Radiation protection for surgeons and anesthetists: practices and knowledge before and after training

Monitoring of surgical staff x-ray exposure in the operating room with DosiBadge

Surgical procedures involving the use of x-rays in the operating room (OR) have increased in recent years, thereby increasing the exposure of OR staff to ionizing radiation. An individual dosimeter makes it possible to record the radiation exposure to which these personnel are exposed, but there is a lack of compliance in the wearing of these dosimeters for several practical reasons. This makes the dose results obtained unreliable. To try to improve the rate of dosimeter wearing in the OR, the Dosibadge project studied the association of the individual dosimeter with the hospital access badge, forming the Dosibadge. Through a study performed at the Tours University Hospital in eight different ORs for two consecutive periods of 3 months. The results show a significant increase in the systematic use of the dosimeter thanks to the Dosibadge, which improves the reliability of the doses obtained on the dosimeters and the monitoring of personnel. The increase is especially marked with clinicians. Following these results and the very positive feedback to this first single-centre study, we are then planning a second multicentre study to validate our proof of concept on different sites, with the three brands of individual dosimeters used in France i.e. dosimeters supplied by Dosilab; Landauer and IRSN.

Worker's exposure to radiation in fluoroscopy, assessing and instruments: A systematic literature review

This review aims to identify and analyze the instruments employed for assessing the overall performance of workers exposed to fluoroscopy during surgical procedures and/or interventional procedures, using the PRISMA methodology. The studies were located through searches conducted on PubMed, Web of Science, Lilacs, ScienceDirect, B-ON, EBSCOhost, and EBSCO Discovery Service on March 27, 2023. Additional studies were identified using backward and forward citation techniques. The PEO strategic model was followed. The search spanned studies published between 2012 and 2022. The quality of the studies underwent assessment using the Joanna Briggs Institute checklist for analytical cross-sectional studies. Out of the 23 studies identified, encompassing 3604 individuals, 12 (52%) addressed the reliability and/or validity of the instruments, while 3 (13%) focused on the development and psychometric testing of the instruments. Only 5 instruments (23%), validated and reliable, exclusively evaluated occupational radiological protection. The predominant dimension covered was knowledge (82%, n = 19). The population was assessed in 18 studies, pre- and post-intervention in 2 studies, and 21 studies provided recommendations or tools for improvement. Individuals in the studies utilized passive dosimeters (ranging from 5% to 98%), thyroid shields (15% to 98%), and aprons or lead skirts/coats (28% to 99%). The evidence quality was moderate (6/8). This study underscores the imperative to enhance compliance with protective and monitoring equipment. Furthermore, additional information is warranted concerning the validity and reliability of the instruments used, as well as the development of instruments that are both valid and reliable.

The Effect of Pre-Operative Verbal Confirmation for Interventional Radiology Physicians on Their Use of Personal Dosimeters and Personal Protective Equipment

Interventional radiology (IR) physicians must be equipped with personal passive dosimeters and personal protective equipment (PPE); however, they are inconsistently used. Therefore, we aimed to explore practical measures to increase PPE usage and ascertain whether these measures could lead to an actual decrease in exposure doses to IR physicians. Dosimeters and PPE were visually inspected. Then, a pre-operative briefing was conducted as a direct intervention, and the use of dosimeters and PPE was verbally confirmed. Finally, the intervention effect was verified by measuring the use rates and individual exposure doses. Because of the intervention, the use rate markedly improved and was almost 100%. However, both the effective dose rate (effective dose/fluoroscopy time) and the lens equivalent dose rate (lens equivalent dose/fluoroscopy time) showed that the intervention led to a statistically significant increase in exposure (effective dose rate: p = 0.033; lens equivalent dose rate: p = 0.003). In conclusion, the proper use of dosimeters and PPE raised the radiation exposure values for IR physicians immediately after the intervention, which was hypothesized to be due to the inclusion of exposure overlooked to date and the changes in the dosimeter management method from a single- to a double-dosimeter approach.

Diagnostic Imaging of Pregnant Women and Fetuses: Literature Review

Healthcare providers have acknowledged the dangers of radiation exposure to embryonic and fetal health, yet diagnostic imaging of pregnant women is increasing. Literature that pertains to the topic of interest was reviewed to collect tertiary data. The purpose of this literature review was to present the various radiation risks for pregnant women and the fetus depending on the gestational age of the pregnancy. The specific effects of radiation on pregnant women and the fetus, X-ray risks depending on the gestational age of the pregnancy, and other potential health effects when performing diagnostic imaging procedures on pregnant women were discussed in this review. In addition, ethical issues have been considered by improving overall communication to minimize unnecessary radiation exposure to pregnant women and fetuses.

Development and evaluation of the effectiveness of educational material for radiological protection that uses augmented reality and virtual reality to visualise the behaviour of scattered radiation

Understanding the behaviour of scattered radiation is important for learning appropriate radiation protection methods, but many existing visualisation systems for radiation require special devices, making it difficult to use them in education. The purpose of this study was to develop teaching material for radiation protection that can help visualise the scattered radiation with augmented reality (AR) and virtual reality (VR) on a web browser, develop a method for using it in education and examine its effectiveness. The distribution of radiation during radiography was calculated using Monte Carlo simulation, and teaching material was created. The material was used in a class for department of radiological technology students and its influence on motivation was evaluated using a questionnaire based on the evaluation model for teaching materials. In addition, text mining was used to evaluate impressions objectively. Educational material was developed that can be used in AR and VR for studying the behaviour of scattered radiation. The results of the questionnaire showed that the average value of each item was more than four on a five-point scale, indicating that the teaching material attracted the interest of users. Through text mining, it could be concluded that there was improved understanding of, and confidence in, radiation protection.

Assessment of Health Professionals' Attitudes on Radiation Protection Measures

(1) Background: Health professionals' knowledge, beliefs and perceptions concerning radiation protection may affect their behaviour during surgery and consequently influence the quality of health services. This study highlights the health professionals' average knowledge level and captures the beliefs, perceptions, and behaviours in a large public Greek hospital. (2) Materials and Methods: A cross-sectional study was carried out, including health professionals working in operating rooms. One hundred thirty-two staff members participated by responding to an original questionnaire. The sample consisted of nurses, radiographers and medical doctors of various specialties involved daily in surgical procedures where ionizing radiation is required. The survey was conducted from March to June 2021, and the response rate was 97%. (3) Results: The level of overall knowledge of health professionals regarding radiation protection safety was not satisfactory. Females and employees with a lower level of education had more misconceptions about radiation and radiation protection. Employees of younger ages and with less previous experience were more likely to have negative emotions towards radiation exposure. Finally, employees with fewer children tended to express physical complaints caused by their negative emotions due to radiation exposure. (4) Conclusions: Health professionals' lack of basic and specialized knowledge concerning radiation protection safety had a negative impact on the provision of health services. The continuing training of the staff seemed to be the only solution to reverse this trend. The training should highlight how radiation exposure can be minimized, safeguarding health professionals' trust and sense of security by significantly improving their working environment.

Estimation of occupational radiation doses in neuroendovascular procedures

To estimate the mean effective dose per procedure with multiple dosimetry, to calculate the annual effective dose to personnel working in neuroendovascular procedures and compared with methods reported in the literature and with national and international limits. The radiation dose to personnel was monitored in 20 procedures classified as diagnostic or therapeutic. During each procedure, the equivalent dose to eyes, thyroid, under and over the lead apron at chest level, hands, gonads and knees was measured with lithium fluoride thermoluminescent dosimeter chips (TLD-100). Estimations of the annual effective dose from different methods found in literature that use one or two dosimeters and from this work were compared. Also, a comparison was made with the safety limits recommended in national and international regulations. Radiation exposure to eyes, thyroid, gonads and knees is relevant to the effective dose, and therefore to the annual effective dose estimations. Personnel position is important, as the performing physician, who is closer to the patient, received the highest dose measured. In particular, this was observed in the equivalent dose received over the apron. However, the equivalent dose to the right eye was higher for neuroanaesthesiologists than for performing physicians due to their position relative to the patient. In general, effective doses estimated using one- and two-dosimeter methods found in the literature were, respectively, lower and higher than those obtained with the ten-dosimeter method in this work. The annual effective doses to personnel estimated with the multiple dosimetry algorithm ranged from 1.3 to 1.5 mSv y^-1and are within the national and international limits.

Occupational radiation exposure in doctors: an analysis of exposure rates over 25 years

OBJECTIVES

Healthcare professionals' occupational exposure to ionising radiation may be increasing due to increasing use of imaging and image-guided intervention. This study aims to assess the occupational exposure of doctors over a 25-year period at an NHS teaching hospital.

METHODS

Dosemeter measurements were collected prospectively from 1995 to 2019. Two retrospective analyses were performed over time (first including all measurements, second excluding "zero-dose" measurements), and by speciality. Group comparisons were undertaken using multilevel linear regression; a p-value <0.05 was deemed significant.

RESULTS

8,892 measurements (3,983 body, 1,514 collar, 649 eye, 2,846 hand), of which 3,350 were non-zero measurements (1,541 body, 883 collar, 155 eye, 771 hand), were included. Whole dataset analysis found a significant decrease in exposure for radiologists and cardiologists, as measured by body, hand and collar dosemeters over the last 25 years (p < 0.01 for all). The non-zero readings reflect the whole cohort analysis except in the case of eye dosemeters, which showed a significant decrease in exposure for cardiologists (p < 0.01), but a significant increase for radiologists and surgeons/anaesthetists (p < 0.01 for both).

CONCLUSIONS

Whilst ionising radiation remains an occupational risk for doctors, the overall decreasing trend in occupational exposure is reassuring. However, a significant rise in eye dose for radiologists, surgeons and anaesthetists is concerning, and close monitoring is required to prevent future issues.

ADVANCES IN KNOWLEDGE

This paper is one of few evaluating the occupational radiation exposure to doctors over a 25-year period, showing that although most dosemeter measurements reflect decreasing exposure, the increase in eye exposure warrants caution.

Radiation protection among health care workers: knowledge, attitude, practice, and clinical recommendations: a systematic review

OBJECTIVES

This study was performed to determine the knowledge, attitude, and practice (KAP) of health care workers (HCWs) towards radiation protection.

METHODS

In this systematic review study, three international databases (Web of Science, PubMed, Scopus) were searched for related published articles in the English language from 1 January 2000 to 1 February 2020. The quality of the included studies was evaluated using the Hoy et al. tool.

RESULTS

Out of the 1,848 studies examined, 41 studies that were performed on 11,050 HCWs were included in the final stage. The results indicated that in most studies, more than half (50%) of the participants had average knowledge. Furthermore, 60% of the participants had a positive attitude, but in most studies, they had average practice regarding radiation protection. The most important recommendation for improving KAP among the participants was incorporating radiation protection standards in the student curriculum.

CONCLUSION

Considering the results of the study, further attention should be paid to proper education regarding radiation protection standards and improvement of HCW performance.

Orthopaedic Surgeon Brain Radiation During Fluoroscopy: A Cadaver Model

BACKGROUND

The aims of this study were to quantify exposure of the surgeon's brain to radiation during short cephalomedullary (SC) nailing, to extrapolate lifetime dose, and to determine the effects of personal protective equipment (PPE) on brain dose.

METHODS

Two cadaveric specimens were used: (1) a whole cadaveric body representing the patient, with a left nail inserted to act as the scatter medium, and (2) an isolated head-and-neck cadaveric specimen representing a surgeon, with radiation dosimeters placed in specific locations in the brain. The "patient" cadaver's left hip was exposed in posteroanterior and lateral radiographic planes. Measurements were performed without shielding of the head-and-neck specimen and then repeated sequentially with different PPE configurations. An average surgeon career was estimated to be 40 years (ages 25 to 65 years) with the caseload obtained from the department's billing data.

RESULTS

The mean radiation dose to the surgeon brain without PPE was 3.35 µGy (95% confidence interval [CI]: 2.4 to 4.3) per nail procedure. This was significantly reduced with use of a thyroid collar (2.94 µGy [95% CI: 1.91 to 3.91], p = 0.04). Compared with use of the thyroid collar in isolation, there was no significant additional reduction in radiation when the collar was used with leaded glasses (2.96 µGy [95% CI: 2.15 to 3.76], p = 0.97), with a lead cap (3.22 µGy [95% CI: 2.31 to 4.13], p = 0.55), or with both (2.31 µGy [95% CI: 1.61 to 3.01], p = 0.15). The extrapolated lifetime dose over 40 working years for SC nailing without PPE was 2,146 µGy (95% CI: 1,539 to 2,753), with an effective dose of 21.5 µSv.

CONCLUSIONS

The extrapolated cumulative lifetime radiation to a surgeon's brain from SC nailing based on our institution's workload and technology is low and comparable with radiation during a one-way flight from London to New York. Of note, we studied only one of many fluoroscopy-aided procedures and likely underestimated total lifetime exposure if exposures from other procedures are included. This study also demonstrates that thyroid collars significantly reduce brain dose for this procedure whereas other head/neck PPE such as lead caps appear to have minimal additional effect. This study provides a methodology for future studies to quantify brain dose for other common orthopaedic procedures.

CLINICAL RELEVANCE

This study, based on our institutional data, demonstrates that although the lifetime brain dose from SC nailing is low, thyroid collars significantly reduce this dose further. As such, in accordance with the "as low as reasonably achievable" radiation exposure principle, radiation safety programs and individual surgeons should consider use of thyroid collars in this setting.

Development of an application to visualise the spread of scattered radiation in radiography using augmented reality

As radiation is widely used in medical institutions, the lack of radiation protection education for health workers increases the risk of radiation exposure. The purpose of this study is to develop an application for radiation medical personnel that visualises the distribution of scattered radiation by using augmented reality (AR). The irradiation conditions for mobile chest and pelvic radiography were simulated using Monte Carlo simulations (Particle and Heavy Ion Transport code System). Monte Carlo results were verified using physical measurements. The behaviour of scattered radiation was displayed three-dimensionally in virtual reality using ParaView. Subsequently, an application to visualise scattered rays was developed in Unity for tablet devices. An application with a sense of reality was developed by visualising the scattered radiation distribution of a mobile imaging in a real space in AR in a three-dimensional size, which is close to the actual size. The radiation dose could be estimated at any position and the behaviour of scattered radiation became easier to understand.

Simple preoperative radiation safety interventions significantly lower radiation doses during central venous line placement in children

PURPOSE

The purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job-instruction model with a preradiation time-out.

METHODS

We reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013-2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph.

RESULTS

100 patients with valid DAP measurements were identified for analysis (59 preintervention, 41 postintervention). Following implementation of the radiation safety process, there was a 79% decrease in median DAP (61.4 vs 13.1 rad*cm², P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01).

CONCLUSION

A preoperative radiation safety briefing and a radiation safety time-out supported by a job-instruction model were effective in significantly lowering the absorbed doses of radiation in children undergoing CVL insertion.

TYPE OF STUDY

Case-control study.

LEVEL OF EVIDENCE

Level III.