NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 1 of 9

PURPOSE:
To Provide imaging services as per the requirement of the patient

SCOPE:
All the imaging services provided by the Hospital. (X-ray, Computed Tomography (CT) scans, C-Arm
and ultrasounds

RESPONSIBILITY:
Radiologist & Radiographer

POLICY:
SCOPE OF IMAGING DEPARTMENT AND ITS COMPLIANCES WITH LEGAL
REQUIREMENTS

 Compliance to legal and other requirements

Service Legal requirement Compliance

Radiography (X-Ray & Get registered with Atomic Energy Registration Done
CT) Regulatory Board

Carryout quality assurance At periodic intervals the quality

performance test of the X-ray unit assurance test are carried out as per
AERB prescribed format.
Employ qualified staff Staffs are employed with adequate
Technical qualification.
Provide personnel monitoring All radiation staff are provided with
badges for staff members Personnel monitoring TLD badge
associated with the operation of X- and are maintained.
ray machines
Comply with AERB Safety Code “Yes”
No. AERB/SC/MED-2 (Rev – 1).

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 2 of 9

Regulatory documents concerning All equipments posses Registration,

requirements for safe operation of License for installation and
medical X-ray machines are operation from AERB.

Atomic Energy Act, 1962

Radiation Protection Rules, 1971

Radiation Surveillance Procedures

for Medical Applications of
Radiation, 1989

AERB Safety Code for Medical

Diagnostic X-ray Equipment and
Installations No. AERB/SC/MED-
2 (Rev – 1) 2001
Ultrasound The pre-natal diagnostic Ultrasound equipments are
techniques (regulation and authorized and licensed by the
prevention of misuse) ACT, 1994. Health welfare department.

X-RAY EQUIPMENTS:

Tube Housing :  Location at 1m from focus with the applied voltage : 125kv,
MAS : 60
Maximum leakage level: 55.5MR in one hour.
Tolerance : Upper limit : Leakage Radiation level
at 1 meter from the focus <100MR in one hour.
Beam limiting Devices :  Light Beam collimators, cones are used to limit the primary & my
beam.
Beam filtration :  Focus to detector distance 50cms

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 3 of 9

Operating potential Total filtration (m & Al)

70 KVP 3.0
80 KVP 3.5
Tube Positioning :  The X-ray tube can be rotated and positioned to any desired angle.
 The target - to – film distance is measured using scale mounted on
the tube column.
 The Beam centering is done with the help of crosswire present on the
collimator.
Locking Devices :  Locking facility adequacy for Immobilizing the X-ray tube.
 Locking facility adequacy for immobilizing tube column.
 Locking facility adequacy for immobilizing the X-ray tube arm.
Bucky alignment :  Motorized moving Bucky is being used which is aligned to both the
X-ray tube and to the X-ray table.
Cable length :  Cable length and about 4m is provided from the nearest position and
the X-ray tube.
Control panel :  Control panel is provided with the display, showing selected kv, mAs
and engagement & Bucky mechanism as Bucky ON/OFF.
 During preparation for X-ray exposure it being indicated as stand by,
at the time of exposure it is indicated by Beep sound with X-ray ON
display on the console.
Exposure switch :  The control panels have provision to terminate X-ray exposure
automatically with pre-set time.

CT SCAN EQUIPMENTS:

Tube Housing :  Location at 1m from focus with the applied voltage : 140kv,
MAS : 800
Maximum leakage level: 55.5MR in one hour.
Tolerance : Upper limit : Leakage Radiation level

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 4 of 9

at 1 meter from the focus <100MR in one hour.

Beam limiting Devices :
Beam filtration :
Tube Positioning :
Locking Devicer :
Cable length :
Control panel :
Scan plane visualizer :
Couch position Accuracy :
Beam ON indicator :
Scan increment Accuracy :
Gantry aperture clearance :
Visual Indication :
 Shutters are used to collimate the beam to desired thickness.
 Inherent filtration 1.0Al / 75 – permanent filtration.
- For scanogram 90 & 180
- During the Helical scans (coros sectional scan) tube rotates 360
 Digitally / Electromagnetically the locking are applied as per
Hiprecision feed back.
 8 meter of cable length in provided.
 Control panel is provided with
a. Inditation of table movements both in vertical and
Horizontal position.
b. Gantry tilt.
c. Voice controller.
d. Exposure indication.
e. Emergency stop.
 Scan plane visualizer is displayed while planning the scan over
the scanogram, which indicates the actual scan through the body.
- The patient couch is digitally controlled both in vertical and
horizontal direction.
 Visual indicators are provided at the control panel and on the
gantry of the scanning system to indicate. The indication light
when the X-ray beam is ON.
 As all the movements ex : table, gantry are controlled digitally /
electromagnetically, there is nil deviation in the scan increment.
 The existing gantry allows 80cm thick patient.
 Entire view of the Gantry and patient are visible from any
position from the operating console.

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 5 of 9

Timer  The Exposure are automatically terminated as soon as the

Warm-up conditions :
selected scan has been completed, Also it is possible for the
operator to terminate the X-ray exposure at any time during the
scan or series of scans.
 Warm up conditions are done to energies the X-ray tube to keep it
ready for the X-ray exposure.

INFRASTRUCTURE:
 The infrastructure (layout) of the Radiology Department is planned as per AERB specification
and obtained its approval.
 The Departments is designed in such a way that there is smooth flow of work, (Attending the
patient for various examinations, processing of film, report dictation, report generation and
dispatching) which helps the patient to get his report within the stipulated time.
 The Department functions with Radiologist, Technologist, Nurse and assistant to ensure that the
patients are attended as per the appointment schedule and also deliver the reports within the
turnaround time.

IMAGING RESULTS ARE AVAILABLE WITHIN A DEFINED TIME FRAME:

 All critical values (Emergency Reports) are being informed to the Referring Consultant, Duty
doctors and Concerned Nurse immediately after the procedure.

 For General Radiography (Routine non-emergency) – The turn around time is 24 hrs.

 For Ultrasound and Colour Doppler Studies – The turn around time is 6 hrs.

 For CT scan (Routine non- emergency) studies – The turn around time is 24 hrs.

STAFF QUALIFICATIONS:
 The Radiology department employs qualified staff (radiologist and radiographer). The
minimum qualification and experience of the staff comply with AERB Safety Code for Medical
Diagnostic X-ray Equipment and Installations (Code No. AERB/SC/MED-2) (REV – 1). The
Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 6 of 9

qualification and experience for performing / supervising ultrasound, is defined by the HR

department as Job description manual.

SAFE TRANSPORTATION OF THE PATIENT:

 The Department of Radiology & imaging are consultation services for diagnostic procedures.
Medical staff of Koshys Hospital is authorized to request procedures on patients who are
receiving care. Doctors practicing outside the hospital may refer patients for imaging
procedures. Self- referral patient is also performed with approval after consultation with the
Radiologist.
 Scope of the Imaging services commensurate to the services provided by the Koshys Hospital.
 The patient is shifted from wards in a wheel chair / stretcher accompanied by the concerned
Nursing staff with the patient’s attendant.
 In case of an unstable patient either from the ward or ICUs, the patient is always transported in
a stretcher accompanied by a Duty Doctor, Nursing staff and patient attendant.
 The Radiology Dept. gets a prior Intimation regarding the stability of the patient from the
concerned Nursing staff.
 The patient attendant accompanies the patient for the necessary formalities like signing consent,
paediatric cases etc.

 For all routine investigations reports shall be given to patients within 24 hrs.
 For all emergency investigations reports shall be given to patients as soon as possible
(immediate)

INTIMATION OF THE CRITICAL REPORTS TO THE CONCERNED PERSONNEL:

 Critical values followed by the department :

General radiography:
a. Ischemic bowel
b. Massive pleural effusion
Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 7 of 9

c. Pneumoperitoneum
d. Pneumothorax

 CT scan :
a. Pneumothorax, Pneumoperitoneum
b. Hemothorax, Hemoperitoneum
c. Ischemic bowel
d. Acute Appendicitis
e. Critical coronary artery stenosis
f. Cardiac tamponade
g. Large infarcts with mass effect

 Ultrasound:
a. Appendicitis
a. Subarachnoid hemorrhage
b. Post traumatic organ damage
c. Ectopic pregnancy
Massive pleural effusion
d. Hemoperitoneum
e. Acute arterial occlusions
f. DVT

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 8 of 9

Communication of critical values to the concerned

Serial # Patient category Order of communication Time limits

1 Inpatients a. Consultant 10 – 15 minutes

b. Duty Doctor 15 – 20 minutes
c. Nursing Incharge 25 – 30 minutes
d. Staff nurse < 45 minutes

2. Out patients Consultant 10 -15 minutes

3. Emergency Room Casualty medical officer 10 minutes

4. Critical care a. Consultant < 20 minutes

b. Duty Doctor
c. Nursing Incharge
d. Staff nurse

 Routing reporting of imaging findings is communicated through the usual channels established
by the department. However, in case of critical results, the Radiologist and the department staff
expedites the delivery of a diagnostic imaging report (verbal, preliminary or final) in a manner
that reasonably ensures timely receipt of the findings.

Situations that may require critical value communication include:

a. Findings that suggest a need for immediate or urgent intervention.

b. Generally, these cases may occur in the emergency and surgical departments or ciritcal
care units any may include pneumothorax, pneumoperitoneum or a significantly
misplaced line or tube as indicated above.

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent
 NABH Policy: IMAGING SERVICES

NABH Standard Reference: AAC.9

Policy/Version Pol/KH/AAC.9/05/01.01.2021
No./IssueDate:
Page No. 9 of 9

c. Findings that are discrepant with a preceding interpretation of the same examination and
where failure to act may adversely affect patient health.

d. These cases may occur when the final interpretation is discrepant with a preliminary
report or when significant discrepancies are encountered upon subsequent review of a
study after a final report has been submitted.

e. Findings that the Radiologist reasonably believes may be seriously adverse to the patient’s
health and are unexpected by the treating or referring physician.

REPORTS ARE IN A STANDARDISED MANNER:

 Though various types of examination are carried out from different modalities, results are
reported in a standardized format, with Patient name. Age, Sex, Date, Unique identification
number (MPI Number) and Respective producer number.

OUTSOURCING OF IMAGING SERVICES NOT PROVIDED IN THE HOSPITAL

 Department of Radiology & Imaging has outsourced the following procedures based on their
certification :
a. PET scan Sampige Hospital
b. MRI –I- Max and CLUMAX Diagnostics

Prepared by Approved by Issued by

Dr. Santhosh Koshy Dr. Gopika K.S

Dr. Padma Medical Director Accreditation Co-ordinator
Medical Superintendent