Professional Documents
Culture Documents
and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists,
radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it
has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR
Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice guideline and technical standard by those entities not providing these services is not authorized.
These guidelines are an educational tool designed to assist Therefore, it should be recognized that adherence to these
practitioners in providing appropriate radiologic care for guidelines will not assure an accurate diagnosis or a
patients. They are not inflexible rules or requirements of successful outcome. All that should be expected is that the
practice and are not intended, nor should they be used, to practitioner will follow a reasonable course of action
establish a legal standard of care. For these reasons and based on current knowledge, available resources, and the
those set forth below, the American College of Radiology needs of the patient to deliver effective and safe medical
cautions against the use of these guidelines in litigation in care. The sole purpose of these guidelines is to assist
which the clinical decisions of a practitioner are called practitioners in achieving this objective.
into question.
I. INTRODUCTION
The ultimate judgment regarding the propriety of any
specific procedure or course of action must be made by This guideline has been revised by the American College
the physician or medical physicist in light of all the of Radiology (ACR) to guide appropriately trained and
circumstances presented. Thus, an approach that differs licensed physicians and medical physicists involved in
from the guidelines, standing alone, does not necessarily diagnostic procedures using ionizing radiation. The
imply that the approach was below the standard of care. establishment of reference levels in diagnostic medical
To the contrary, a conscientious practitioner may imaging requires close cooperation and communication
responsibly adopt a course of action different from that between the physicians who are responsible for the
set forth in the guidelines when, in the reasonable clinical management of the patient and the medical
judgment of the practitioner, such course of action is physicist responsible for monitoring equipment and image
indicated by the condition of the patient, limitations of quality and estimating patient dose. Adherence to this
available resources, or advances in knowledge or guideline should help to maximize the efficacious use of
technology subsequent to publication of the guidelines. these procedures, minimize radiation dose to patients and
However, a practitioner who employs an approach staff, maintain safe conditions, and ensure compliance
substantially different from these guidelines is advised to with applicable regulations.
document in the patient record information sufficient to
explain the approach taken. Application of this guideline should be in accordance with
the specific ACR guidelines or standards for the relevant
The practice of medicine involves not only the science, imaging modality; considerations of image quality
but also the art of dealing with the prevention, diagnosis, monitoring; radiation safety; and the radiation protection
alleviation, and treatment of disease. The variety and of patients, personnel, and the public. There must also be
complexity of human conditions make it impossible to compliance with applicable laws and regulations.
always reach the most appropriate diagnosis or to predict
with certainty a particular response to treatment.
The goal of this guideline is to provide guidance and The physician is the principal individual involved in
advice to physicians and medical physicists on the establishing and implementing reference levels in
establishment and implementation of reference levels in diagnostic medical imaging using ionizing radiation. The
the practice of diagnostic medical X-ray imaging. The physician should work closely with a Qualified Medical
goal in medical imaging is to obtain image quality Physicist in this process. The clinical objectives of all
consistent with the medical imaging task. Diagnostic diagnostic medical imaging procedures must be in
reference levels are used to manage the radiation dose to accordance with current ACR guidelines or standards and
the patient. The medical radiation exposure must be should be periodically reviewed by the physician.
controlled, avoiding unnecessary radiation that does not
Continuing Medical Education
contribute to the clinical objective of the procedure. By
the same token, a dose significantly lower than the
The physicians continuing medical education should be
reference level may also be cause for concern, since it
in accordance with the ACR Practice Guideline for
may indicate that adequate image quality is not being
Continuing Medical Education (CME) and should include
achieved. The specific purpose of the reference level is to
CME in general radiography as is appropriate to his/her
provide a benchmark for comparison, not to define a
practice.
maximum or minimum exposure limit.
B. Qualified Medical Physicist
IV. QUALIFICATIONS AND
RESPONSIBILITIES OF PERSONNEL
A Qualified Medical Physicist is an individual who is
A. Physician competent to practice independently one or more of the
subfields in medical physics. The ACR considers
Procedures using radiation for diagnostic medical certification and continuing education and experience in
purposes must be performed under the supervision of, and the appropriate subfield(s) to demonstrate that an
interpreted by, a licensed physician with the following individual is competent to practice one or more of the
qualifications: subfields in medical physics and to be a Qualified
Medical Physicist. The ACR recommends that the
1. Certification in Radiology or Diagnostic individual be certified in the appropriate subfield(s) by the
Radiology by the American Board of Radiology, American Board of Radiology (ABR), the Canadian
the American Osteopathic Board of Radiology, College of Physics in Medicine, or for MRI, by the
the Royal College of Physicians and Surgeons of American Board of Medical Physics (ABMP) in magnetic
Canada, or the Collge des Mdecins du Qubec. resonance imaging physics.
or
2. Completion of a residency program approved by The appropriate subfields of medical physics for this
the Accreditation Council for Graduate Medical guideline are Diagnostic Radiological Physics or
Education (ACGME), the Royal College of Radiological Physics.
Physicians and Surgeons of Canada (RCPSC),
the Collge des Mdecins du Qubec, or the
The medical physicist must be familiar with the principles For radiographic entrance skin exposure measurement,
of imaging physics, radiation dosimetry, and radiation the chest or abdomen phantom is centered in the field of
protection; the current guidelines of the National Council view with beam collimation adjusted to the phantom
on Radiation Protection and Measurements; laws and edges. An exposure is made using the automatic exposure
regulations pertaining to the performance and operation of control settings or manual technique routinely used
medical X-ray imaging equipment; the function, clinical clinically for the appropriate patient thickness. The
uses, and performance specifications of the imaging technique chosen for the exposure (kVp, mA, and time if
equipment; and calibration processes and limitations of not exposed under automatic exposure controlled
the instruments used for radiation measurement. The conditions) should be the same as that used clinically for
medical physicist must also be familiar with relevant an AP abdomen radiograph or PA chest radiograph for an
clinical procedures. average size adult patient. The entrance skin exposure
may be either measured directly or calculated from a free-
V. DIAGNOSTIC REFERENCE LEVELS FOR in-air output (mR/mAs) measurement with appropriate
IMAGING WITH IONIZING RADIATION inverse square correction to the actual phantom entrance
surface. See AAPM Report No. 31 for further instructions
This guideline recommends reference levels and suggests on exposure measurement techniques [8]. For a PA chest
the methods of measurement for comparison for radiograph, the reference level is 25 mR (0.22 mGy air
procedures in radiography, fluoroscopy, and CT. kerma). For an AP abdomen radiograph, the reference
level is 600 mR (5.3 mGy air kerma).
A. Radiography
B. Fluoroscopy
For radiography, including screen-film and digital
imaging, this guideline bases reference levels on a A reference level is provided for abdominal fluoroscopy.
measurement of entrance skin exposure (without The abdomen phantom described in Section V.A is
backscatter) to a standard phantom using the X-ray configured with a 10 cm air gap between the entrance
technique factors the facility would typically select for an plane of the phantom and the table for undertable X-ray
average size adult patient. Reference levels are provided tube configurations with the aluminum plate facing the X-
for 2 common imaging tasks: a posteroanterior (PA) chest ray tube. For overtable X-ray tube fluoroscopy, the
radiograph and an anteroposterior (AP) abdomen (e.g., abdomen phantom is placed directly on the table with the
KUB) radiograph. The standard phantoms recommended aluminum plate toward the X-ray tube [4,9].
are the chest and abdomen phantoms developed for the
ACR Radiography/Fluoroscopy Accreditation Program or Reference levels for fluoroscopic entrance skin exposure
equivalent phantoms. These phantoms consists of several rate are based on the use of an image intensifier field of
25.4 by 25.4 cm acrylic blocks (Plexiglas, polymethyl view of 23 cm. Exposure rates are measured with the
methacrylate [PMMA], or Perspex) and a type 1100 abdomen phantom centered in the field of view, with
aluminum plate that combine to form chest and abdomen beam collimation to a width of 14 cm on the beam exit
equivalent phantoms [4]. These phantoms are similar in side of the phantom. For undertable X-ray tube systems,
composition to phantoms developed by the Center for position an ion chamber under the phantom so that the
Devices and Radiological Health (CDRH) for the chamber volume is centered 1 cm above the tabletop. For
National Evaluation of X-ray Trends (NEXT) surveys [5- overtable X-ray tube systems, position the ion chamber 30
7]. Dose estimates obtained using these phantoms may cm above the tabletop using an external probe support
differ somewhat from those obtained using the NEXT stand. Center the ion chamber under fluoroscopic
phantoms. guidance. Using the same fluoroscopic imaging settings