How to Choose a C-arm

Deciding to invest in a major piece of equipment like a C-arm is no easy task, and once you decide to make the investment, choosing a make and model can be equally as challenging. Will the model serve your needs now and in the future? Will it be easy to use and move? Will you be prepared to quickly address any technical problems that crop up? In this article, we'll offer some answers to these and other questions so you can make the best purchasing decision for your facility.

Make Realistic Projections
When assessing your need for a C-arm, it's important to look at three factors, according to James Nunley, DO, outpatient director of the Manchester, Tennessee-based St. Thomas Healthcare Systems ASC and vice president of Surgical Management Inc. First, determine exactly what you'll use the device for and who will use it. Second, realistically estimate the number of procedures that will require the new C-arm. Dr. Nunley says physicians tend to overestimate the volume of new procedures they can bring in. In his consulting work, he routinely takes 20 percent right off the top of all physician new-case volume estimates. Third, be sure to assess your reimbursement for the procedures, so you can be sure the investment will be worthwhile.

Don't Skimp on the Necessities
Experts say it's OK to shy away from features that are nice but not necessary, such as laser sighting. Keeping it simple can not only minimize cost but can also reduce the potential for device failure. Importantly, however, experts also warn against underbuying; a de-featured device that doesn't meet your needs is as good as no device at all. "Cost is what's driving the market," emphasizes Dr. Nunley, "but by the same token, cost is also what's driving the market to outpatient procedures. There has to be some sensibility." To determine what features you need, experts advise assessing your surgical and state regulatory requirements, then ????-??demoing' the unit without the manufacturer's rep on hand.

Assess Your Surgical Needs
Knowing your surgical needs is paramount to selecting the right C-arm. Orthopaedic and podiatric centers, for example, may be well served by a mini-C. Those who use the relatively inexpensive, small devices say technology has advanced to the point where the mini-Cs can provide excellent image quality and ease of use-all without the need for a costly radiology tech. Karen Gabbert, clinical director with the Wichita Orthopaedic ASC, says her facility relies solely on two mini-Cs for all outpatient orthopaedic procedures-including foot, ankle, knee, elbow, shoulder, hand, forearm, and pediatric procedures. "The nurses turn it on and program in the patient information," she says, "and the physician runs the machine." For Ms. Gabbert, the only downside of relying solely on the mini-C is that the center cannot follow through with its plans to become a full-service pain management facility until she purchases a full-body unit.

Indeed, for offering full-service pain management services, a full-body C is mandatory. Only full-body Cs can have enough power, or anode current, to penetrate deep, dense tissues and allow visualization of target areas such as the lateral lumbar spine. A dual screen is also essential because the surgeon needs to visualize needle placement in two distinct planes, according to Eugene Lipov, MD, pain management specialist with the Poplar Creek Center for Pain Management in Hoffman Estates, IL. Without sufficient fluoroscopy, says Dr. Lipov, as many as 40 percent of pain management procedures fail.

C-arm users agree that the best way to clearly define your individual needs is through collaboration. "We elicited the aid of the local hospital's radiology department chief to evaluate things like X-ray tubes, shutter speeds, power supplies, and processors," says Bonnie Dinwoodie, RN, MBA, clinical director and administrator of the Surgery Center of Salem County in Salem, NJ. "Then the surgeons helped us differentiate between what the various C-arms had to offer and what we absolutely had to have."

Remember State Regulatory Requirements
Before buying a full-body unit, be sure to consider your state's regulatory requirements, as well. Some states may require lead within the walls of the facility itself. Others require that you hold on to the records for many years, and this can influence the type of storage media you chose. "Here in Pennsylvania, we need to maintain a hard copy for seven years," says Mary Louise Dietrich, RN, director of the Coordinated Health Systems Ambulatory Surgery Center in Bethlehem, Pa. "Some paper products don't hold up that long."

DIY (Demo it Yourself!)
Although C-arm companies have several ways to describe image quality, ease of use, and mobility, the only way to truly evaluate these important features is to demo the machine. Experts warn, however, that even demos can be misleading if the company representative is there to hold your hand through the procedure. For this reason, don't just demo a C-arm; demo it yourself. "Surgeons may think they know what they want until they actually use the equipment for themselves," notes Ms. Dinwoodie. "Our C-arm demos were great because they made our decision crystal clear."

When demoing a full-body unit, some also advise independently verifying radiation exposure. Although manufacturers provide these ratings, an independent evaluation during the on-site demo may be the only way to accurately quantify the radiation emission during surgery. For the mini-Cs, however, this is not necessary because radiation output and scatter are minimal. "The procedures we do are very short, and the average time spent on the foot pedal is 20 seconds per case," notes Ms. Gabbert. "At our facility, lead aprons are optional."

Consider the Fundamentals
To get the best use out of your C-arm, experts recommend that all centers consider three basic features: maximal C geometry, a printer, and the capability to increase memory.

Maximize C Geometry: For all applications, the larger the C and the greater the distance between the imaging surface and tube, the better. This will help accommodate larger patients and maximize your uses for the C-arm. Ms. Gabbert recalls several cases in which their older model mini-C-which has a smaller tube-to-imaging surface distance than their newer model-could not accommodate the shoulders of large patients.

The C-arm should also allow maximum freedom of movement as it rotates through both the AP-to-lateral and caudal-to-cephalic arcs. During pain management procedures, the surgeon should be able to angle the device to visualize difficult areas, such as the facet joints of the spine, without rolling or bolstering the patient. Moving the patient can be difficult when a needle is partially inserted.

Save Space with a Printer: Dr. Nunley believes a printer, which can run from $4,000 to $5,000, is mandatory, because a 3" x 5" print can serve as a permanent record, thus reducing the space needed for film storage.

Allow for Upgrades: Allowing room for more memory is one way to increase the chance that the C-arm you buy today will serve your needs tomorrow. Although it may cost a little more up front, an upgradable device may help you keep the door open for future applications.

Consider the Purchasing Options Carefully
Leasing: In some circumstances, leasing appears to be a viable alternative to buying. One user chose a short-term lease for his C-arm because he wasn't convinced the unit would pay off. This turned out to be a good idea, as the unit sat unused much of the time. Both Ms. Dietrich and Ms. Dinwoodie recommend considering a lease so you can stay on top of the technological advances in video technology. Ms. Dinwoodie leases her C-arm so she can trade up every three years.

Buying: If you are sold on buying, experts advise calling around to other centers to determine which companies are reputable. In addition, suggests Ms. Dietrich, look into buy-back or trade-in programs so you'll be able to upgrade to a new machine in the future. It may also be wise to consider availability. "C-arms aren't always readily available," she notes.

Refurbished Units: To save costs, some centers may also want to consider a refurbished unit. Before buying an older unit, however, experts advise taking a hard look at both the unit and the company. Older systems may not provide the image quality you need, and if they do, it may be at a cost. "Older units may put out twice as much or more radiation than modern units," says one long-time industry representative. In addition, Dr. Nunley advises ensuring that the company is dependable, and that the unit comes with a limited warranty and sufficient anode current to accommodate your needs. "Some older models may not have enough power to accommodate outpatient surgery needs," he says. Importantly, Dr. Nunley also recommends assessing parts availability, as well as the age of the tube. It can cost $30,000 to $40,000 to replace a tube in an older model. So you don't get caught short on parts, Dr. Nunley recommends purchasing a device that is currently in production.

Think Warranty, Training, Service
Finally, once you decide on a make and model, it may behoove you to look into the company's warranty, training, and service programs before signing on the dotted line.

A good warranty will cover parts (including glassware) and labor for at least a year and will be a full, rather than a prorated, plan. Be sure to check the details, as some warranties cover certain parts for only six months. In addition, you may be able to negotiate an extended two-year warranty as part of the deal. Of course, the dependability of the machine is foremost, as a warranty becomes less important when you are purchasing a C-arm from a reputable company in the first place.

Ms. Dietrich advises looking into the company's training program, so you can be sure the staff is sufficiently educated at the time of purchase-and in the future. "If you call the company a year later and ask them to come out to train a new radiation tech, will they oblige?" she asks.

Lastly, advises Ms. Dietrich, be certain you have someone to turn to in the event of device failure. Although she uses independent contractors to service most of the equipment in her facility, she recommends securing a service contract directly with the C-arm maker and tying in a preventive maintenance plan. Many independent firms may not be capable of working on a C-arm that is out of warranty, she says. Be sure the company can provide a service technician to you within 24 hours, or the downtime could cost the facility a lot of money. Other things to look for include a technical support hotline and loaner availability within 24 hours.