South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-64 - X-Rays (Title B)
Part IV - USE OF X-RAYS IN THE HEALTH PROFESSIONS
Section 61-64.IV.RHB 4.9 - Fluoroscopic X-ray Systems

Universal Citation: SC Code Regs 61-64.IV.RHB 4.9

Current through Register Vol. 48, No. 9, September 27, 2024

In addition to the applicable provisions of this regulation, the requirements of this Part apply to all stationary, transportable, mobile, portable, and C-Arm type fluoroscopes. All fluoroscopic x-ray systems shall be image intensified or direct digital receptor, and meet the following requirements.

4.9.1 Source-to-Skin Distance (SSD). The SSD shall not be less than:

4.9.1.1 Thirty-eight centimeters (38 cm) on stationary and transportable fluoroscopic systems manufactured on or after August 1, 1974;

4.9.1.2 Thirty-five and one half centimeters (35.5 cm) on stationary and transportable fluoroscopic systems manufactured prior to August 1, 1974;

4.9.1.3 Thirty centimeters (30 cm) on all mobile and portable fluoroscopes; and

4.9.1.4 Twenty centimeters (20 cm) for mobile fluoroscopes used for specific surgical procedures. If removable, the appropriate spacer shall be replaced after the specific surgical procedure application is complete.
4.9.1.4.1 For stationary, transportable, mobile, or portable fluoroscopes manufactured on or after June 10, 2006, having a maximum source-to-image receptor distance of less than forty-five centimeters (45 cm), means shall be provided to limit the source-to-skin distance (SSD) to not less than nineteen centimeters (19 cm). Such systems shall be labeled for extremity use only.

4.9.1.4.2 For those systems intended for specific surgical applications that would be prohibited at the source-skin distance specified above, provisions may be made for operation at shorter source-skin distances but in no case less than ten centimeters (10 cm).

4.9.2 Limitation of Useful Beam.

4.9.2.1 Primary Barrier
4.9.2.1.1 The fluoroscopic imaging assembly shall be provided with a primary protective barrier which intercepts the entire cross section of the useful beam at any SID.

4.9.2.1.2 The x-ray tube used for fluoroscopy shall not produce x-rays unless the barrier is in position to intercept the entire useful beam.

4.9.2.2 X-ray field. Neither the length nor the width of the x-ray field in the plane of the image receptor shall exceed that of the visible area of the image receptor by more than three percent (3%) of the SID. The sum of the excess length and the excess width shall be no greater than four percent (4%) of the SID. In addition:
4.9.2.2.1 Means shall be provided to permit further limitation of the x-ray field. Beam-limiting devices manufactured after May 22, 1979, and incorporated in equipment with a variable SID and/or a visible area of greater than three hundred square centimeters (300 cm2) shall be provided with means for stepless adjustment of the x-ray field;

4.9.2.2.2 All equipment with a fixed SID and a visible area of three hundred square centimeters (300 cm2) or less shall be provided with either stepless adjustment of the x-ray field or with means to further limit the x-ray field size at the plane of the image receptor to one hundred twenty-five square centimeters (125 cm2) or less. Stepless adjustment shall, at the greatest SID, provide continuous field sizes from the maximum obtainable to a field size of five centimeters by five centimeters (5 cm x 5 cm) or less.

4.9.2.2.3 For equipment manufactured after February 25, 1978, when the angle between the image receptor and beam axis is variable, means shall be provided to indicate when the axis of the x-ray beam is perpendicular to the plane of the image receptor.

4.9.2.2.4 Compliance shall be determined with the beam axis indicated to be perpendicular to the plane of the image receptor. For rectangular x-ray fields used with circular image reception, the error in alignment shall be determined along the length and width dimensions of the x-ray field which pass through the center of the visible area of the image receptor.

4.9.2.2.5 For uncertified image-intensified fluoroscopic equipment with a spot film device, the x-ray beam with the shutters fully opened (during fluoroscopy or spot filming) shall be no larger than the largest spot film size for which the device is designed. Measurements shall be made at the minimum SID available but at no less than twenty centimeters (20 cm) table top to the film plane distance.

4.9.2.3 Spot film devices which are certified components shall meet the following additional requirements.
4.9.2.3.1 Means shall be provided between the source and the patient for adjustment of the x-ray field size in the plane of the film to the size of that portion of the film which has been selected on the spot film selector. Such adjustment shall be automatically accomplished except when the x-ray field size in the plane of the film is smaller than that of the selected portion of the film. For spot film devices manufactured after June 21, 1979, if the x-ray field size is less than the size of the selected portion of the film, the means for adjustment of the field size shall be only at the operator's option.

4.9.2.3.2 Spot film field size. Neither the length nor the width of the x-ray field in the spot film plane shall exceed the image receptor by more than three percent (3%) of the SID. The sum of the excess length and the excess width shall be no greater than four percent (4%) of the SID.

4.9.2.3.3 It shall be possible to adjust the x-ray field size in the plane of the film to a size smaller than the selected portion of the film. The minimum field size at the greatest SID shall be equal to, or less than, five centimeters by five centimeters (5 cm x 5 cm).

4.9.2.3.4 The center of the x-ray field in the plane of the film shall be aligned with the center of the selected portion of the film to within two percent (2%) of the SID.

4.9.2.3.5 On spot-film devices manufactured after February 25, 1978, if the angle between the plane of the image receptor and beam axis is variable, means shall be provided to indicate when the axis of the x-ray beam is perpendicular to the plane of the image receptor, and compliance shall be determined with the beam axis indicated to be perpendicular to the plane of the image receptor.

4.9.3 Activation of the Fluoroscopic Tube. X-ray production in the fluoroscopic mode shall be controlled by a device which requires continuous pressure by the fluoroscopist for the entire time of any exposure. When recording serial fluoroscopic images, the fluoroscopist shall be able to terminate the x-ray exposure(s) at any time, but means may be provided to permit completion of any single exposure of the series in process.

4.9.4 Exposure Rate Limits. Entrance Exposure Rate Allowable Limits.

4.9.4.1 For equipment manufactured prior to May 19, 1995:
4.9.4.1.1 Equipment with automatic exposure rate control. Fluoroscopic equipment which is provided with automatic exposure rate control shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of ten Roentgens (10 R)(2.58 mC/kg) per minute at the point where the center of the useful beam enters the patient, except:
4.9.4.1.1.1 During recording of fluoroscopic images, or

4.9.4.1.1.2 When an optional high level control is provided. When so provided, the equipment shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of five Roentgens (5 R)(1.29 mC/kg) per minute at the point where the center of the useful beam enters the patient unless the high level control is activated. Special means of activation of high level control shall be required. The high level control shall only be operable when continuous manual activation is provided by the operator. A continuous signal audible to the fluoroscopist shall indicate that the high level control is being employed.

4.9.4.1.2 Equipment without automatic exposure rate control. Fluoroscopic equipment which is not provided with automatic exposure rate control shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of five Roentgens (5 R)(1.29 mC/kg) per minute at the point where the center of the useful beam enters the patient, except:
4.9.4.1.2.1 During recording of fluoroscopic images, or

4.9.4.1.2.2 When an optional high level control is activated. Special means of activation of high level controls shall be required. The high level control shall only be operable when continuous manual activation is provided by the operator. A continuous signal audible to the fluoroscopist shall indicate that the high level control is being employed.

4.9.4.2 For equipment manufactured after May 19, 1995:
4.9.4.2.1 Equipment with automatic exposure rate control. Fluoroscopic equipment which is provided with automatic exposure rate control shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of ten Roentgens (10 R)(2.58 mC/kg) per minute at the point where the center of the useful beam enters the patient, except:
4.9.4.2.1.1 During recording of fluoroscopic images, or

4.9.4.2.1.2 When an optional high level control is provided. When so provided, the equipment shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of twenty Roentgens (20 R)(5.16 mC/kg) per minute at the point where the center of the useful beam enters the patient when the high level control is activated. Special means of activation of high level control shall be required. The high level control shall only be operable when continuous manual activation is provided by the operator. A continuous signal audible to the fluoroscopist shall indicate that the high level control is being employed.

4.9.4.2.2 Equipment without automatic exposure control. Fluoroscopic equipment which is not provided with automatic exposure rate control shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of five Roentgens (5 R)(1.29 mC/kg) per minute at the point where the center of the useful beam enters the patient, except:
4.9.4.2.2.1 During recording of fluoroscopic images, or

4.9.4.2.2.2 When an optional high level control is provided. When so provided, the equipment shall not be operable at any combination of tube potential and current which will result in an exposure rate in excess of twenty Roentgens (20 R)(5.16 mC/kg) per minute at the point where the center of the useful beam enters the patient when the high level control is activated. Special means of activation of high level control shall be required. The high level control shall only be operable when continuous manual activation is provided by the operator. A continuous signal audible to the fluoroscopist shall indicate that the high level control is being employed.

4.9.4.3 Compliance with RHB 4.9.4.1 and 4.9.4.2 shall be determined as follows:
4.9.4.3.1 If the source is below the x-ray table, the exposure rate shall be measured one centimeter (1 cm) above the tabletop or cradle.

4.9.4.3.2 If the source is above the x-ray table, the exposure rate shall be measured at thirty centimeters (30 cm) above the tabletop with the end of the beam-limiting device or spacer positioned as closely as possible to the point of measurement.

4.9.4.3.3 In a C-arm type of fluoroscope, the exposure rate shall be measured thirty centimeters (30 cm) from the input surface of the fluoroscopic imaging assembly.

4.9.4.3.4 For a variable SID C-arm type of fluoroscope the exposure rate shall be measured thirty centimeters (30 cm) from the input surface of the fluoroscopic imaging assembly, with the end of the beam-limiting device or spacer positioned as close as possible to the point of measurement.

4.9.4.3.5 In a C-arm type of fluoroscope having an SID less than forty-five centimeters (45 cm), the exposure rate shall be measured at the minimum SSD.

4.9.4.3.6 In a lateral type fluoroscope, the exposure rate shall be measured at a point fifteen centimeters (15 cm) from the centerline of the x-ray table and in the direction of the x-ray source with the end of the beam-limiting device or spacer positioned as closely as possible to the point of measurement. If the tabletop is movable, it shall be positioned as closely as possible to the lateral x-ray source, with the end of the beam-limiting device or spacer no closer than fifteen centimeters (15 cm) to the centerline of the x-ray table.

4.9.4.3.7 Conditions of measurement of maximum entrance exposure rate are as follows:
4.9.4.3.7.1 The measurement shall be made under the conditions that satisfy the requirements of RHB 4.9.4.3.

4.9.4.3.7.2 The kVp, mA, and other selectable parameters shall be adjusted to those settings which give the maximum entrance exposure rate.

4.9.4.3.7.3 The x-ray system that incorporates automatic exposure rate control shall have sufficient attenuative material placed in the useful beam to produce the maximum output of that system.

4.9.4.3.7.4 Testing shall be performed in each mode used clinically.

4.9.4.3.8 Conditions of measurement of typical entrance exposure rate are as follows:
4.9.4.3.8.1 The measurement shall be made under the conditions that satisfy the requirements of RHB 4.9.4.3.

4.9.4.3.8.2 The kVp and mA shall be typical of clinical use of the x-ray system.

4.9.4.3.8.3 The x-ray system(s) that incorporates automatic exposure rate control shall have sufficient attenuative material placed in the useful beam to produce a milliAmpere and/or kiloVoltage typical of the use of the x-ray system.

4.9.4.3.8.4 Testing shall be performed in each mode used clinically.

4.9.5 Barrier Transmitted Radiation Rate Limits. The exposure rate due to transmission through the primary protective barrier with the attenuation block in the useful beam, combined with radiation from the image intensifier, shall not exceed two milliRoentgen (2 mR)(0.516 uC/kg) per hour at ten centimeters (10 cm) from any accessible surface of the fluoroscopic imaging assembly beyond the plane of the image receptor for each Roentgen per minute of entrance exposure rate.

4.9.5.1 Measuring Compliance of Barrier Transmission.
4.9.5.1.1 The exposure rate due to transmission through the primary protective barrier combined with radiation from the image intensifier shall be determined by measurements averaged over an area of one hundred square centimeters (100 cm2) with no linear dimension greater than twenty centimeters (20 cm).

4.9.5.1.2 If the source is below the tabletop, the measurement shall be made with the input surface of the fluoroscopic imaging assembly positioned thirty centimeters (30 cm) above the tabletop.

4.9.5.1.3 If the source is above the tabletop and the SID is variable, the measurement shall be made with the end of the beam-limiting device or spacer as close to the tabletop as it can be placed, provided that it shall not be closer than thirty centimeters (30 cm).

4.9.5.1.4 Compression devices shall be removed from the useful beam during the measurement.

4.9.6 Indication of Potential and Current. During fluoroscopy and cinefluoroscopy the kV and mA shall be continuously indicated.

4.9.7 Fluoroscopic Timer.

4.9.7.1 Means shall be provided to preset the cumulative on-time of the fluoroscopic x-ray tube. The maximum cumulative time of the timing device shall not exceed five (5) minutes without resetting.

4.9.7.2 A signal audible to the fluoroscopist shall indicate the completion of any preset cumulative on-time. Such signal shall continue to sound while x-rays are produced until the timing device is reset.

4.9.8 Control of Scattered Radiation.

4.9.8.1 Fluoroscopic table designs when combined with procedures utilized shall be such that no unprotected part of any staff or ancillary individual's body shall be exposed to unattenuated scattered radiation which originates from under the table. The attenuation required shall be not less than 0.25 millimeter lead equivalent.

4.9.8.2 Equipment configuration when combined with procedures shall be such that no portion of any staff or ancillary individual's body, except the extremities, shall be exposed to the unattenuated scattered radiation emanating from above the tabletop unless that individual:
4.9.8.2.1 Is at least one hundred twenty centimeters (120 cm) from the center of the useful beam, or

4.9.8.2.2 The radiation has passed through not less than 0.25 millimeter lead equivalent material including, but not limited to, drapes, bucky-slot cover panel, or self-supporting curtains, in addition to any lead equivalency provided by the protective apron referred to in RHB 4.2.9.2.

4.9.8.3 The Department may grant exemptions to RHB 4.9.8.2.2 where a sterile field will not permit the use of the normal protective barriers. Automatic exemptions will be granted for fluoroscopic procedures listed in Appendix E.

4.9.9 Spot-Filming Procedures. Fluoroscopic x-ray systems equipped with a spot-film device must meet the following requirements for spot-film procedures:

4.9.9.1 Timers. Means shall be provided to terminate the exposure at a preset time interval, preset product of current and time, a preset number of pulses, or a preset radiation exposure to the image receptor. In addition, it shall not be possible to make an exposure when the timer is set to a "zero (0)" or "off" position if either position is provided.

4.9.9.2 Timer Reproducibility. With a timer setting of one-half (0.5) second or less, the average exposure period (T) shall be greater than or equal to five (5) times the maximum exposure period (Tmax) minus the minimum exposure period (Tmin) when four (4) timer tests are performed: T >= 5 (Tmax - Tmin).

4.9.9.3 Exposure Reproducibility. The coefficient of variation of exposure shall not exceed 0.05 when all selectable technique factors are held constant. This requirement shall be deemed to have been met if, when four exposures are made at identical technique factors, the value of the average exposure (E) is greater than or equal to five (5) times the maximum exposure (Emax) minus the minimum exposure (Emin): E >= 5 (Emax - Emin).

4.9.10 Mobile and Portable fluoroscopic x-ray systems which are used in a single location for a period of greater than four (4) consecutive days shall be considered a stationary fluoroscopic system, and shall meet all the requirements of RHB 4.4.

4.9.11 Radiation Therapy Simulation Systems. Radiation therapy simulation systems shall be exempt from all the requirements of RHB 4.9.2, 4.9.4, 4.9.5, and 4.9.7 provided that:

4.9.11.1 Such systems are designed and used in such a manner that no individual other than the patient is in the x-ray room during periods of time when the system is producing x-rays, unless the procedure requires the presence of other individuals.

4.9.11.2 Systems which do not meet the requirements of RHB 4.9.7 are provided with a means of indicating the cumulative time that an individual patient has been exposed to x-rays. Procedures shall require in such cases that the timer be reset between examinations.

4.9.12 Fluoroscopic Quality Assurance. In addition to the requirements of RHB 4.2.16, the fluoroscopic image resolution shall be tested as part of the quality assurance program. This shall be performed at least annually.

4.9.13 Vertical Fluoroscopic Imaging Systems.

4.9.13.1 SSD. The SSD shall not be less than thirty-eight centimeters (38 cm).

4.9.13.2 Limitation of Useful Beam. All provisions of RHB 4.9.2 apply.

4.9.13.3 Entrance Exposure Rates. All provisions of RHB 4.9.4 apply.

4.9.13.4 Activation of the Fluoroscopic Tube. X-ray production in the fluoroscopic mode shall be controlled by a device which requires continuous pressure by the fluoroscopist for the entire time of any exposure. When recording serial fluoroscopic images, the fluoroscopist shall be able to terminate the x-ray exposure(s) at any time, but means may be provided to permit completion of any single exposure of the series in process.

4.9.13.5 Indication of Potential and Current. During fluoroscopy and cinefluorography the kV and mA shall be continuously indicated.

4.9.13.6 Fluoroscopic Timer.
4.9.13.6.1 Means shall be provided to preset the cumulative on-time of the fluoroscopic x-ray tube. The maximum cumulative time of the timing device shall not exceed five (5) minutes without resetting.

4.9.13.6.2 A signal audible to the fluoroscopist shall indicate the completion of any preset cumulative on-time. Such signal shall continue to sound while x-rays are produced until the timing device is reset.

4.9.13.7 Operators shall remain in a protected area during exposures, or shall be protected by aprons of not less than 0.25 millimeter lead equivalent material.

4.9.13.8 Spot-Filming Procedures. Fluoroscopic x-ray systems equipped with a spot-film device must meet the following requirements for spot-film procedures:
4.9.13.8.1 Timers. Means shall be provided to terminate the exposure at a preset time interval, preset product of current and time, a preset number of pulses, or a preset radiation exposure to the image receptor. In addition, it shall not be possible to make an exposure when the timer is set to a "zero (0)" or "off position if either position is provided.

4.9.13.8.2 Timer Reproducibility. With a timer setting of one-half (0.5) second or less, the average exposure period (T) shall be greater than or equal to five (5) times the maximum exposure period (Tmax) minus the minimum exposure period (Tmin) when four (4) timer tests are performed: T >= 5(Tmax - Tmin).

4.9.13.8.3 Exposure Reproducibility. The coefficient of variation of exposure shall not exceed 0.05 when all technique factors are held constant. This requirement shall be deemed to have been met if, when four exposures are made at identical technique factors, the value of the average exposure (E) is greater than or equal to five (5) times the maximum exposure (Emax) minus the minimum exposure (Emin): E >= 5(Emax - Emin).

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