Minimally invasive techniques have created a high demand for digital imaging. Modern orthopedics, pain management and urology couldn't operate without it. If you're in the market to acquire digital imaging or upgrade your C-arm, here are 10 tips from seasoned administrators.

Procedure type and case volume
Review your procedures that use fluoroscopic imaging, says Lynda Petty, RN, director of perioperative services at Ohio State University Hospital in Columbus. Their case volumes can help you decide whether more than one C-arm will be needed. An objective assessment of the types of procedures that call for imaging will also help you determine whether to buy a full-sized mobile C-arm, which can examine nearly any part of a patient's body, or a mini C-arm, which is ideal for extremities and occupies less floor space.

Reliability and dependability
"There is nothing more irritating than to have an irate surgeon yelling because the C-arm isn't working correctly," says Debbie Womble, RN, CNOR, administrator of Children's West Surgery Center in Knoxville, Tenn. Since not every facility can own a backup, breakdowns due to overuse or malfunction can wreak havoc, especially if you're booking back-to-back fluoroscopy cases.

Ask vendors for a list of clients who use the specific C-arm you're considering, and then ask those clients about the model's dependability. Even if their case volumes and types differ from yours, their reports are a good barometer. Also research the technology that supports reliability. Some manufacturers incorporate advanced cooling systems for extended fluoroscopy time.

Usability
Conventional wisdom says the more sophisticated the technology, the more difficult it is to learn. C-arms are no exception. While having an X-ray technician on staff might save setup time and boost case volume, not every facility has the volume or budget to hire one, and some features can confuse OR staffers who aren't radiology experts. Seek out an easy-to-understand interface.

"We have various techs that come from the hospital to our surgery center," says Missy Hawley, RN, BS, MS, administrator of Springfield Surgery Center in Springfield, Ohio. "We want a C-arm that is easy to use, so that there is no wasted time during cases and no confusion to slow the procedure down." Some now include pre-programmed settings that select the optimal parameters for imaging applications to limit the need for manual adjustments.

Archiving and networkability
Most current C-arms print images on paper or film, and many incorporate the printer into the machine itself. But your C-arm should be able to record images to a CD, DVD, external disk drive or other storage media for efficient archiving.

Networkability is another key factor. A C-arm that can easily import and display pre-op images from any modality on its monitor component will virtually eliminate the need to carry X-ray slides into the OR for surgeons to consult. "We made sure when we purchased our C-arm that it could be integrated with our PACS system," says Ms. Petty. "This way, the surgeon can access images within the hospital's or surgery center's network and see them on the C-arm monitor."

One emerging technology to look out for is DICOM (Digital Imaging and Communications in Medicine) integration. An electronics industry compatibility standard for medical imaging information handling, DICOM can, for example, allow outpatient surgeons to access information from any facility where they've operated.

Upgradeability
As with any piece of technological equipment, the ability to upgrade and add new features and software can save time and money in the long run. Find out how well the C-arms you're considering are able to accommodate software, hardware and memory upgrades, even if this leads you in the direction of more expensive equipment. "It is important to purchase the newest technology that is stated to interface with the other technology in your OR," says Ms. Petty. The additional upfront expense can ensure that the C-arm you buy today will still serve your needs tomorrow.

Size and maneuverability
The larger the C in your C-arm, the wider the distance between the imaging surface and tube. A greater distance can maximize the use of your C-arm, particularly in the case of larger patients.

But don't forget that it's a mobile device. You'll need to make sure that your staff can easily maneuver the equipment through the limited spaces of the OR and hallways, says Pamela Ertel, RN, BSN, CNOR, RNFA, administrative director of the Reading Hospital SurgiCenter at Spring Ridge in Wyomissing, Pa.

Manufacturers have reduced the size of their C-arms' viewing stations by introducing flat-panel monitors that take up less space. But because the C itself must remain equally balanced, lightweight technology has yet to arrive in that component.

Image quality
Image quality is of utmost importance. A sharp intraoperative image provides precision navigation, while a low-quality image hinders surgical efficiency and wastes time. If you host pain management procedures, don't forget to seek those specialists' approval on a trial model's image quality, since image is all-important for needle placement.

As previously mentioned, a C-arm with a larger X-ray generator will enable the best possible image of larger patients. But be aware of the amount of radiation that's required to obtain a high-quality image.

Safety
"Safety is incredibly important to keep in mind when purchasing a C-arm," says Ms. Womble. The smaller the amount of radiation required to produce usable images means a smaller dosage to which the user and patient are exposed, a strategy summed up in the acronym "ALARA," or "as low as reasonably achievable," the thinking which guides radiation safety.

Consulting with a medical physicist can educate you on the amounts of radiation that different C-arms and applications produce, help you navigate state and local radiation regulations and safety precautions and optimize your equipment's use for safer, more efficient use.

While you may already have lead aprons and other barrier protection for your OR staff, consider also leaded glasses and thyroid shields if you're doing a high volume of imaging work.

Training and service
The training and service you receive from your C-arm's manufacturer can, in the long run, make or break the success of your purchase. Our experts recommend a training program that can educate your staff both at the time of purchase and when turnover creates the need to retrain a new tech. A company that refuses to assist in future in-services is shifting that burden to you and your staff, and this should eliminate them from consideration.

Don't lose money on account of a manufacturer's substandard service. You'll want a plan that delivers repairs and maintenance within 24 hours of your request. Investigate the service plans they promise and their warranty options, ask other users about their experiences and get a contract in writing.

Purchasing options
With C-arms, as with many other capital investments, you've got three purchasing options: buying new, leasing or buying refurbished.

Buying new is an investment that requires certainty of use and trust in a manufacturer, but it makes a state-of-the-art technology yours.

If you're not sure that buying new will pay off in the long term, though, leasing a C-arm from a manufacturer or equipment service will demonstrate its usefulness in your facility and assist in the case costing of a potential purchase. It also lets facilities stay on top of emerging technologies, since it can be periodically traded in for a newer model. Should you choose the leasing option, talk to your accountant about whether to conduct it as an operating lease or a capital lease, as these two methods have differing impacts on your facility's financial statements.

Trialing the equipment is of critical importance in buying any C-arm, but especially when you're considering a refurbished C-arm: You'll want to test the image quality, radiation output and availability of parts while also researching the refurbishing process, service contract and warranty. Provided you buy from a reputable dealer, the result could be efficient equipment at substantial savings for you.

Comed Medical Systems
KMC-950 Mobile C-arm System
(888) 316-2205
www.comedusa.com
List price: $89,500
FYI: The KMC-950 Mobile C-arm System, distributed in the U.S. by KenQuest Medical (www.kenquestmedical.com), is integrated with a triple-field 9-inch image intensifier tube, a CCD digital camera and a rotating anode X-ray tube for r/f applications, says Comed. Its X-ray generator is designed with state-of-the-art microprocessor control and a touchscreen control panel for easy operation and visualization, says the company.

GE Healthcare
OEC 9900 Elite
(801) 328-9300
www.gehealthcare.com
List price: Not disclosed
FYI: The OEC 9900 Elite C-arm is designed for easy operation with multiple control interfaces, flexible positioning capabilities and different methods of transferring data, says the company. It delivers a high-resolution image with Dynamic Range Management technology that enhances contrast and sharpens edges to accentuate what you need and attenuate what you don't.

Hologic
Fluoroscan InSight
(781) 999-7300
www.hologic.com
List price: $85,000
FYI: Hologic's InSight mini C-arm provides orthopedic surgeons with precision and versatility in extremity surgery, says the company. InSight combines capable maneuverability, ultra-fine fluoroscopy images and automated adjustments to deliver the optimum image every time for every patient. The advanced degree of automation incorporated into the InSight allows surgeons to focus on procedures and patients, not instrumentation and adjustments, says Hologic.

OrthoScan
OrthoScan HD 1000
(480) 503-8010
www.orthoscan.com
List price: $60,000
FYI: OrthoScan's high-definition mini C-arm provides superior extremity imaging in a small package, says the company. At only 185 pounds — one-third the weight of its competitors — it is easy to maneuver, and its one-touch functionality is intuitive and easy to operate. The C-arm's arm is light and balanced enough that it can be moved with one finger, and the unit's state-of-the-art, embedded circuitry provides fast image acquisition and reliable, quiet operation.

Philips Medical Systems
BV Pulsera
(800) 229-6417
www.medical.philips.com
List price: Not disclosed
FYI: The BV Pulsera C-arm features a new, digital 1K2 imaging chain; a motion-stopping, pulsing and rotating anode and a powerful 15-kilowatt generator to produce excellent image quality, says the company. The equipment's 3D-RX feature allows rapid acquisition and reconstruction of three-dimensional image volumes and a compact viewing station that incorporates the full functionality of a PACS workstation.

Siemens USA
Arcadis Orbic 3D
(888) 826-9702
www.medical.siemens.com
List price: Not disclosed
FYI: Staffers using Siemens' Arcadis Orbic 3D can eliminate the need for readjustments by changing this C-arm's orbital projection angle, which results in less radiation and smoother workflow. Exposing 50 or 100 two-dimensional images in 1024 x 1024 pixel (1K2) resolution takes only 30 or 60 seconds respectively, with complete three-dimensional images available immediately after the scan.

Simad Medical Technology
Moonray Compact C-arm
011-39-051-974324
www.simad.net
List price: Not disclosed
FYI: The Moonray Compact C-arm is designed for a wide range of surgical applications, including orthopedics, pain management, gastroenterology and urology, says the company. Its technological features include a fully digital and upgradeable system, a CCD camera, a 13-inch image intensifier, an automatic radiation dose report, low-dose controls and dynamic density compensation.

Ziehm Imaging
Ziehm Vision FD
(800) 503-4952
www.ziehm.com
List price: $330,000 to $350,000
FYI: The Ziehm Vision FD incorporates cutting-edge technology and state-of-the-art design to offer fully digital imaging with distortion-free images, says the company. The flat-panel detector is insensitive to magnetic fields, which makes it possible to work close to MRI devices or other sites where strong magnetic fields are present. The Vision FD can produce fine-quality soft tissue imaging and skeletal imaging simultaneously, adds Ziehm.