Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 AFRICA 271 Establishing ionising radiation safety culture during interventional cardiovascular procedures Belinda van der Merwe Abstract Introduction: The safety culture of an interventional labora- tory was investigated in terms of the application of the three cardinal principles of radiation protection, namely distance, time and shielding. Methods: The application of these principles was observed and recorded with a radiation safety-culture checklist that was compiled by consulting international recommendations. The checklist evaluated the optimal compliance, especially with reference to monitoring of staff exposure, distance from the X-ray source, fluoroscopy techniques pertaining to frame rate, protective devices and personal shielding. The effective radiation dose was measured to the eyes, thyroid, hands and feet of the cardiologist, nurse, floor nurse and radiographer by means of finger dosimeters that were readily available from the local radiation-protection dosimetry service. Results: The results, after observing 11 procedures, indicated the absence of table and ceiling-suspended shields, and the distance of the cardiologist’s and scrub nurse’s feet from the X-ray tube were between 16 and 68 cm, with a mean distance of 59.7 and 58.5 cm, respectively. Most staff (91%) wore the dosimeter inside the lead apron at the collar level without eye protection. The highest dosimeter values recorded were 0.73 mSv to the hand of the cardiologist, 0.45 mSv to the eye of the cardiologist, 0.65 mSv to the hand of the scrub nurse, 0.54 mSv to the eye of the scrub nurse and 0.52 mSv to the foot of the scrub nurse. The dosimeter value to the radiographer’s thyroid was 0.42 mSv. Conclusions: The dosimeter readings confirmed the highest doses were to the scrub nurse and hand of the interventional- ist. The safety culture was non-compliant in terms of staff distance being too close to the X-ray tube, the absence of ceiling and table screens, the theatre door not always being completely closed, and for staff without lead eye glasses, wearing dosimeters outside the lead apron at the collar level. Keywords: occupational exposure, radiation safety, interven- tional, cardiovascular Submitted 5/12/19, accepted 4/6/21 Published online 18/8/21 Cardiovasc J Afr 2021; 32 : 271–275 www.cvja.co.za DOI: 10.5830/CVJA-2021-030 The International Commission on Radiological Protection (ICRP) analysed the radiological protection in fluoroscopically guided procedures performed outside the imaging department, urging the radiological protection of the lens of the eye during fluoroscopy and recommending the use of shielding screens and the establishment of relevant training programmes for specific clinical practices. 1 The ICRP publication 120 on radiological protection in cardiology recommended that when there is a risk of occupational radiation exposure, staff should use personal protective shielding, and quality-assurance programmes should ensure the regular use of personal dosimeters. 2 Although these recommendations are common knowledge and mostly applied during cardiovascular procedures, a question that can be raised is: are these measures optimally implemented by cardiologists, radiographers and nursing staff ? In the editorial of 2017, Brown highlighted the need for training and the set-up of precautions as a matter of urgency in order to protect the interventionalists, emphasising the urgency for action to be taken. 3 Rose and Rae concluded, after interviews with interventionalists in South Africa, that there is indeed a need to change and promote the safety culture during cardiovascular procedures because cardiologists reported limited training regarding radiation safety practices. 4 Safety culture in the interventional laboratory has been described in terms of the application of three cardinal principles of radiation protection, namely, time, distance and shielding. 2 The time of fluoroscopy exposure is operator dependent and linked to the expertise of the physician or the complexity of the case. Nevertheless, certain techniques, for instance, distance from the source, can be applied to lower radiation exposure to both the patient and staff. A strict policy on the regular use of personal dosimeters to monitor staff should be part of any quality-assurance programme because cardiologists have double the exposures per head of that of radiologists. 2,5 Despite the recommendations to keep radiation dose as low as reasonably achievable (ALARA), the occurrence of radiation-induced cataracts and other harmful effects are still reported. 6 Certain parts of the operator are not shielded, and the possibility of brain cancer in interventional cardiologists highlights the importance of occupational radiological protection. 7 In the recently published ICRP publication 139 regarding occupational radiological protection in interventional procedures, one of the main issues mentioned was the occupational limit of equivalent dose for the lens of the eye that was lowered to 20 millisievert per year (mSv/y). 8 The publication also reiterated that without monitoring data, ‘radiation safety professionals will not have the information needed to offer improvements to reduce doses and optimise radiological protection’. 8 Therefore, observation of the radiation safety culture for this specific setting where the study had been conducted would not have been complete without investigating the possibility of measuring and recording the effective radiation exposure to the eyes, thyroid, Department of Clinical Sciences, Faculty of Health and Environmental Sciences, Central University of Technology Free State, Bloemfontein, South Africa Belinda van der Merwe, PhD, bevdmerwe@cut.ac.za