Innovative Initiatives in Radiation Safety Lower Patient, Operator Dose in the Cath Lab

PARIS, France—In the fight to reduce both patient and operator radiation exposure, cardiac care teams are getting creative. Two presentations here at EuroPCR 2016 outline successful strategies that have resulted in improved cath lab safety.

Exposure to harmful radiation is increasingly recognized as a potentially serious cause of cataracts, brain tumors, and orthopedic issues. Yet some find many of the available protection devices cumbersome and neglect to use them, despite ample evidence of benefit.  

The nursing staff at Cardiovascular Centre Aalst (Belgium), decided to take matters into their own hands. Liesbet De Block, a long-time cardiovascular nurse, explained how her team worked with GE to create three additional settings on their institution’s imaging machines. Originally, there were settings for PCI (high dose), Ventriculogram (medium dose), and Coronaries (low dose), she explained. The PCI setting was used 31% of the time, but accounted for 49% of the total radiation dose.

Without telling the physician staff, they made the following changes, renaming the different settings:  

•  PCI Extra: the former “PCI” dose
•  PCI: a new lower-dose setting
•  Ventriculogram: same medium dose
•  Coronaries: same low dose
•  Coronaries Low: even lower dose
•  Right Heart Cath: lowest dose

After implementing the new settings, they found that the Coronaries Low setting was used in 47% of cases, followed by PCI in 22%, and Ventriculogram for 10%. PCI Extra was used only 7% of the time. This resulted in estimated reductions of 20% and 25% in patient fluoroscopy and cinefluoroscopy doses, respectively.

The second phase was an awareness campaign. The staff hung creative and colorful posters around the cath lab that posed questions like “What if we use collimators?” and showed proper pedal technique. The team also produced a video entitled “DJ Nurses,” which showed various ways nurses could reduce radiation dose set to upbeat music.  

One year after they started their campaign, total estimated patient fluoroscopy and cinefluoroscopy doses were reduced by 32% and 41%, respectively, from baseline. “Commitment, awareness, and teamwork” are what were required to make a program like this work, De Block concluded. 

Session comoderator Johannes Laub (Contilia Heart and Vascular Center Essen, Germany), said the presentation “opened up our eyes how to reduce radiation.” He said that his hospital tried a similar initiative. “We didn’t tell anybody, and it worked,” Laub said.  

De Block stressed the importance of working with the manufacturer to change the modes for each individual institution. “We could not do it [alone],” she said.

Also, this is something cath lab personnel need to think about on a daily basis, De Block commented. With regard to emergency cases when CPR is required and staff are exposed to radiation, “do the best you can” because the patient always comes first, she said, but otherwise, protect yourself and be smart.

Secondary Operators At High Risk Also

In another presentation, Glenn Ison (St. George Hospital, Sydney, Australia), said his group has been increasingly concerned about the rising incidence of rear-eye cataracts in cath lab staff. His team simulated a cardiac angiography procedure using normal imaging dose settings with and without a 0.5-mm lead equivalent ceiling-mounted shield.  

While the shield reduced estimated exposure for operators in both the first and second position, the second operator actually received triple the amount of radiation compared with the first operator with the shield.

Even though the second operator is standing farther from the radiation source, Ison explained that the scatter radiation bounces off the shield and creates a situation where the second operator experience greater amounts of unprotected exposure at eye level.

To further explore these results, Ison and his team are planning a larger-scale eye-dose trial of over 1,000 cases using miniaturized scatter detectors with operator glasses. “We are hoping that this will show ways to minimize eye dose from understanding the variables of case types, operator position, and more,” he said.

All cath lab operators should always wear secondary protective measures, Ison warned, commenting that he was disturbed by how many of the operators in the live cases during EuroPCR 2016 neglected to wear lead glasses. 

The long-term effects of radiation exposure “sneak up on you” over the course of a career, he said, adding that nurses should be as concerned as physicians. “We have to be worried.”

Lastly, it is important to think of events with regard to whether they are stochastic or deterministic, Ison concluded. “The only deterministic events we can do to patients is skin burns, but there’s nothing you can do acutely to stop cell DNA damage and cancer short term to us,” he said. “The longer you work in the lab, the more important this becomes to us because odds start getting against you.”  

Disclosures:  

• De Block reports no relevant conflicts of interest.
• Ison reports receiving travel support from Toshiba Medical.

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