Question

1- Explain the need for radiation protection efforts by operators of radiation-protection efforts by operators of radiation-producing equipment.

2- List and describe the practical radiation protection methods expected of all radiologic technologists on each radiographic test.

Answer 1

The increasing use of ionization radiation for diagnostic and therapeutic purposes especially in higher dose procedures such as computed tomography (CT) and interventional radiology have raised serious safety and health concerns for both patients and medical staff.

During the last 15-year period the number of CT examinations has almost tripled and now contribute to more than 60% of the total collective dose from X-ray examinations. A typical head CT scan, which is the most frequent CT examination in adults and children, delivers an effective dose of about 4 mSv whereas the effective doses for abdomen and coronary angiography CT examinations can reach 25 and 32 mSv, respectively. The concern for the increased use of CT exams is more pronounced for pediatric patients. A recent survey revealed that the frequency of CT examinations has doubled in children under 5 years old while it has tripled in older children the last 20 years. Pediatric patients are more sensitive to radiation-induced risks compared to adults due to their longer post-exposure life expectancy and their rapidly dividing cells. Two recent epidemiological studies on large pediatric populations demonstrated positive association between radiation exposures received from CT scans and cancer incidence. It is worth mentioning that even today there is lack of optimized, size-based protocols for pediatric procedures in clinical routine and therefore children may be over-exposed to radiation.

Concerning the field of interventional radiology (IR), the new advances in fluoroscopy imaging equipment as well as the development of new interventional tools and devices (balloon, catheters, stents) led to a significant increase of 78% in interventional (non-CT) procedures.

Radiation protection and safety is an extremely important issue for IR medical staff. IR procedures are usually complex, demands high fluoroscopy times, high dose rates and a large number of cine acquisitions. Therefore, they deliver high radiation doses both to patients and medical staff. IR procedures deliver effective dose to the patients ranging from 5 to 160 mSv and contribute about 8% to collective dose even though they consist of a small percentage in the total number of X-ray examinations performed in a given population. Variations in the value of occupational doses for the same type of procedure are largely due variations in the X-ray equipment, the technique, the training of health professionals on radiation protection issues, the optimization of protocols as well as to the availability and use of protection tools. The most common deterministic effects in patients are erythema, skin necrosis, hair loss and permanent epilation as well as cataract formation in occupational settings. Most of the time, the deterministic injuries arise from the poor knowledge on radiation protection rules, the lack of quality assurance programs, the performance of wrong practices and the improper or no use of radiation protection tools.

The key role for the implementation of RPC in a Radiology Department is initially the development of a strategic plan where every decision and process takes into account radiation safety of staff and patients. Then this strategic plan must be turned into an action plan in order to create the conditions for the incorporation of radiation safety in the routine work of the department. But how we can achieve the establishment of a RPC program in Radiology Departments and how easy is it to apply a “culture” on a daily basis?

The most important factor contributing to the creation of a RPC is the continuous education and training of the staff and professionals with the attendance of courses, workshops, seminars and electronic-learning programs in a normal periodical basis. Theoretical education and practical training in radiation protection aim to ensure that healthcare professionals will obtain a strong foundation in radiation protection and a basic knowledge of the technology of each modality. Education is an essential aspect for the optimization of clinical protocols and the reduction of radiation exposure. Physicians, radiographers, nurses and other medical staff need to have a substantial knowledge of radiation protection regulations and a comprehensive understanding of the factors that affect patient and occupational dose in order to minimize the harmful effects of ionizing radiation. Medical staff should be adequately trained in order to keep the dose as low as reasonably achievable (ALARA principle), be familiar with radiation quantity units, pay special attention to radiation protection of pregnant and pediatric patients and proper use of the radiation protection equipment.

The active stakeholder engagement of all levels including health authorities, researchers, medical staff and patients is the second milestone for the establishment of a RPC. In a Radiology Department, multi-disciplinary collaboration is needed. Radiologists, medical physicists, radiographers, nurses and other specialists must collaborate closely one to each other, in order to ensure patient safety and best clinical outcome. RPC is strongly dependent on the behavior of all stakeholders. The effective communication among workers leads to the creation of a supportive and motivating work environment where everyone has a clear role. A positive workplace is characterized by trust and respect among stakeholders and allows the exchange of experience and knowledge. A strong leadership increases the radiation risk awareness and allows the performance of safer practices, which prompts minimizing errors.

Quality assurance (QA) program is another essential step in the implementation of RPC. According to WHO, the QA program in diagnostic radiology is defined as “an organized effort by the staff operating a facility to ensure that the diagnostic images produced are of sufficiently high quality so that they consistently provide adequate diagnostic information at the lowest possible cost and with the least possible exposure of the patient to radiation’’.

The objectives of a QA program is to improve patient care and comfort, ensure accurate diagnosis and proper function of the equipment, produce high quality images

(1) Responsibility: There should be an assignment of the responsibility with specific duties for the performance of QA procedures. Both managers and employee are responsible for the implementation and improvement of QA programs in clinical routine;

(2) Equipment specifications: Accurate specifications must be provided for each modality according to the facilities needs;

(3) Standards for image quality: Standards, criteria and limits for diagnostic acceptable images should be documented and accessible;

(4) Monitoring and maintenance: Monitoring, testing and maintenance of radiology equipment should be established and performed on a regular basis;

(5) Evaluation: There must be regularly recurring evaluation of the adequacy and effectiveness of the X-ray equipment performance and the QA program itself;

(6) Records: Every department should keep records about the equipment, quality control tests, dosimetry data, maintenance and repair of the modalities. The records must be easily accessible to the staff;

(7) Manual: The manual must include list of duties and responsibilities of the staff as well as a list of the tests to be performed;

(8) Education: QA specialists shall have continuing education and training in order to be qualified and up-to-date;

(9) Committee: Each department should establish a committee composed of radiologists, medical physicists and radiographers with the top priority being the QA and the radiation safety; and

(10) Review: Ongoing review of the QA program is important in order to assess the effectiveness of the QA procedures.

The implementation of a RPC should be driven from the highest level. Managers, medical professionals and workers should be directly involved and have a key role in the execution of RPC in every department. Radiation protection experts enhance safety culture, provide leadership, develop relationships with the administration and the employees and are responsible for the staff training and the creation of guidelines and recommendations under the guidance of radiation protection associates (e.g., IRPA). Managers should be able to change unsafe practices and behavioral hazards, recognize safe practices and report accidents in order to prevent recurrence. Furthermore, the healthcare staff should implement the guidelines and the recommendations, ensure the proper practice of examinations, improve patient health care and build trust between patients and staff.

RPC is a combination of attitudes, priorities, policies and practices concerning radiation safety. The foundation of a RPC program is a dynamic process that needs continuous evaluation and systematic improvement with the use of quantitative and qualitative tools in order to examine how well the RPC is being implemented and to check whether the program is achieving the desired goals. RPC should be an integral part of clinical routine and demands deep knowledge of radiation risks, safety rules and active participation of all stakeholders. Insufficient knowledge and lack of collaboration are the most significant barriers in the implementation of RPC. For the successful establishment of a strong RPC program, authorities, professionals, employee and patients must fully comprehend the role and the impact of RPC in a Radiology Department and fill the gap between theory and practice.