By Elaine Sanchez Wilson

When selecting their C-arm of choice, health organizations have a litany of factors to weigh. Chief among them: What kinds of surgical and interventional procedures will it be used for? What image resolution does it deliver? Does it support the radiation safety program in place at the facility? How does it address user and patient ergonomics? How much technical support will be offered upon purchasing the unit?

Furthermore, depending on the health provider’s budget, another question may linger: Should one buy new or used?

Buying from an OEM versus a reseller each comes with its own set of unique considerations. Nevertheless, at the end of the day, both markets aim to serve one ultimate goal—quality patient-centered care.

OEM Offerings

Today’s customers seek an optimized combination of features and services for their particular needs, at the right price, says Ronald Tabaksblat, business leader of image-guided therapy systems at Philips Healthcare. “Common considerations customers have include image quality, workflow efficiency, x-ray dose, and supporting services,” he adds.

Philips offers a broad portfolio of solutions, ranging from C-arms for orthopedic procedures, to C-arms for vascular and cardiac procedures, and advanced hybrid labs, Tabaksblat says. For example, the company recently launched its new Azurion platform around the globe. The image-guided therapy solution is equipped with more than 1,000 new components, including an enhanced flat-panel detector and an advanced user interface, designed to facilitate workflow efficiencies.

Another major player in the C-arm market is Waukesha, Wis.-based GE Healthcare. During the 2016 meeting of the Radiological Society of North America, the company showcased its OEC Elite MiniView C-arm with complementary metal-oxide-semiconductor (CMOS) flat-detector technology, designed to enhance the user experience by minimizing positioning struggles and increasing imaging confidence through real-time general fluoroscopic visualization of patient anatomy.

According to GE, surgeons can single-handedly maneuver the unit, and less physical force is needed to position the C-arm around a patient’s anatomy. It also features SmartLock, a button that automatically locks the C-arm in place to reduce drift concerns.

Similarly, one of the market’s leading vendors, Malvern, Pa.-based Siemens Healthineers, recently received U.S. FDA clearance for its Artis pheno, a robotic C-arm angiography system created for use in minimally invasive interventional procedures. Featuring a zen40HDR flat-panel detector and Gigalix x-ray tube, the system reportedly delivers 2D imaging resolution that is four times higher in all recording processes than its predecessor system, the Artis zeego.

During the development of the system, Siemens was particularly mindful of patient safety, applying an antimicrobial coating on the surface of the C-arm, stand, and patient table to minimize patient infection. Moreover, a StructureScout exposure control feature regulates acquisition parameters to achieve optimal image contrast at “As Low As Reasonably Achievable” (ALARA) dose levels.

Looking at the Resale Market

While manufacturers are increasingly providing C-arms with flat detectors typically marked by higher image resolution for greater accuracy, the vast majority of C-arms in the refurbished market are equipped with image intensifiers, according to Matthew Blaustein, founder and CEO of Bluestone Diagnostics in Thornwood, N.Y. “OEMs set the newest trends, and then the refurbished market follows, albeit slowly,” Blaustein explains. “Flat-panel monitors are now the trend on the refurbished market.”

According to Blaustein, different factors come into play depending on whether a customer is choosing equipment that is new or refurbished. “But as far as my company [goes], and as far as resellers in general go, selling preowned or refurbished C-arms, No.1 of all is the reputation of the reseller,” he says.

When selecting new versus used or refurbished equipment, price is a major catalyst. Other important considerations include the intended diagnostic and surgical procedures, as well as the strength of the maintenance program.

“Ease of use and service support for proper maintenance and repair, as well as access to an applications specialist, is key,” says Patrick Kluge, technical director at Baltimore-based Rad Rays LLC. “This is a relationship business and the customer needs to trust the sales and service teams. All of this is important to make sure that the facility does not buy ‘two left shoes,’” he adds.

Blaustein agrees that healthcare providers should consider specific attributes in partnering with a reseller.

“Service is key,” Blaustein says. “When I say service, I mean when they say they’re going to do something, they execute on what they say. They’re responsive in delivering the quotation or proposal, and they’re responsive if they get the order to deliver exactly what they say they’re going to do.”

Ethics are also highly important, Blaustein maintains.

“Get as many customer references as possible, and make sure that those references indicate that the reseller adhered to the model and specifications it contracted to sell. Also, have the reference indicate how well the reseller serviced the product—and, among other things, how responsive said reseller was in providing service for the system in an emergency (if that is possible). A prospective customer should obtain no less than three references of the same system in which they are interested. If a reseller does not provide references or is slow in responding to your request, I would be very weary.”

Offering a cautionary tale representing why customers should do their due diligence in selecting their service or sales provider, Kluge recounted a recent case his company handled for an Internet-based sales company, which was seeking to install an OEC 9800. “We were shocked to find that this ‘refurbished’ system was leaking battery acid onto the operating room floor upon arrival,” Kluge recalls. “The system-specific knowledge of the operators, biomeds, or in-house imaging specialist is very important.”

Radiation Safety Considerations

Both OEMs and resellers alike must ensure that their equipment is compliant with governmental regulations surrounding radiation dose, to protect users as well as patients.

“Monitoring x-ray dose management remains essential,” says Philips’ Ronald Tabaksblat. “Facilities should take steps to increase their staff’s awareness of ways to help reduce dose. These steps include increasing the distance between the operator and the source as much as possible; keeping the detector as close to the area of interest as possible to reduce scatter dose and increase image quality; keeping the x-ray source, when possible, under the table; using collimation appropriately; and ensuring the right imaging protocol is selected for the procedure.”

Radiation-emission monitoring is among the most important issues when it comes to governmental regulations. “Whether new or refurbished, a C-arm must be properly calibrated to ensure that it meets state and federal guidelines,” Blaustein says. “Radiation levels must be carefully monitored at all times to ensure that they’re within state regulations.”

A safety program may include personal protection, such as lead aprons and thyroid shields, certain parameters for collimation and magnification. “The operators need to have a clear understanding of x-ray physics, including the Inverse Square Law and ALARA,” Kluge says. “A properly trained operating room x-ray technologist understands this.”

Even so, Kluge questions whether nurses, physicians, and staff members in some private practices fully comprehend these concepts. He says it’s why “operators need to be trained specifically on that piece of equipment.”

Seeking Best Practices

As an OEM, the top challenge that Philips encounters is training users on the systems, Tabaksblat says. “Over time, there is usually turnover in staff members who operate C-arms, and this tends to erode the knowledge of the system,” he notes. Combating such issues, he says, requires healthcare providers to recognize this challenge and properly train staff members on all aspects of the system—not just some parts of it.

In addition, software upgrades should be done regularly and in a timely manner, Tabaksblat adds. “While this may seem like a basic maintenance requirement, it is hugely impactful to the uptime of a system,” he says.

Moreover, Blaustein offers best practices for providers who opt to go the refurbished route: “You want to have a backup C-arm to replace the broken one, or have access to a system that a reseller can rent out to you for a short period of time,” he advises. “Have parts on hand or be able to get those parts, and of course, access to a trained engineer that knows how to repair the system in a pinch.”

Not that finding someone to perform such repairs is always easy, Kluge cautions. C-arms are rather complicated devices—and not every HTM professional has received proper training on them. “This, by no means, is a statement that the OEM provides the best service or PM,” he says. “We find systems that were poorly maintained by the OEM, in-house biomed departments, or ‘jack-of-all-trades’ x-ray companies. Routinely replaced coin cells, generator batteries, and high-voltage greasing are overlooked or skipped.”

To thwart such problems, Blaustein recommends that comprehensive preventive maintenance (PM) be performed on C-arms at least twice a year. During the PM, HTM professionals should examine the wheel locks, brakes, steering, control panels, electronics, collimator, lights, keyboards, and batteries, he advises. “The PM ensures proper operation, continuously,” Blaustein says.

Summing It Up

As healthcare facilities face increasing cost pressures and seek ways to gain efficiencies, many are rigorously analyzing their OR operations—paying close to attention to such areas as staff management, consumable cost, capital equipment utilization, patient flow, and room turnover times among other improvements, Tabaksblat says.

“In response to the increasingly value-focused healthcare environment, customers are concentrating on total cost of ownership,” he continues. “Administrators and clinicians are focused on efficiency improvements and are seeking solutions that can improve outcomes and reduce cost and time.”

Some of the hottest improvements currently being touted as the “latest and greatest” in the C-arm market include LCD/LED monitors, retrofit kits for existing systems, wireless DICOM, and flat-detector systems. Such technologies are certainly noteworthy, Kluge concedes, but he encourages facilities to pay more attention to their particular equipment needs—rather than the bells and whistles of a new C-arm.

What matters most, he says, is what works for your facility—be it an old or new system. “The correct selection of the system is the most important part,” he concludes. Words of wisdom, indeed.

Elaine Sanchez Wilson is associate editor of 24×7. For more information, contact Elaine Sanchez Wilson at [email protected].