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Compliance With Radiation Protection Practices Among Radiologists

Abdelrahman, Mostafa A.1; Abu Alfwares, Ahmad2; Alewaidat, Haytham1; Alhasan, Mustafa1; Rawashdeh, Mohammad A.1; Al Mousa, Dana S.1

doi: 10.1097/HP.0000000000000886
PAPERS

Background: Radiologists are at higher risk of adverse health effects due to their occupational radiation exposure; therefore, applying protection techniques is imperative. Studies on radiologists’ compliance in this regard are scarce. We aimed to assess compliance with radiation safety practices among radiologists. Methods: Questionnaires were distributed to radiologists in tertiary hospitals. The questionnaire was designed to assess compliance in three domains: using personal protective devices, using exposure-reduction techniques during fluoroscopic exposures, and using personal dose-monitoring devices. Descriptive analysis of the compliance was performed. Results: Sixty-two radiologists were included in the analysis. Use of leaded aprons and thyroid shields was commonplace, whereas only 3.2% ever use leaded eyeglasses. About half of the radiologists always considered reducing the time of exposure and avoided exposure by the primary beam, and the other half did that sometimes. Most of the radiologists (66.1%) always complied with reducing the number of unnecessary exposures, and the rest only complied sometimes. Most of the radiologists (93.5%) always used single personal dose-monitoring devices, most commonly at the neck level over the collar. There was no difference in compliance between different sexes, position descriptions, hospital types, hospital sizes, or years of experience. Conclusion: Future compliance improvement strategies for radiologists should focus on use of thyroid shields and leaded eyeglasses and use of exposure-reduction techniques during fluoroscopic operations.

1Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan;

2Department of Legal Medicine, Toxicology, and Forensic Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.

The authors declare no conflicts of interest.

For correspondence contact: Mostafa A. Abdelrahman, Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan, or email at maabdelrahman5@just.edu.jo.

(Manuscript accepted 23 February 2018)

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INTRODUCTION

RADIOLOGISTS ARE at risk of occupational radiation exposure during various diagnostic and interventional procedures. Occupational exposure may be associated with increased incidence of adverse health effects, mainly cataracts and cancer (Stewart et al. 2012). Increased incidence of cataract has been reported in radiologists and other radiation workers in many countries (Milacic 2009 ; Vano et al. 2010 ; Mrena et al. 2011). In addition, increased incidence of cancer of the thyroid, testis, lung, rectum, and brain has been reported among radiation workers (Ashmore et al. 1998 ; Carozza et al. 2000 ; Hardell et al. 2001).

Although data on compliance with radiation protection practices among radiation workers is available (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Kim et al. 2010 ; Taylor et al. 2013 ; Zivile et al. 2016), it is scarce among radiologists. The authors are aware of a single study on interventional radiologists in the United States, which concluded that radiation protection tools are not universally employed (Lynskey et al. 2013).

Therefore, this study aimed to assess the level of compliance with radiation protection practices among radiologists in Jordan and to identify factors associated with it.

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MATERIALS AND METHODS

Study design and sample

A cross-sectional questionnaire survey was carried out in two major cities in Jordan: Amman and Irbid. These two cities were selected because they encompass most of hospitals (66%, N = 71) in Jordan (Ministry of Health 2013) and more than half of the population (61%, N = 5.8 million) (Jordan Department of Statistics 2015). Twelve tertiary hospitals were selected by means of convenient sampling, i.e., based on their convenient accessibility and proximity to the authors. Data collection was over a 2 mo period during May and June 2015. The radiology departments in the selected hospitals were visited during daytime and outside lunch hours. Staff radiologists, including residents irrespective of their year of training, were invited to complete the questionnaire. All radiologists who performed x-ray-guided procedures, worked during the shift at the time of the visit, and were present in the radiology department were invited to participate in the study. Subjects who worked on a part-time basis were excluded from the study. The study was approved by the Institutional Review Boards (IRB) at Jordan University of Science and Technology.

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Questionnaire design

The study tool used was a self-administered questionnaire that was designed to assess the radiologists’ compliance with radiation protection practices. The questionnaire was composed of two parts: questions in the first part were on demographics including sex, age, position description (consultant radiologist, resident radiologist), years of experience (including residency), type of hospital (public, private), receipt of official training/courses in radiation safety in the past 5 y (yes, no), and willingness to receive training in radiation protection. Information on the bed capacity of each participating hospital was obtained through direct contact with the hospital administration.

The second part (Table 1) was composed of eight questions to gauge the level of compliance with international recommendations on occupational radiation protection practices during x-ray-guided procedures (Miller et al. 2010 ; NCRP 2010 ; IAEA 2014). This part was comprised of three sections. The first section contained three questions (Q1–3) about use of radiation personal protective equipment (PPE). The second section (Q4–6) contained questions about management of exposure time and frequency and about maneuverability around the x-ray source. The third section had a question about the use of personal dose-monitoring device (Q7) and where it was worn (Q8). Available choices for Q1–7 were never, sometimes, and always; and for Q8 choices were at neck level over the collar, at neck level under the collar, on the trunk over the apron, and on the trunk under the apron. The questionnaire had expert validity having been developed in consultation with a group of radiology academics.

Table 1

Table 1

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Statistical analysis

Means and standard deviations (SDs) were calculated to describe data. Data were analyzed using IBM SPSS (IBM Corp., v.21.0. Armonk, NY, U.S.).

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RESULTS

Characteristics of respondents

Sixty-two radiologists out of 84 (73.8%) agreed to participate in the study and are included in the analysis. A summary of the characteristics of participants is provided in Table 2. Forty-eight (77.4%) were males. Ages of participants ranged from 25 to 45 y old with a mean age of 32.7 y (SD: 5.8). The study population included 30 (48.4%) radiology consultants and 32 (51.6%) residents. Working experience of participants, including years of residency, ranged from 1 to 19 y with a mean experience of 6.7 y (SD: 5.3). Working experience of the radiology consultants alone ranged from 5 to 19 y with a mean experience of 11.4 y (SD: 3.8). Half of the participants were working in private hospitals and the rest in public government hospitals. Numbers of radiologists working in different hospital sizes were comparable. Surprisingly, none of the radiologists reported receiving any on-site radiation safety training in the past 5 y, although the majority (N = 60, 96.8%) showed interest in receiving such training.

Table 2

Table 2

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Compliance with radiation safety practices

Participants’ responses to the compliance part of the questionnaire are summarized in Fig. 1. Almost all of the radiologists (N = 61, 98.4%) always used leaded aprons during x-ray-guided examinations, and most of them (N = 52, 93.5%) used thyroid shields sometimes at least; whereas only three (3.2%) ever used leaded eyeglasses. Only half of the radiologists always considered reducing the time of exposure (N = 34, 54.8%) and avoided exposure to the primary beam (N = 31, 50.0%) during x-ray-guided examinations, and the other half did that only sometimes. More radiologists (N = 41, 66.1%) always complied with reducing the number of unnecessary exposures, and the rest only complied sometimes. Most of the radiologists (N = 58, 93.5%) always wore single personal dose-monitoring devices during x-ray-guided examinations, of which 81% (N = 47) wore it at neck level over the collar and 19.0% (N = 11) at neck level under the collar.

Fig. 1

Fig. 1

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Compliance according to radiologists’ characteristics

Results of compliance responses according to radiologists’ characteristics are summarized in Figs. 2–6. There was no clear pattern that supports the effect of sex, position description, experience, hospital type, or hospital size on radiologists’ practices. However, radiologists with greater experience (> 14 y) appeared to be more compliant with eye protection practices than the other experience groups (Fig. 4). In addition, 10% of consultant radiologists (Fig. 3), who also worked in public hospitals (Fig. 5), reported using eye protection compared to none of the residents.

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Fig. 5

Fig. 5

Fig. 6

Fig. 6

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DISCUSSION

In this study, a questionnaire survey was conducted to assess radiologists’ compliance with radiation protection practices. Particular areas where compliance needs more attention were identified. Similar to previous reports on use of leaded aprons during various studies among radiologists, cardiologists, and speech-language pathologists (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Kim et al. 2010 ; Lynskey et al. 2013 ; Zivile et al. 2016), almost all radiologists in this study always wore leaded aprons during x-ray-guided procedures. In contrast, compliance with thyroid protection practices was poorer than that reported for radiologists, cardiologists, and speech-language pathologists: only 21% of radiologists in this study wore leaded collars compared to 94% of radiologists, 54–94% of cardiologists, and 76% of speech and language pathologists in previous reports (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Kim et al. 2010 ; Lynskey et al. 2013 ; Zivile et al. 2016). The annual maximum permissible dose to the thyroid is 500 mSv (NCRP 1993), whereas equivalent dose to the neck can be anywhere between 0.03 and 1.2 mSv per x-ray-guided study (Kim et al. 2012). Effective dose can be reduced by approximately 50% by the use of a thyroid shield (Niklason et al. 1994) because the shield protects the underlying skin, esophagus, bone, and bone marrow as well as the thyroid gland (Kim et al. 2012).

In contrast, most radiologists reported never using leaded eyeglasses. Compliance with eye protection practices was previously reported as 32–54% among radiologists, cardiologists, and urologists (Rahman et al. 2008 ; Lynskey et al. 2013 ; Zivile et al. 2016). Recently, the International Commission on Radiological Protection (ICRP) recommended reducing the equivalent dose limit for the lens of the eye from 150 to 20 mSv in a year (Stewart et al. 2012) in response to evolving evidence that the risk of eye cataract is substantially higher than previously thought (Kleiman 2012). Depending on the applied working practice, eye lens doses per procedure range from 0.01 to 2.8 mSv (IAEA 2013). In a study on fellow and consultant radiologists, the annual equivalent dose to eye lens ranged from 4 to 45 mSv (O’Connor et al. 2015). These data highlight the importance of using eye protection during x-ray-guided procedures. In fact, protective eyewear can reduce ocular exposure by a factor of up to 10 times, depending on the type of eyewear and head orientation in relation to the x-ray source and imaged area (van Rooijen et al. 2014).

Although radiologists in this study reported using exposure-reduction strategies such as reduction of exposure time, unnecessary exposures, and exposure by primary radiation, only approximately half of the radiologists reported constant compliance with these practices. Limiting x-ray tube activation time, using tailored frame rate and stored last-image-hold, and minimizing the number of fluoroscopic runs are direct strategies to reduce dose (Detorie et al. 2007 ; Miller et al. 2010). Comparable to this study, only 58% of cardiologists reported reducing fluoroscopic frame rate in a study by Valuckiene and colleagues in Lithuania (Zivile et al. 2016). Radiologist should also stay as far from the x-ray beam as possible and use tools such as needle holders and power injectors to avoid placing their hands in the x-ray field (Detorie et al. 2007).

In compliance with the Jordanian Energy and Minerals Regulatory Commission (EMRC) regulations (Energy and Minerals Regulatory Commission 2015), reading of individual monitoring results must generally be arranged on a monthly basis. This allows adequate time to identify factors that may lead to high radiation exposure. It is, therefore, important to wear personal monitoring devices constantly and correctly in order to obtain accurate personal exposure readings. Radiologists in this study always wore their personal dosimeters. This is better than previously reported compliance among cardiologists in Pakistan (7%) and Lithuania (87%) and speech-language pathologists in Australia (60%) (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Zivile et al. 2016). The ICRP recommends the use of dual personal monitoring during x-ray-guided examinations, one at collar level over the apron and one on the trunk under the apron (Valentin 2000). However, this practice is not a regulatory requirement and is limited (Ciraj-Bjelac et al. 2011 ; Martin 2011 ; Khelassi-Toutaoui et al. 2016). Jordanian EMRC regulations are in line with ICRP recommendations (Energy and Minerals Regulatory Commission 2007). Most radiologists in this study used one dosimeter at neck level over the collar during x-ray-guided examinations, and the rest wore their dosimeters incorrectly at neck level under the collar. Other studies in the United Kingdom, Eastern Europe, and Algeria showed that wearing a single dosimeter under the apron is the common practice (Ciraj-Bjelac et al. 2011 ; Martin 2011 ; Khelassi-Toutaoui et al. 2016). This method provides a measure of penetrating exposure to sensitive organs in the trunk but omits exposure to unprotected organs, especially the head. Using a single dosimeter at neck level over the collar will do the opposite. Therefore, using dual monitoring is recommended in order to obtain accurate measurements of personal radiation dose.

The current study has limitations. An inherent limitation for self-reporting questionnaire studies is that the results may be biased by social desirability, i.e., the tendency of participants to respond in a manner that will be viewed favorably by others. This may cause radiologists to overreport good behavior or underreport bad. However, the anonymity of this study is expected to reduce this bias. Also, sample size and method of sampling may reduce the accuracy of generalizability. Moreover, radiologists who chose to participate may have had more confidence in their compliance than radiologists who chose not to participate. In addition, other factors that may have affected the level of compliance (such as attitude, comfort, physical strain, availability, ease of use, and supervision) may have been overlooked. Therefore, these factors warrant further investigation.

In conclusion, there are radiation protection practices with which radiologists in Jordan showed high levels of compliance and other practices with which they showed suboptimal compliance. Practices for which high levels of compliance were demonstrated included use of leaded aprons and wearing personal dose-monitoring devices. On the other hand, other dose-reduction methods (including use of thyroid shields and eye protection, reduction of unnecessary exposures, and avoidance of the primary beam) were not universally applied among radiologists.

Therefore, future compliance improvement strategies for radiologists in Jordan should focus on the use of thyroid shields and leaded eyeglasses and on the use of exposure-reduction techniques during fluoroscopic operations.

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Acknowledgment

The authors would like to thank Jordan University of Science and Technology for funding this study (grant no. 20150042).

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Keywords:

diagnostic radiology; radiation protection; personnel monitoring; occupational safety

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