure that the relevant decontamination/reprocessing section is
completed in the June 2003 version of the Pre Purchase Questionnaire
which must be submitted with your quotation.
33) The systems must be able to be powered by the mains supply, and the
manufacturer must make inquiries to ensure that the supply meets the
needs of the system.
34) Does the system need external water cooling? Please state all of the
environmental requirements (temperature, humidity, power rating etc).
Other features
35) Please specify all other features of the device not requested in this
product specification and describe how this improves patient safety or
benefits the patient.
36) Please specify the dimensions and weight of the device, include values
for external power supply units.

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166

37) Please provide details of the equipment's protection against fluid


ingress, ie IPxy rating, as set out in standards such as lEC 60529.
Maintenance
38) In order to ensure the equipment is maintained in proper working order
the basic maintenance requirements are as follows:
a. engineer call-out response time of XXXXX hours
b. appropriate Annual preventative planned maintenance programme please describe the expected programme
c. appropriate annual validation (calibration and additional
parts/components) - please describe the annual procedure
programme
d. suppliers are required to specify the services they will provide at
their cost.
39) Please provide a list of parts that are required to be replaced regularly
as part of routine maintenance (eg X-ray tube). Please specify the
interval and current cost of replacement parts.
40) Please specify the number of trained engineers competent with this
type of equipment who serve the territory.
41) Please indicate any cost reduction to annual service charges if Medical
Physics engineers are trained in first line support, or in full maintenance
procedures for the system.
Training
42) In line with clinical governance issues around the use of equipment it is
essential all staff using and supporting the use of the device are
appropriately trained.
43) Training requirements are:
a. user training for all staff within the trust who would be expected to use
this device as part of their routine duties. This currently includes
approximately xxx radiographers

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167

b. ongoing regular applications training of trust staff


c. further support and advice throughout the life of the device as required.

Notes
44) Evaluation of the proposed systems will be possible during the tender
evaluation phase, with the approval of the Procurement department.
45) The device supplied must be of sound construction, fit for the purpose,
comply with all relevant safety and construction standards for medical
equipment, and be CE marked. A PPQ form (June 2003 version) will
need to be completed and presented prior to an order being confirmed;
ideally this should be submitted at the same time as your tender.
46) Preference will be given to devices that are reliable, are easy to use,
have the appropriate degree of flexibility and versatility, and are easy to
keep clean and maintain.
47) The final choice of device will depend not only on meeting this
specification but also on user preference. Trials of suitable equipment
may be necessary before a final decision is made. Users will assess
the various features of any equipment on trial.
48) The likely full cost of a standard procedure must be estimated, including
the cost of kits of all disposable parts, fluids, etc.
49) All instructions for the use, cleaning and maintenance must be included
with the quotation. The costs of any repair and maintenance contracts
that are available should also be stated, together with the typical costs
of major repairs if these are not included in standard maintenance
contracts.
50) Any training provided, including any courses offered/recommended by
the manufacturer/supplier should be stated together with any costs that
may be incurred.
51) In presenting a quotation, the supplier must fully specify the device that
will be provided, and clearly identify where this does not meet the
requirements cited in this document.

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168

52) The offered price, excluding VAT, should include any discounts or
special offers available, but should however be detailed separately. The
terms of the warranty must be stated. If applicable, ex-demonstration
units available at this time can also be shown, with offer prices, and
provided that the same guarantee terms and conditions apply as if the
device(s) were new.
53) All enquires concerning this specification should be addressed to
.. .
54) A copy of this operational requirement specification, and other related
documents, are available electronically ain Microsoft Office Word format
(version 2003) from to assist you in
presenting your responses to our requirements. This will help us in
matching your responses to our requirements when assessing and
evaluating the tenders.
55) During the duration of the tender process you must not contact any
member of Trust staff associated with this tender with the exception of
staff in the Procurement department. Failure to comply with this
requirement may exclude your submission during the assessment and
evaluation stages.

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169

Purpose of a site visit


During the tendering phase of a purchase, the manufacturers will invite the trust to
attend a site visit. Normally, the site chosen will be a leading user of that
manufacturers equipment. For the manufacturer, it is a chance to show the scanner
in operation. For the purchasers the site visit is an opportunity to validate in concrete
examples the operational performance of the scanner in a clinical context similar to
that where the purchased scanner will be used.
A site visit is not a technical demonstration of all the facilities of the scanner. It is a
chance to see the scanner operating in a clinical context. It may also be that the
scanner you visit is not the same specification as that in the tender. It is important to
liaise with the company representative to establish before the visit what capabilities
of the scanner are included in tender.
During the site visit the purchasing team should evaluate the objective and subjective
elements of scanner performance, and gather the experience of existing operators of
the scanner both good and bad. This relates both to the technical performance of
the scanner and the operational issues relating to its usage. It may be that as a result
of a site visit, plans for clinical services, workflow design and such may need to be
re-assessed.
Each site visit should be consistent, factual and unbiased. A protocol should be
drawn up to ensure that site visits focus on the issues of greatest importance to the
department, and are demonstrably fair to suppliers. Questions asked should be
related to the purchasing decision and must be reasonable. It is acceptable to
request that the manufacturers representatives allow some time for private
discussions between the staff of the host institution and the visitors.

Suggested scope of site visit


Although every purchasing exercise will have its own priorities, drivers and focuses,
the areas to be covered can generally be divided into the categories listed below:

general
scanning performance
operational aspects
clinical applications software
image quality and dose
installation
reliability and servicing.

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170

Some suggested questions and factors to observe for each category are provided at
the end of this section. The answers to the questions may be obtained by
observation and/or interrogation.

Organising the site visit


Choosing the site
Generally the site will be determined by the manufacturer, however, it should ideally
be in the UK so that the scanner is observed in a clinical context similar to the one in
which it is to be used. The site chosen should be undertaking scans in the major
clinical areas of interest to the purchasing team. It may be necessary to visit a
second site to observe particular features of the scanner.
Who to involve
Ideally the site visit team should include the key members of the purchasing team
and whenever possible the same team members should visit every scanner being
considered for purchase. However, not every department needs to be represented on
the visit team, provided the questions that are included in the visit brief are sufficient
to address their needs.
The team may include:

lead radiologist
superintendent radiographer
business manager
physicist
other radiologists representing a range of clinical specialties of interest,
eg cardiology, paediatrics, oncology, gastro-intestinal, pulmonary.

One of the team members should be assigned the responsibility of organising the site
visits. Their role will include:

liaising with the manufacturers to arrange dates and venues of site visits
liaising with staff to ensure availability
co-ordinating the visit brief
assigning tasks to individual team members
collating notes and scores from each site visit.

Preparation
Prepare a visit brief a list of key goals for the visit, must ask questions
and tests, additional questions, team responsibilities, scoring sheets and
guides

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171

check for any known issues for that scanner or even rumours that can be
addressed at the time
establish the questions to be asked at the visit and scoring system to be
used
each team member should have a set of questions they need to address and
these should be covered on each site visit
ensure that specialist scans of interest, eg cardiac, will be performed on the
day of the visit
ensure that appropriately qualified personnel, both from the manufacturer
and the host institution will be available for discussions/questions during the
site visit.

What to do on a site visit


The visit should start with introductions of the visiting purchase team and an outline
of their goals for the day. Each team member should spend time with their
counterparts at the visiting site and cover the questions in their brief. If possible make
notes during the site visit or as soon as possible after.
Clinical images obtained for standard-sized patients should be viewed for a range of
examinations of interest. Note scan parameters and dose values for these images
and request copies of this data on a disc for subsequent review.
In addition it is particularly recommended that the radiographer on the team requests
some hands-on experience on the scanner.
It is easy on such visits to be distracted by some additional features and information
that crops up. One member of the team should ensure that all the mandatory
questions and assessments are addressed. If necessary, any issues arising should
be recorded and included in visit notes; these can then be followed up subsequently
with the manufacturers representative.

What to do following a site visit


It is essential that a site visit is properly recorded. Notes and scores from the visit
should be placed on record as soon after the event as possible. If it is necessary that
other people attend the next site visit they may need to refer to these visit notes in
order to ensure that a consistent approach is maintained.
The notes and scores may be used to decide between tenders and so should be
treated as important records; it may also be necessary to use them as part of the debriefing to the failed bidders.

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172

Suggested questions and features to observe


The following is a list of suggested questions and features to observe. It is not
intended to be prescriptive nor exhaustive.
General
Ask about the general operation and installation of the scanner:
do people like it
is it user-friendly?
has it been reliable?
what features and functions have they found most / least useful?
what scans are carried out?
if not all the scans you are considering are done at this centre, what are their
reasons are they related to the scanner at all?
were any unforeseen problems encountered during purchase or installation?
have any particular problems been encountered with the operation of the
scanner?

Scanning performance
Observe some scans being set up. The radiographer in the team should also ask to
operate the scanner so as to make hands-on assessment of its user-friendliness
and ergonomics. Note the following:

ease with which a patient can be placed and orientated on the scanner
ease with which the scan is selected and planned
how intuitive is the scanning software?
how quickly the images are available from the scan button being hit?
the quality of the images and other information presented to the operator.

As it will not be possible to observe the full range of clinical examinations further
questions should be asked relating to the scanning performance:
have any problems been encountered with setting up of patients for any
particular examinations?
how easily can an operator amend scan parameters?
can protocols be made tamper-proof?
Operational
Scanning workflow
Is the scanning workflow satisfactory?
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173

did workflow require any modification to accommodate scanner?


do users have any recommendations that could improve this?
time taken for start-up satisfactory?
time taken and frequency of routine calibrations satisfactory?
time taken for daily qc satisfactory?
scanner couch/gantry controls satisfactory?
setting up patients satisfactory?
image reconstruction time satisfactory? (if possible make an objective
assessment of this by setting up a scan with a given number of
reconstructed images and measuring the time taken from the start of the
scan to the appearance of the final image, for at least two specific
examinations, eg standard brain and standard abdomen scan.)
have there been any tube cooling issues?

Reporting workflow
What are the reporting patterns, eg on console, on workstation, on PACS,
remotely?
what standard post-processing, eg MPRS, can be integrated into protocols?
what are the post-processing patterns, ie where is it done and by whom?
is the post-processing and reporting workflow satisfactory?
do the users have any recommendations that could improve this?
are there any data transfer issues?
is speed of data transfer satisfactory?
were any changes required to the network or data servers due to the CT
workload?
Training

Was training provided by manufacturer adequate?


what areas required most training?
what training model was used? Was everyone trained or was it cascaded?
what level of on-going training is provided?

Installation
Assess the scanner suite in terms of whether the space is adequate and how it
compares with the area available at your site:
is there any additional plant located outside the scanner suite?
were there been any issues with the availability of the scanner for delivery?
were there any problems during the purchase, eg additional items having to
be purchased?

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174

were there any problems during the installation, eg unanticipated infrastructure requirements?
Clinical applications software
Assessment of the clinical applications software may be part of the site visit, but often
the manufacturer will make a separate arrangement for this, as it may require a full
day for all interested parties to evaluate this. Ideally the manufacturer will bring the
workstation to your hospital site.
The assessment will generally start with a general demonstration of the software by
the applications specialist. Opportunity should then be given for all interested parties
to get some hands-on experience.
Each radiologist should select some clinical applications of interest and run through
the same ones on every manufacturers system.
Make a note of the following:

length of time taken to perform post-processing


any desired features not available
particular features liked
image quality score
user-friendliness score.

Image quality and dose


Ask to see some clinical examples of images that are similar to those that you will be
acquiring in your clinical context. The images viewed must be for standard-sized
patients, otherwise dose comparisons will not be valid. If you are contemplating an
expansion of service into another area of scanning, try to view some images to
assess the potential of the system for your future needs.
For each set of images viewed tasks note the following:
scan parameters, particularly imaged slice thickness
window width and level used (if possible use similar settings to view images
on each site visit)
image quality score
spatial resolution
contrast resolution
artefacts
associated radiation dose as given by CTDIVOL and DLP.

CEP08007: March 2009

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175

You may wish to perform a more objective assessment of image quality using CT
performance phantoms. It is unlikely there will be sufficient time for this during the
site visit, so the physicist on the team may wish to make separate arrangements.
Reliability & servicing
Have any clinical issues arisen as a result of scanner problems?
have there been any problems with the availability of parts if required?
what is the tube replacement option?
what options were chosen for engineer support (and reasoning)?
have engineer call-out times been satisfactory?
has adequate support in terms of advice on any problems encountered been
satisfactory?
is the servicing carried out as was specified in the service contract?

Scoring metrics
The site visit is one means of obtaining information for the evaluation process used
for scanner selection. However, each aspect assessed in the site visit should also be
scored. An example scoring scheme may be of the nature:
1)
2)
3)
4)

unacceptable
not ideal, but could be used clinically
meets our basic requirements
exceeds requirements.

It is important to note that in such a scheme, a score of 3 or 4 is acceptable. A score


of 2 indicates that it would be possible to use the scanner if this is a minor feature.

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Appendix 7: Evaluation scoring

176

Evaluation scoring
This scoring mechanism is a suggested method of determining your order of
preference, and is not obligatory, but will help make the selection process more
objective and help in the debriefing process to unsuccessful tenderers.
You will need to establish the scoring and weighting system.
Scoring should be on a scale (such as from 1 to 10) comparing each model to some
base level of acceptability, and not against each other model. It is useful include a
brief description of your scoring methodology, ideally with concrete benchmark
examples for each score.
You will need to determine the weighting given to each criterion; this will be
dependent on your own local circumstances. The weightings should sum to 100.
The total for each topic is achieved by multiplying the score by the weighting. These
are then summed to give a total mark for the scanner being evaluated.
Scoring criteria and weightings should be the same for all scanners
Possible options are:
each department has its own weighting based on their perception of the
relative importance of each topic
weightings are agreed as a whole by the evaluation team
weightings are agreed in advance and kept secret from those undertaking
scoring.
There are many other options possible. Please consult with the local Procurement
officer to ensure that local requirements are met.
For each scanner system being evaluated, team member should consider the
performance of the scanner in a number of topic areas. Table 25 below gives some
examples and items that should be considered in each area. These can be modified
or added to according to local needs. Team members should then score each topic
according to the stated and agreed criteria. You should provide an explanation of
your reasoning behind each score, ie the advantages and disadvantages each
element that you evaluated.

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177

Table 25. Clinical and technical evaluation score sheet template

Company and model:

Topic

Items to consider

Scanner

Dimensions and weight


Ancillary plant
Gantry aperture
Patient friendliness
Generator power
X-ray tube
Rotation time
Detector array
Image quality
Radiation dose

CEP08007: March 2009

Sites and dates of assessment visits:

Advantages

Disadvantages

Weight

Score

Total

Appendix 7: Evaluation scoring

Topic

Items to consider

Patient couch

Patient handling
Couch controls
Dimensions
Couch movement
Patient comfort
Positioning accessories
Ease of cleaning

Operator console

Dimensions
Ergonomics
layout
user-interface
User friendliness
scan set-up
protocol set-up
data management
Software options included

Diagnostic
workstation

User friendliness
Functionality
Connectivity
Software options included

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178

Advantages

Disadvantages

Weight

Score

Total

Appendix 7: Evaluation scoring

Topic

Items to consider

Workflow

Reconstruction speed
Ease of data transfer
Speed of data transfer
Postprocessing options in
protocols
Integration with HIS/RIS/PACS

Software

Post processing options


Applications available
Applications included in package
Licensing models

Data storage

Hard disc capacity


Optical disc options

Networking and
connectivity

Transfer of data
Compatibility with existing
modalities and HIS/RIS/PACS
IHE and DICOM conformance
Teleradiology links

Support

Maintenance
Tube replacement
Call out / remote support
Cost of parts
Routine servicing
Training provision

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179

Advantages

Disadvantages

Weight

Score

Total

Appendix 7: Evaluation scoring

Topic

Items to consider

Company

Sales approach
Reliability
Research / product development
Reference site opportunities

Installation

Works required
Provision of replacement service
Disruption of other services

180

Advantages

This schema has been adapted from CIP documentation [81].

CEP08007: March 2009

Disadvantages

Weight

Score

Total

Author and report details


Buyers guide:
Multi-slice CT scanners
The ImPACT Group
St Georges Healthcare Trust
(Medical Physics Department)
Bence Jones Offices
Perimeter Road
Tooting
London
UK
SW17 0QT
Tel: +44 (0)20 8725 3366
www.impactscan.org

About CEP
The Centre for Evidence-based
Purchasing (CEP) is part of the Policy
and Innovation Directorate of the NHS
Purchasing and Supply Agency. We
underpin purchasing decisions by
providing objective evidence to support
the uptake of useful, safe and
innovative products and related
procedures in health and social care.
We are here to help you make
informed purchasing decisions by
gathering evidence globally to support
the use of innovative technologies,
assess value and cost effectiveness of
products, and develop nationally
agreed protocols.

CEP08007: March 2009

181

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