Fluoroscopy safety: Not just for patients, but also for practitioners

Fluoroscopy safety is crucial for effective medical care, not only for patients but also for providers.

A multidisciplinary panel of experts recently delineated processes aimed at helping interventional radiologists and their care teams to stay healthy over the long term. 

In addition to strongly recommending the use of enhanced radiation protection devices (ERPDs), the statement highlights the ethical and legal responsibilities of government, fluoroscopy equipment manufacturers, and healthcare institutions to protect all healthcare professionals from avoidable workplace hazards.

"Health care professionals in fluoroscopic laboratories face significant occupational hazards, including cancer, cataracts, and reproductive concerns due to prolonged exposure to iodizing radiation, and orthopedic injuries stemming from long-term use of heavy aprons protection from radiation," wrote a team led by David Rizik, MD, of Banner University in Scottsdale, AZ, in the Journal of the Society for Cardiovascular Angiography & Interventions. 

The panel also included representatives from the Society for Cardiovascular Angiography (SCAI), the American Society of Echocardiography (ASE), the Heart Rhythm Society (HRS), the Society for Interventional Radiology (SIR), and the Society for Vascular Surgery (SVS).

Practitioners need protection

Patients depend on interventional radiologists and their teams for timely access to image-guided treatments that can relieve pain, restore function, and save lives, SIR president Saher Sabri, MD, told AuntMinnie.com.

Saher S. Sabri, MDSaher Sabri

"Protecting access to that care means protecting the teams who deliver it," he said. "Enhanced radiation protection in the angio suite is not an optional workplace upgrade, but a key component of ensuring patient access to interventional radiology teams who can safely deliver these critical minimally invasive procedures. With technologies such as ERPDs now available, it is an ethical responsibility to adopt this technology widely in angio suites."

In the published statement, Rizik and colleagues explained that radiation safety efforts over the past number of years have focused on personal protective measures, such as lead or lead-free garments. But these place a "literal and figurative burden on individual operators working in close proximity to the radiation source," they wrote.

"The significant reduction in achievable radiation exposure made possible by contemporary ERPDs represents a technological shift, moving beyond protective aprons and smaller, movable shields," the team noted. "Reliance solely on protective aprons and operator-positioned small shields is no longer an acceptable standard and is inconsistent with the ALARA [As Low as Reasonably Achievable] principle."

In fact, use of heavy lead aprons, vests, and thyroid collars and glasses can lead to long-term negative health effects for fluoroscopy practitioners including brain and breast cancers (associated with radiation-induced DNA damage) and cataracts, as well as musculoskeletal injuries caused by bending at the waist, craning the neck, and repeated neck flexion and extension to visualize small anatomic structures -- all of which shift the load of the apron to the operator's back, neck, and shoulders. Rizik and colleagues noted that recent surveys show 62% of technicians and 66% of physicians report orthopedic symptoms related to wearing protective aprons, and this prevalence increases with practitioner age, years in practice, and case load.

The good news is that ERPDs reduce operator and staff radiation exposure by up to 99% compared with standard practices, they wrote.

"Such levels of protection may allow performance of fluoroscopic-guided procedures with minimal or even no reliance on heavy, orthopedically crippling lead or lead-free aprons," the group explained.

What are ERPDs?

ERPDs include technologies such as disposable radiation attenuating drapes, mobile and fixed barrier systems, and robotic or remote-controlled platforms that allow for the reductions in operator and staff exposure, according to the statement authors, who listed the following types of ERPDs:

· Body-worn protection systems (redistributes weight of protective lead apparel);

· Configurable radiation protection systems (shields the fluoroscope);

· Panel-based transparent barrier systems (shields the fluoroscope);

· Device-mounted source-attenuating shielding systems (prevents scatter from the fluoroscope); and

· Modular radiation protection systems (shields the fluoroscope).

Image courtesy of the Journal of the Society for Cardiovascular Angiography & Interventions and republished under a Creative Commons license (CC BY 4.0).Rizik and colleagues also outlined ERPD performance metrics, including radiation protection capabilities (for tableside operators, anesthesia staff, primary nurses and echocardiographers) and operational functionality (i.e., the ability to obtain necessary vascular access, C-arm angles, intraprocedural shield movements, and device setup while maintaining protection from radiation exposure).

Finally, the group recommended that federal regulations mandate adherence to ALARA; that an initiative to standardize regulations for barrier protection across states be established as well as a national certification program for angio suite staff; and the creation of a national dose registry for occupational radiation exposure that would include fluoroscopy data in particular.

Resolving resistance

Even though ERPDs are available, making the fluoroscopic suite safer for practitioners will require a concerted effort, Rizik and colleagues explained, writing that the task will involve "more consistent application of existing radiation safety tools and techniques," and that this would entail regular in-person observation and real-time feedback to fluoroscopy laboratory staff from medical physicists.

Are radiology departments resistant to shifting from a personal protection strategy to one based on ERPDs? Perhaps, but this resistance can be addressed by raising hospital and departmental leader awareness, according to Sabri.

"Given how effective ERPDs are, it is clearly worth the investment to retrofit our suites with more ergonomic radiation protection solutions that help us continue our life-saving work," he said. "That is why the ALARA+ Coalition produced a toolkit to give hospitals, clinicians and policymakers practical steps to strengthen radiation safety, reduce orthopedic risk and make angio suites safer. Now that we have awareness of the orthopedic risks, we can use these resources to assess gaps and make our case to leaders and administrators so we can take action to protect the teams delivering this essential care to patients."

In any case, SIR members have long supported advocacy for improved safety in the angio suite, Sabri told AuntMinnie.com.

"Interventional radiologists and our care teams depend on fluoroscopy to deliver minimally invasive, lifesaving treatments, but that work should not come at the expense of our long-term health or the health of our colleagues," he concluded. "We are dedicated to our patients and want to serve them as long as possible, and the ALARA+ guidelines will help us do so in a way that protects our teams."