Patient-Focused Radiation Safety Program in the Electrophysiology Lab

Radiation safety is a high priority quality initiative for cardiac procedural areas given the increasing utilization of minimally invasive treatment options for patients today. As technology advances and the volume of specialized treatments utilizing ionizing radiation grows in the cardiac catheterization and electrophysiology (EP) labs, hospitals must ensure that a robust radiation safety program is in place to both educate and protect patients and staff. At the Medical University of South Carolina (MUSC), our EP and cardiac cath labs are specialized departments staffed by multiple types of credentialed caregivers including registered nurses, registered radiologic technologists, and registered cardiovascular invasive or electrophysiology specialists. 

Our EP lab performs around 1000 ablation and device procedures per year, treating 1500 patients on average. Given the variety of educational backgrounds involved in procedural areas using ionizing radiation, it is critical that the program contain standardized education in radiation safety practices as well. 

Our procedural radiation safety program was developed to educate patients, staff, and MD fellows, and utilizes annual competencies, Epic electronic medical record tools, and educational tools for communicating risk to patients. This article outlines our initiatives put into practice in MUSC’s cardiac procedural areas.

Patient-Centered Initiatives

Using the guidelines set forth by the National Council on Radiation Protection and Measurements (NCRP), we put the following initiatives into practice:¹

• Pre-procedural Preparation and Education: Patients may not be aware that the cardiac procedures they are undergoing may utilize ionizing radiation. As recommended by the NCRP, specific language communicating the risk of radiation skin injury was added to our procedural consent forms and is communicated to patients by the physicians or advanced practitioner when discussing risks and benefits of the procedure.¹ The Society of Interventional Radiology (SIR) recommends stating the possibility of the necessity of use of significant amounts of radiation, followed by outlining specific risks in the consent forms.²
• Education in Patient Radiation Exposure Reduction: SIR recommends that all staff in a procedural area receive baseline training in patient dose management followed by yearly refresher training.² Given the diversity in educational backgrounds of our lab staff (registered nurses, registered radiologic technologists, registered cardiovascular invasive specialists, and physician fellows), we felt it was important to require a common knowledge of best practices in radiation safety amongst staff. Annual competencies were established and required for staff members to promote the use of ALARA (As Low As Reasonably Achievable) techniques that directly reduce the patients’ exposure to radiation during procedures. Other SIR-recommended training was adapted in the staff education outlined later.
• Dose Monitoring and Documentation: Our fluoroscopy equipment provides an estimated peak skin dose in units of milligray (mGy) from each x-ray plane. The NCRP and SIR do not recommend monitoring dose in fluoroscopy time (minutes), as this is a poor predictor of actual dose absorbed by the patient.^1,2 The estimated peak skin dose is documented in the procedure report and communicated to the operating physician throughout the procedure at regular intervals beginning at 2000 mGy (or 2 Gy) as provided in the SIR guidelines for patient dose management.² Physicians are alerted at every 500 mGy following the initial alert. Implementing this alert system allows physicians to remain informed of the accumulating dose throughout the procedure, and gives the operator the opportunity to make dose-minimizing adjustments such as changing the field of view or tube angles which will aid in reducing overall exposure. In some cases, this alert may allow the physician to make the decision to end the procedure.
• Post-Procedure Patient Education: Follow-up education is provided to patients that receive a dose exceeding a set threshold that puts them in the high-risk category for radiation skin burns. This threshold was determined by the radiation physicists and is in line with the NCRP’s Report No. 168, which defines a substantial radiation dose level to be either a peak skin dose of 3 Grays (3000 mGys) or a cumulative air kerma dose of 5 Gy (5000 mGy).¹ The patient benefits from this initiative in that they can proactively self assess for effects of radiation as well as make informed decisions regarding future exams utilizing ionizing radiation.
• Follow-up Phone Calls: Patients receiving a dose exceeding the specified threshold of 5000 mGy will receive a screening phone call in the 2- to 4-week window of time when radiation burns are most likely to present. Phone calls are performed by procedural staff and documented in the patients’ chart in Epic. Each patient procedure falling into this category is analyzed by the physicist to calculate an actual skin exposure dose, which is delivered to the patient to fully understand and assess risk. Should a positive screening arise, the patient is advised to follow specific recommended guidelines and will be assessed in the clinic by the procedural physician to be monitored closely for radiation exposure symptoms. 

Staff-Centered Initiatives

1. New Staff and Fellow Orientation: At MUSC, we follow a competency-based orientation that includes a standardized education on radiation safety practices. This competency is provided to all new staff and cardiology fellows, and covers the basics of radiation physics, patient dose reduction, and practices to reduce occupational exposure as outlined by the SIR guidelines for radiation safety training.² The educational module is then repeated yearly as part of the annual competency requirements to keep staff current.
2. MD/Staff Champion: A team approach is imperative in successful implementation of a radiation safety program. Our physician champion, Frank Cuoco, MD, MBA, was brought on board to implement and communicate our initiatives involving the physician, fellow, and advanced practitioner teams. Our staff member champion, Ryan Garding, RT(R), CCI, spearheaded the procedural radiation safety initiative as a result of a Six Sigma IMPROVE Process, and continues to coordinate the team’s efforts. 
3. Advanced Occupational Exposure Reduction Technology: Currently the RADPAD^® disposable lead-free scatter radiation reduction protection (Worldwide Innovations & Technologies, Inc.) is utilized at the tableside during procedures to reduce occupational exposure to the staff. On-site studies that have been performed in our labs exhibited a significant reduction in exposure to procedural staff members. Full-body protective lead shielding is utilized during ablation procedures by the operator as added reduction in occupational exposure during high-dose procedures.
4. Epic Tools: After implementing Epic in 2014, we decided to use electronic tools to assist as many radiation safety initiatives as possible. In the near future, educational tools will be electronically tied to procedural orders, ensuring each patient receives information at discharge, follow-up phone calls to high-risk patients will be documented in the Epic chart, and the procedural radiation dose will be captured as a discrete data point in Epic.

Our cardiac procedural areas have made great strides in radiation safety while maintaining a focus on patients and staff. Implementing best practices and education into the cardiac procedural area has been an ongoing effort. Continuous improvement to our radiation safety quality initiative requires a team approach and ongoing monitoring of the program to ensure success.

Acknowledgement. The author would like to acknowledge and thank Ryan Garding, RT(R) and Jamie Spann, RN, BSN, Electrophysiology Nurse Manager, for their contributions and collaboration in developing this program in the EP lab.

Disclosure: The author has no conflicts of interest to report regarding the content herein.

References

1. Balter S, Bushberg JT, Chambers CE, et al. Outline of Administrative Policies for Quality Assurance and Peer Review of Tissue Reactions Associated with Fluoroscopically-Guided Interventions. NCRP Statement No. 11. Published December 31, 2014. Available online at https://ncrponline.org/Publications/Statements/Statement_11.pdf. Accessed February 4, 2015.
2. Stecker MS, Balter S, Towbin RB, et al. Guidelines for patient radiation dose management. J Vasc Interv Radiol. 2009;20(7 Suppl):S263-S273.