Gold Standard Cleaning For X-Ray Aprons & Lead Wearables

What Does Gold Standard Cleaning Look Like For X-Ray Aprons And Lead Wearables?

Thus far in this lead apron based blog series, we have examined the infection issues and concerns associated with contaminated lead x-ray aprons and the science behind how staff members can easily test such surfaces for contamination using ATP testing.

This third blog entry will examine methodologies and practices utilized by clinical staff and facilities in the “cleaning” and maintenance of these protective lead wearables, and also explore what “cleaning” such a surface really entails. In discussing bioburden levels in the previous blog, we addressed how one cannot judge cleanliness on a surface by appearance alone.  Let’s take a deeper dive into what it means to truly clean and sanitize these protective, lead garments.

Survey Says…

In researching the topic, speaking with professionals at symposiums and inquiring with colleagues and peers, there is little consistency across the continuum of care with how these garments are cleaned and/or serviced. Shockingly, a number of Radiology, Cath Lab and Operating Room staff have lamented that such surfaces “never” get cleaned, while other staff and administrators have shared that such surfaces are sometimes cleaned, “when the case load is light on a Friday” or “on the midnight shift by the environmental services department.” Both patient and staff safety are at risk due to lack of staff compliance and clinical efficacy issues posed through improper cleaning practices.

Online research lead to a few administrators sharing that they ran these lead aprons through a cart washer, which lead manufacturing companies clearly advise not to do. Clinicians have also shared that they try to use products such as Lysol or Febreeze to “eliminate the odors” yet admit the lead wearables still aren’t “clean.” One of the more popular concepts considered in attempting to clean and service these wearables entails the discussion of “using sanitizing wipes” on such high-touch surfaces.  Unfortunately, the use of these wipes alone does not properly clean and sanitize the garments.

Pesky Directions

There are a number of sanitizing/disinfecting wipes on the market that some clinicians claim to use on lead aprons and wearables. When taking a closer look at the labels on these products, one may very well discover that most wipes are actually not recommended for use on lead wearables. Additionally, some wipes contain bleach and corrosive agents, which are both advised not to be used on aprons, according to the companies that manufacture them. A majority of the wipes on the market today are indicated for use on “non-porous” surfaces such as tables, bed rails, door handles, etc. rather than a porous surface such as a nylon covering of a lead wearable. Though the use of wipes might afford convenience to the user, the real issue with doing so lies in their clinical inefficiency in successfully cleaning the surface, not to mention completely removing any bioburden.

Wax Then Wash?

If your car had dirt, road tar and bird droppings on it, would you attempt to wax it in that condition?

For best outcomes, you would first clean and remove those elements before attempting to wax the car.  The same is true for other surfaces, including lead wearables.  Professionals who routinely assess bioburden understand the importance of a proper cleaning before sanitizing or disinfecting an item.  If an item is not properly cleaned and organic matter remains, nutrients also  remain to better foster the growth of surviving bacteria or future bacterial contamination.  This is by definition a risk factor for increased hospital associated infections.

All You Can Eat Buffet

In watching the news of late, one can gather that the world of microbiology is ever changing.  Bacteria are highly adept at persisting.  Through changes in their DNA they can gain antibiotic and/or antiseptic resistance, and these changes can happen through mutations or through integration of foreign DNA, but where would they find foreign DNA?  When bacteria die and the cells break open, then the DNA is accessible to the remaining bacteria.

The Problem with Sanitizing and Disinfecting Wipes

When facilities only use wipes on a surface and don’t completely remove the debris, they are in essence creating an “all you can eat buffet” for the surviving bacteria to thrive upon. If the dead bacteria had antibiotic or antiseptic resistance markers, now that DNA is fair game for susceptible bacteria to gain resistance!   In fact, numerous studies have shown that certain bacteria can pick up various genes from different species that makes them more pathogenic (either by making it antibiotic resistant, antiseptic resistant, or by allowing it to survive in a host better).

Layers Of Bacteria? Gross?

As if that wasn’t scary enough, what if I told you that some bacteria could gain antibiotic and antiseptic tolerance simply by growing?  (IT IS TRUE!)

Some bacteria can attach to a surface (particularly porous or textured surfaces such as lead wearables) and as they grow and form groups of bacteria (colonies) that can then form a biofilm.  Biofilms are clusters of bacteria that have attached and produced an extracellular polymeric substance (EPS) which are essentially a protective coating.

Extracellular Polymeric Substance (EPS)

EPS consists of DNA, proteins, lipids (fats) and polysaccharides (sugars).  This coating protects the bacteria inside the human body from cells that can either tag the bacteria for destruction or destroy the bacteria outright.  Externally (on a surface) it can protect the bacteria from anti-microbial drugs or antiseptic agents.  In fact, bacterial biofilms are 10 – 1,000 times more resistant to antibiotics than there standalone bacterial counterparts.  Their EPS is essentially a bacterial Teflon coating.  This Teflon coating only gets stronger when multiple species of bacteria co-inhabit the same biofilm, and if these attributes weren’t scary enough, bacteria in a biofilm can sense their microenvironment and may even produce toxins while in a biofilm that they wouldn’t normally produce.

Biofilm Life Cycle

Like all living things, biofilms have a life cycle, and a part of that life cycle involves dispersion of some bacteria that are then free to go and attach elsewhere, including in a human host. In 2007, the National Institutes of Health estimated that approximately 80% of chronic infections were biofilm related; thus, biofilms remain a serious problem in many facilities. When surfaces such as the nylon covering of a lead wearable are not cleaned properly, it allows different bacteria to begin to congregate.

Layers of Bacteria

Thinking this all sounds like something from a fictional book or movie, as if biofilms can only exist in some weird lab conditions or in some rare disease?  Nope!!!!

The most common example of a biofilm is one that everyone is probably familiar with, but may not realize is a biofilm, is dental plaque!  Biofilms are so hard to remove from surfaces that companies have spent millions of dollars trying to prevent their formation.  If you think about dental plaque, it makes sense.  We brush our teeth twice a day to best prevent plaque.  Unfortunately, when it comes to medical devices or any surface (particularly a porous or textured surface) in a medical treatment facility (such as lead wearables), biofilms can form once the surface is exposed to organic matter such as blood.  Now with the mental picture of layers of bacteria (such as plaque) on surfaces in medical treatment facilities, consider that some high-touch surfaces, such as radiological shields and aprons have not been properly cleaned for years (if ever!)

Elbow Grease Helps Break Up Biofilms

Biofilms are so tolerant of antimicrobials and antiseptics, that even the CDC positions the best way to remove a biofilm is to disrupt it physically, and they have included the ‘use of friction’ in their definition for proper cleaning.  Studies have been done that show that physically disrupting the biofilm by using friction is the primary means for destruction of the layers and thus removal of the biofilm.  (In the example of dental plaque, this would be equivalent of one going to the dentist and having them scrape the teeth in order to remove the plaque.)  The procedural process and outcomes are different when looking at the process of “cleaning” and “sanitizing” and it takes both of these separate processes to eradicate biofilms from porous, high touch surfaces. The surface on a lead wearable first needs to be cleaned before it can then be sanitized.

  • Cleaning – According to the CDC, cleaning entails the use of EPA registered products, coupled with the use of friction to physically remove dirt, microorganisms and bioburden and then removing/rinsing them away from the surface. Though a vast majority of the bioburden is removed during this process, the cleaning process does not always remove 100% of all bioburden & microorganisms.
  • Sanitizing – This process then “inactivates” 99.9% of all remaining microorganisms on environmental surfaces if allowed to sit visibly wet or “dwell” on the surface for the recommended amount of “dwell time” as per manufacturer instructions and guidelines.

Cleaning and Sanitizing really can’t be done in one-step, let alone with just a wipe. When you go to the dentist, the first step in the process is to scrape the plaque from the teeth before they are polished, just like your car needs to be adequately washed and dried, before it can be then waxed. Cleaning and sanitizing of a neglected surface such as a lead apron cannot be accomplished in one step either. In an effort to address such biofilms “head on” X-Ray apron servicing companies, such as Radiological Care Services (IN) are implementing multi-step, cleaning and sanitization programs for X-ray aprons and lead wearables. These programs are built in accordance with governing bodies, such as the CDC, JCAHO, AORN and HFAP, which position that surfaces should first be cleaned, before attempting to sanitize or disinfect them.

Stay Tuned For The Next Post

Stay tuned for the next follow up blog post, as we look specifically at what policies, regulations and expectations these governing bodies have of high touch surfaces, such as X-ray aprons and lead wearables. Between now and then, go brush your teeth and think about the layers of bacteria building up on lead wearables and aprons as they continue to invite bacteria to the biofilm party!

About The Author:

Kathleen R. Jones received her BS from Purdue University (West Lafayette) in Biology specializing in Genetics and Microbiology.   After working for five years in Quality Control she then completed her MS at Purdue University in Indianapolis.  Her growing interest in Infectious Diseases lead her to the Uniformed Services University of the Health Sciences where she obtained a Doctorate in Emerging Infectious Diseases.  Kathleen has a passion for progressive sciences and initiatives, and employs her keen understanding of the biofilm formation and elimination processes into her research and work.

Evaluating Microorganism Levels On X-Ray Aprons And Lead Wearables: The Science Of ATP Testing

How Have Microorganisms and Bioburden Been Measured?

In the previous blog post regarding X-Ray lead aprons, we explored the history of healthcare associated infections or HAIs, and how transmission risks are posed to patients and staff via contaminated “high touch, non-critical surfaces,” including X-Ray aprons and protective lead wearables.  In laying out the content of this blog, I was reminded of the phrases, “things aren’t always as they appear” and “don’t judge a book by its cover.” Is it possible that newer (clean looking) X-Ray aprons can carry a higher level of biological contamination when tested in comparison to older X-Ray aprons (which are dirty looking & smelling)? It is completely possible and plausible due to the concept of bioburden.

What is Bioburden?

Bioburden is defined in numerous medical dictionaries as the number of microorganisms contaminating an object.  So how does one assess for bioburden?  The gold standard for assessing for bacterial/fungal contamination has been to assess for colony forming units or CFUs.  A CFU equals one viable bacterium that has the ability to spread and replicate.

3 Main Ways to Measure CFUs: 

  1. A scientist could dilute the sample and count the bacteria by microscopic examination or through the use of a cell counter.  However, if bacteria are too small or clump together, then this method is problematic.  This method will yield total bacteria counts, both living and dead.
  2. A scientist could use Optical Density (OD) to estimate the number of viable bacteria in a sample.  This is where the scientist measures how cloudy a liquid culture of bacteria is.  While the bacteria are actively growing the liquid culture should continually become more and more cloudy.  Again, this method will yield total bacteria counts, both living and dead.
  3. A scientist could make serial dilutions of a liquid culture and plate out the bacteria in known dilutions until they can count single colonies and extrapolate back to figure out total CFU in a sample. This method only yields viable bacteria totals.

4 Challenges Associated with Bioburden Assessment

Assessing for bioburden (microorganisms) by calculating CFUs is not as easy or straight forward as one might imagine.

  1. The first challenge posed is that one needs to have a lab in which to grow bacteria, and depending on the bacteria one is dealing with there are different governmental regulations to follow.
  2. The second challenge presented is that of time, one needs to have the time and equipment to properly grow the bacteria/fungus.  Different species of bacteria or fungus grow at different rates, for example, culturing of bacteria on plates can take anywhere from overnight to multiple days.
  3. A third and very important challenge is posed by the bacteria and fungus themselves.  They are similar to people in the fact that not all of them grow and thrive under the same conditions.  In lab work, if only one kind of food source is used, one will only be able to assess for bacteria that grow on that particular food source.
  4. Finally, one needs to have a trained technician who knows how to assess which bacteria to grow under the correct conditions and then also how to properly count the bacteria.

While assessing for CFUs has traditionally been viewed as the gold standard for assessing bioburden, and it is vitally important for various microbial studies, it is not a good way to assess bioburden in real time.  It can be complicated.

What is ATP and How is it Evaluated?

What if there was an easier way to determine surface levels of biological contamination?

What if there was an easier way to assess for a molecule that is found only in living cells, both bacterial and human living cells?

There IS an easier way to evaluate for this molecule in real time (by using a simple swab and handheld reader), and it can be used by any hospital staff member as a surrogate for such complicated CFU work.  Let me introduce you to the molecule known as the “molecular workhorse,” called adenosine triphosphate (ATP).

Adenosine Triphosphate (ATP)

ATP is an energy molecule utilized by cells. It is present in humans, animals, plants and microbial cells.  ATP levels rise as a cell is undergoing apoptosis (programed cell death), but is generally consider to be completely degraded within 30 minutes of cell death (1).  This makes ATP a useful marker for the presence of unwanted biological contamination, including organisms that can cause infection and disease.

Okay – Get to the Point!

An increase in biological cells on a surface results in an increase in the amount of ATP present on that surface, thus making ATP an effective marker for the assessment of the hygienic status of an environmental surface. Simply stated, the amount of ATP present on a testing swab is a quantitative measurement of the cleanliness of the surface tested! In fact, ATP cell viability assays were determined to be the fastest, most sensitive, and least prone to artifacts, partially due to a lack of an incubation period (2).  The sensitivity of laboratory cell based ATP cell viability assays can detect fewer than 10 cells per well (2).  This technology has been modified to create a portable, ATP bioluminescence test, using a swab instead of plated cells.  This now allows for a real time assessment of bioburden on site.  These tests have been used to assess bioburden in many healthcare settings, including the ICU (3).  ATP measuring units, called luminometers, are handheld, user friendly, and display the results in seconds. (It doesn’t take a scientist to use an ATP luminometer!) The read out of an ATP bioluminescence test is not in CFUs, but is in relative light units or RLUs.  In the past, some scientists have questioned the validity of using a bioluminescence test instead of assaying for CFU.

Is There a Correlation Between CFUs & RLUs? 

Like most assessments, ATP bioluminescence assays also have limitations, but they are an excellent surrogate that allows the everyday staff member to assess bioburden in real time.  Those new to ATP bioluminescence testing often inquire about a correlation between CFUs and RLUs.  (Most laboratory microbiologists have the capability to perform CFU testing, and are not confined to real time assessment of bioburden.)  The most controlled way to achieve this is to look at different known amounts of CFUs and assess whether or not the RLUs increase accordingly.  That is exactly what Dr. Sciortino’s group did when they assessed three different portable ATP bioluminescence kits for their ability to detect various CFUs of two different HAI relevant bacteria (Staphylococcus aureus and Acinetobacter baumannii) and one strain of fungus (Candida albicans).

What they discovered was there was a linear relationship between bacterial CFUs and RLUs for all three luminescence kits, and for two of the three kits between fungal CFUs and RLUs (1).  Such research validates that the use of ATP luminometers can be used to assess for bioburden on surfaces in real time.  This research, plus Dr. Jaber’s study, in which 25 lead aprons were cultured for CFUs and showed that 21 were colonized with Tinea species (the family of fungus that causes ringworm) and 21 were colonized with Staphylococcus aureus, of which 3 aprons were colonized with MRSA (4), validates the ATP bioluminescence results for X-ray aprons and protective lead wearables.

In fact, these X-ray aprons and protective lead wearables, which are worn throughout many different areas within a healthcare system, including the operating rooms, cath labs, radiology/imaging areas, emergency rooms and beyond are regularly testing with RLU readings in the THOUSANDS to HUNDREDS OF THOUSANDS (5), which is scary. The bottom line is regardless if you are a classically trained microbiologist used to looking at CFUs or a hospital staffer looking at luminometer readouts in RLUs, when surfaces inside an OR or Cath Lab are testing in the hundreds of thousands range, it is a problem!

Is ATP Testing Growing in Use?

Through utilization of ATP luminometer testing systems, companies like Radiological Care Services (Indianapolis) are able to enter a facility’s Cath Lab, OR or Radiology Department and test lead apron inventories on site, providing real time numbers (bioburden levels) in a matter of seconds. An advocate for ATP luminometer testing, Dr. Sciortino even states, “ATP system monitoring may uncover the need for new disinfectant designs that adequately remove hospital surface biofilms, rendering used hospital equipment to its native state whereby a zero reading by ATP monitoring can be achieved” (1).  If you look back at the first blog post, “Contaminated X-Ray Aprons and The Risk of HAIs”, I positioned that “using wipes alone” was insufficient and through the use of ATP testing, Dr. Sciortino could be inferring a similar position.

Looking Ahead…

In the next blog post, we’ll specifically look at the science/methodology behind the use of sanitizing wipes and we’ll further explore the differences between true “cleaning” and “sanitization.” We’ll later examine what the governing bodies, such as AORN, CDC, HFAP and JCAHO state regarding their expectations of such surfaces within healthcare facilities. Understanding the science behind HAIs, testing for biological contaminants on surfaces, biofilms, and the difference between “cleaning” and “sanitization” will help us understand that current healthcare protocols in regards “non-critical, high touch surfaces” need to be changed in order to better protect hospital patients and staff.

About The Author:

Kathleen R. Jones received her BS from Purdue University (West Lafayette) in Biology specializing in Genetics and Microbiology.   After working for five years in Quality Control she then completed her MS at Purdue University in Indianapolis.  Her growing interest in Infectious Diseases lead her to the Uniformed Services University of the Health Sciences where she obtained a Doctorate in Emerging Infectious Diseases.  Kathleen has a passion for progressive sciences and initiatives, and employs her keen understanding of the biofilm formation and elimination processes into her research and work.

Sources:

  1. Sciortino, C. V. and R. A. Giles.  2012. Validation and comparison of three adenosine triphosphate luminometers for monitoring hospital surface sanitization: A Rosetta Stone for adenosine triphosphate testing.  AJIC.  40 (e233-9)
  2. Riss T.L., R.A. Moravec, A. L. Niles, H.A. Benink, T.J. Worzella, L. Minor. Minor, L, editor.  2013,  Cell Vialblity Assays. In: Sittampalam G.S., N.P. Coussens, H. Nelson, et al., editors. Assay Guidance Manual [Internet]. Bethesda (MD): Eli Lilly & Company and the National Center for Advancing Translational Sciences; 2004-. Available from: //www.ncbi.nlm.nih.gov/books/NBK144065/
  3. Moore, G., D. Smyth, J. Singleton, P. Wilson. 2010. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting.  AJIC. 38(8):617-622 DOI: //dx.doi.org/10.1016/j.ajic.2010.02.011
  4. Jaber, M., M. Harvill, E. Qiao.  2014.  Lead aprons worn by interventional radiologists contain pathogenic organisms including MRSA and tinea species.  Journal of Vascular and Interventional Radiology.  25:3:S99-S100.  DOI: //dx.doi.org/10.1016/j.jvir.2013.12.279
  5. “Outcomes: What do your numbers look like?” Radiological Care Services. Nov 20, 2014. //www.radcareservices.com/radiolgical-care-services-outcomes.html

What is FluoroSafety?

Identifying Important Risks Associated with FGI

In 1994 the FDA released a public health advisory warning of the potential for serious radiation-induced skin injuries to patients resulting from fluoroscopically guided interventions (FGI).  In the 20 years since this advisory, there have been hundreds of published cases of skin injury resulting from FGI, and the number is steadily increasing even today.  As the scope of disease that can be diagnosed and treated using FGI increases, so does the complexity of these procedures and the radiation doses to patients, physicians, and staff.  While these procedures provide an incredible benefit to the patient compared to open-surgical alternatives, there are important risks that must be understood by the performing physician.

The Need for Effective Training

In 2010, frustrated by the lack of user-friendly, accessible, and effective training focused on this topic, two diagnostic medical physicists started Fluoroscopic Safety, LLC [//www.fluorosafety.com]. Understanding the need for a balanced perspective and considering that radiation is not the only risk from FGI, they collaborated with an experienced board certified interventional radiologist well-known for his work in quality improvement.  Because of the multi-disciplinary M.D. and Ph.D. backgrounds of the authors of FluoroSafety courses, we understand that when a physician is performing an FGI, managing radiation dose is not the first thing on his mind.  Instead, practitioners are thinking about the patient-specific technical challenges associated with these procedures.  The training programs from FluoroSafety are developed with this in mind.  While our courses do provide instruction on the fundamental physics of fluoroscopy and radiation biology, we focus on simple methods for managing patient and staff radiation dose.  Using videos and animations, our courses provide an easy to remember and easy to execute set of practices which benefit both the physician and their patients.  This is one of the key features of our courses, designed by physicians and physicists together.

Fluoro CME Training and Education

The educational programs from FluoroSafety also help providers satisfy state regulatory requirements. Through a joint sponsorship with The University of Texas MD Anderson Cancer Center, our courses have been approved for up to 10.5 hours of AMA PRA Category 1 CreditTM.   Our programs meet the training requirements for practitioners who use fluoroscopy in Oregon, California, and Texas.  In addition, board certified providers who complete these courses are eligible to claim self assessment CME (SA-CME), as required for Maintenance of Certification (MOC) by members of the American Board of Medical Specialties (ABMS).

Interactive and Engaging Content

The educational programs from FluoroSafety are tailored to the needs of busy healthcare professionals and feature on-demand Flash-based learning rich in animations and videos.  Our courses also feature optional narration.  Course content can be accessed at the convenience of the physician from any computer, smartphone, or tablet with Internet access.

Meet State Requirements

Whether you are trying to meet state regulatory requirements or are simply interested in improving the care you provide to your patients, FluoroSafety has a course for you.  The most common feedback we have received from physicians who have taken our course is that they were surprised by how much they didn’t know about the safe use of fluoroscopy—you may be surprised too!

FluoroSafety.com

A. Kyle Jones, PhD

Alexander S. Pasciak, PhD

Joseph Steele, MD

Fluoroscopic Safety, LLC

5 Reasons Why You Should Use Lead Apron Storage Racks

Lead Apron Storage

Improper storage of your lead apron can reduce the attenuating qualities of the apron and ultimately reduce the level of radiation protection your apron provides. Lead apron storage racks come in a variety of styles and configurations to meet the specific needs of your medical facility.

Protection From Radiation Exposure

Lead aprons are used in medical facilities to protect workers and patients from x-ray radiation exposure from diagnostic radiology procedures. Lead aprons are protective garments that have been designed to shield the body from the harmful effects of ionizing radiation during medical imaging procedures.

“As is the case with many protective garments, it is important to remember that a lead apron is only effective when it is worn properly, matched with the appropriate radiation energy and is used in a safe and regularly inspected environment.” – Stanford’s Radiation Protection Guidance for Hospital Staff¹ 

Lead Apron Integrity Check

Medical personnel who are required to wear lead aprons or other related radiation protection devices should visually inspect these protective garments prior to each use for obvious signs of damage such rips and tears, sagging lead, and cracks in the lead lining.

Not sure if a lead apron rack is necessary?

1.  To ensure that you are properly protected. When a lead apron hasn’t been stored properly, you could be putting yourself at risk for increased exposure to ionizing radiation. Small cracks and holes can develop in the lead lining that may not be visible on the exterior fabric of the lead apron.

“Lead aprons should be checked fluoroscopically at least on an annual basis for their shielding integrity².” -Radiology Compliance Branch (Radiation Protection Section), NC Department of Health and Human Services

2.  To protect your radiation protection investment. Properly storing your lead aprons will extend the useful life of the apron by helping prevent damage to the lead lining and the exterior fabric of the lead apron. Aprons should never be folded or creased. Lead aprons should be hung up by the shoulder(s) or on an approved apron hanger. Aprons should not be stored on a flat surface. Even incorrect storage for a short time can result in damage that is not visible to the naked eye.

3. To improve the organization of lead aprons. Managing lead aprons is one task that the imaging director has to cross off their to-do list, although it is probably not at the top of their list. Lead aprons play a vital role in protecting physicians, imaging staff, and patients from unnecessary exposure to ionizing radiation during diagnostic imaging procedures. Properly organizing your aprons will simplify the tracking process and will make State or Joint Commission inspections easier.

4. To help improve efficiency. Having a centralized location to properly store lead aprons will keep them safe and easily accessible the next time they are needed. Properly managing lead aprons can be a time-consuming task, utilizing an appropriate lead apron storage rack can help reduce time spent tracking aprons in the medical facility. As departments grow, it is important to have an apron storage process in place to keep aprons from getting mixed between departments.

5. To help reduce the occurrence of missing aprons. Keeping track of aprons can be difficult, especially when physicians and imaging staff spend time at multiple facilities. Lead apron racks make storage easier and help reduce the chance of lead aprons getting moved between departments and other medical facilities.

Example of A Wall Mounted Apron Rack

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Stay Neat And Organized

Maintaining a neat, uncluttered imaging environment is important in detail orientated medical fields. Lead apron racks allow your facility to provide medical staff with a well-organized treatment facility and workspace. When the necessary equipment is readily available on an x-ray apron rack in a centralized location, X-ray procedures will be completed efficiently and effectively.

 

5 Ways To Minimize Your Occupational Radiation Exposure

Minimizing Occupational Exposure

“The ideal dose is the least amount of radiation possible to produce an acceptable image.”

1. Time

Time is one of the three basic safety measures to reduce external radiation exposure. It is important for healthcare personnel to limit the amount of time spent in close proximity to the radiation source when exposure to the radiation source is possible. Reducing the time of an exposure reduces the effective dose (radiation) proportionally. Consequently, the less time you are around the equipment, the smaller your exposure will be.

2. Notification by Radiation Equipment Operator

Before any treatment or procedure, it is the responsibility of the trained and certified radiation equipment operator to notify healthcare personnel in the x-ray or treatment room prior to the activation of radiation producing equipment (RPE).

Any piece of equipment in which x-rays are produced electrically are classified as radiation producing equipment or RPE. These tools are used in a variety of medical applications including radiography, mammography, computed tomography, and fluoroscopy.

3. Fluoroscopic Procedures

Healthcare personnel performing fluoroscopic procedures must ensure that the patient is kept as close as possible to the image intensifier side of the fluoroscopic unit and away from the tube side of the unit. All healthcare personnel involved in the fluoroscopic procedure must stand on the image intensifier side of the fluoroscopic unit, whenever possible, to reduce the radiation exposure. Standing on the the same side as the image intensifier radiation intensity is decreased.

4. Avoid Direct Beam Exposure

Healthcare personnel assisting with radiological procedures must avoid holding the patient manually during a radiographic study due to the risk of direct beam exposure.  Any individual holding or supporting a person during radiation exposure should wear protective gloves and apron with a minimum of 0.25 millimeters lead equivalent. Under no circumstances should individuals holding or supporting a person’s part of their body be directly in the primary beam. Healthcare personnel must avoid exposing any body parts to direct x-ray beam exposure.

5. Utilize Shielding

Whenever possible, appropriate shielding should be used to provide attenuation of the radiation being delivered to the healthcare personnel who are potentially exposed. Healthcare personnel must keep all body parts out of the direct x-ray beam. There are a variety of shielding options available and may include, but are not limited to:

Specific Shielding Applications

Healthcare personnel who may have to stand with their backs exposed to the radiation beam must wear wrap-around aprons to decrease the risk of radiation exposure.

Bone and Bone Marrow Protection

When healthcare personnel are in close proximity to the radiation beam they should wear an appropriate lead or lead equivalent apron of sufficient length to shield the upper legs and protect the long bones and bone marrow from increased doses of radiation.

Thyroid Protection 

Healthcare personnel must wear a thyroid collar to protect the thyroid whenever the likelihood of the procedure places them at a higher risk of increased exposure.

Female Healthcare Personnel 

Female healthcare personnel must protect their breasts from radiation exposure by utilizing an apron that completely covers the area.

Eye protection

Healthcare personnel must shield the lens of the eye by using leaded eyeglasses with wrap-around side shields or leaded face shields to reduce scatter radiation when it is anticipated that increased fluoroscopic time may be necessary.

Limiting Radiation Exposure 

Reducing radiological exposure in healthcare settings is important for both occupational workers as well as patients. The following guidelines are based on the radiation safety principles of time, distance, and shielding. By following these guidelines, you can reduce your occupational exposure to radiation.

 

//www.slideshare.net/UniversalMedicalInc/5-ways-to-minimize-your-occupational-radiation-exposure

 

 

Note: This information included in this post is intended for general reference information only. The information provided is not a substitute for professional advice and should not be relied upon in the absence of such professional advice.

The ALARA Principle: 3 Safety Measures To Follow

The ALARA principle is an important principle for any worker, exposed to radiation, to fully understand and apply in every day use.

What is ALARA? 

ALARA stands for “As Low As Reasonably Achievable”, a safety principle specifically designed to reduce radiation doses and releases of radioactive materials. ALARA is a regulatory requirement for all radiation safety programs¹. The ALARA principle also factors in the technologic and economic considerations, while keeping radiation doses and releases of radioactive materials to the environment as low as reasonably achievable.

What is the biological basis of ALARA? 

“The biological basis for radiation protection assumes a conservative estimate of radiation dose versus effect, termed “linear hypothesis.” This hypothesis states that, any dose, no matter how small, may inflict some degree of detriment. “This detriment takes the form of an postulated risk of cancer and genetic damage.” While the risk of cancer and genetic damage exists in the absence of radiation, exposure to ionizing radiation increases the level of risk.

Radiation safety programs strive to lower doses, in most situations this can be accomplished, but may involve more costly practices. The ALARA philosophy serves as a balance between dose reduction and economic considerations. There comes a point that the costs outweigh the benefit of further dose reduction.

ALARA Philosophy And Safety 

An effective radiation safety and ALARA program is only possible when a commitment to safety is made by all those who are involved in the use of radiation. This may include members of the radiation safety committee, radiation safety division staff, medical personnel, research faculty, and all radiation workers.

Medical and research facilities will have a radiation safety manual that provides guidelines for the responsibilities and best practices which are consistent with both the ALARA concept and state regulatory requirements. Although these guidelines may vary by state, there is a regulatory requirement that requires radiation workers to adhere to legal dose limits for regulatory compliance, as well as an ALARA investigation dose level which serves as alert points for radiation worker radiation safety practices.

ALARA Safety Measures For Mitigating External Radiation Hazards

  1.  Time: It’s important to minimize your time of radiation exposure.
  2. Distance: Doubling the distance between your body and the radiation source will divide the radiation shielding exposure by a factor of 4.
  3. Shielding: Using absorber materials such as lead for X-rays and gamma rays is an effective way to reduce radiation exposures.

Lead Shielding

Time and distance are two factors that can be controlled by the operator. However, lead shielding is more complex, since there are a variety of shielding options available. Radiation shielding is based on the principle of attenuation, which is the gradual loss in intensity of any energy through a medium. Lead acts as a barrier to reduce a ray’s effect by blocking or bouncing through a barrier material. When X-Ray photons interact with matter, the quantity is reduced from the original x-ray beam.

Protection From X-Rays

The purpose of lead shielding is to protect the patients (when not being examined), X-Ray department staff,  visitors and the general public, as well as the people working near the X-Ray facility. There are three sources of radiation that must be shielded; secondary or scattered (originates via the patient), primary (the x-ray beam), and leakage (from the x-ray tube).

Types Of Lead Shielding

 

Radiation Safety And ALARA

 

Sources:

//www.ncsu.edu/ehs/radiation/forms/alara.pdf

https://www.ehs.washington.edu/manuals/rsmanual/7alara.pdf

Radiation Shielding: A Key Radiation Protection Principle

Time, Distance, and Shielding

Time, distance, and shielding are the three basic concepts of radiation protection that apply to all types of ionizing radiation. Shielding simply means having something that will absorb radiation between the source of the radiation and the area to be protected. Radiation shielding is based on the principle of attenuation, which is the gradual loss in intensity of any energy through a medium.

Lead acts as a barrier to reduce a ray’s effect by blocking or bouncing particles through a barrier material.  When X-ray photons interact with matter, the quantity is reduced from the original x-ray beam. Attenuation is the result of interactions between x-ray and matter that include absorption and scatter. Differential absorption increases as kVp decreases. The greater the shielding around a radiation source, the smaller the exposure.

X-Ray And Gamma Rays

X-ray and gamma rays are forms of electromagnetic radiation that occur with higher energy levels than those displayed by ultraviolet or visible light. Thick, dense shielding, such as lead, is necessary to protect against the energy emitted from x-rays. Shielding and x-ray room design is a very important consideration for any healthcare facility that  performs diagnostic and interventional radiology.

The purpose of shielding is to protect the patients (when not being examined), X-Ray department staff, visitors and the general public, as well as the people working near the  X-Ray facility. There are three sources of radiation that must be shielded; scattered or secondary (from the patient), primary (the x-ray beam), and leakage (from the x-ray tube).

Scatter Radiation

Diagnostic x-ray procedures frequently require medical personnel to remain in the exam room where they are subjected to scatter radiation. Lead aprons offer valuable protection from radiation exposure but there are times that a mobile lead radiation barrier is required to provide a full body shielding barrier.

Imaging procedures performed in remote locations, such as operating rooms, cardiac catheterization labs, and special procedure rooms pose an added challenge to protect against radiation exposure. Lead barriers are excellent for imaging procedures using ionizing radiation such as fluoroscopy, x-ray, mammography and CT.

Lead Shielding

The use of shielding provides a barrier between you and the source of the radiation. Some examples of shielding are lead aprons, lead glasses, thyroid shields and portable or mobile lead shields. Mobile lead shields of at least 0.25 mm lead equivalency are recommended to be used by anyone working near the table during fluoroscopy procedures when possible. Remember to follow ALARA “as low as reasonably achievable” guidelines when involved in diagnostic or interventional radiology procedures. Lead garments, lead gloves, thyroid shields, leaded glasses, lead drapes, as well as mobile and stationary lead barriers between the patient and personnel all reduce exposure to scatter radiation.

Questions? Comments? 

If you have any questions regarding the selection of lead barriers or mobile lead shields, please feel free to leave a comment below or connect with us over on our Google+ community page and keep the discussion going!

How To Choose The Right X-Ray Apron Style (Part 3)

Which x-ray apron style is right for you?

X-ray aprons are available in a wide variety of styles to meet the specific needs of medical professionals. Determining which lead x-ray apron style is right for you may seem overwhelming. The selection process can be simplified into several easy steps and in this post we will walk you through the necessary steps to ensure that you find the right x-ray apron as well as the appropriate level of radiation protection. The x-ray selection process can be broken down into three steps: (1) choosing your core material, (2) selecting the type of protection required, and (3) determining the best x-ray apron style for your needs.

Core Materials

In our previous post, How-To Determine Which X-Ray Apron Material Is Right For You, we discussed the three different types of core x-ray apron material options including traditional lead, lead composite, and non-lead. Each core material offers a distinct benefit, traditional lead aprons are the most economical, lead composite aprons provide an average weight savings of 25% compared to traditional lead aprons, and non-lead aprons are the lightest weight option available. Once you have determined the core material you can then choose the type of protection needed.

X-Ray Apron Coverage Protection Options

When selecting the type of radiation protection required for your specific application, it is important to understand the unique benefits each style offers. The three common x-ray apron styles are front protection, front/back protection, and quick-drop. Front protection x-ray aprons are ideal for those who only require front-protection during procedures. X-ray aprons that offer front and back protection are designed for those who circulate and will have their back to the radiation source.  The quick- drop x-ray apron has been designed for those who need to remove the x-ray apron during surgery without breaking the sterile field.

Understanding The Various Style Options

Now that we understand the coverage and protection offered by the three main x-ray apron styles, we can take a closer look into the unique benefits available for each apron style.

Frontal Protection

X-ray aprons offering frontal protection are available with several important features including closure options, back type and frontal aprons designed for specialty applications. Front protection x-ray aprons are available with three different closure types including buckle closure, strap closure (tie style), and velcro closure.

There are several factors you will want to consider when choosing the right x-ray apron back type including apron weight, the length of procedure, and types of procedures performed. There are a variety of x-ray apron back types to choose from including the standard plain back apron, flex back apron, back relief/support apron, and fast wrap aprons. There are several speciality options available including pregnancy aprons (1.00mm Pb equivalency over fetal area) and lap guards, lead aprons with a sewn in thyroid collar, and the quick ship lightweight lead flex guard apron.

Front and Back Protection

There are several options to choose from when looking for front and back protection including full wrap aprons and vest/skirt aprons.  Standard medical x-ray protection levels commonly available  for front/back protection aprons are offered in the following combinations:

Front Protection Pb Equivalent/Back Protection Pb Equivalent

  • 0.50mm/0.25mm
  • 0.35mm/0.25mm
  • 0.25mm/0.25mm

Full Wrap Aprons

Full wrap aprons are available in several styles including full overwrap, special procedure, and tabard styles while providing maximum protection. Full overwrap aprons provide lumbar support which reduces fatigue and upper back stress during long procedures. Vest/skirt aprons create maximum weight distribution between the shoulders and hips which eliminates stress on the upper and lower back.

Full Overwrap Protection 

The full overwrap aprons are secured via velcro straps and provides maximum radiation protection which reduces back fatigue during long procedures.

Special Procedure

Special procedure aprons have velcro seems that allow the sides of the apron to separate when bending or sitting while still maintaining front protection.

 

Tabard Style

The tabard style apron – a tabard was a short coat that men commonly wore during the middle ages – is a sleeveless, single piece apron that has a right shoulder and side velcro closure that allows for easy access.

Vest/Skirt Aprons

Vest/skirt aprons provide greater flexibility to the wearer with regard to sitting, bending, or stooping. The skirt is designed for complete overlap to provide maximum protection. Many of the vest/skirt sizes can be mixed to provide maximum comfort and fit.

Quick Drop X-Ray Apron

The quick-drop apron style is designed to be worn over the scrub suit and under the O.R. gown for quick removal without breaking the sterile field after x-ray procedures are completed. The quick-drop style aprons do not have arm holes and require assistance from a second party when putting it on or removing the apron. Quick-drop aprons are available with velcro criss-cross back flaps that assure easy removal. The Xenolite O.R. Quick-Drop Apron allows for freedom of movement, maximum flexibility, and optimal comfort.

Questions? 

Now that we have reviewed the various benefits of the core materials used in x-ray aprons, the different types of protection, and highlighted some of the main benefits of the different types of apron styles, you should be able to choose the right x-ray apron for your specific needs. If you have any additional questions, feel free to leave a comment below or contact us via live chat on our e-commerce site during normal business hours (M-F 9-5 EST).

How To Determine Which X-Ray Apron Material Is Right For You (Part 2)

In our previous post, 3 Different Types of Radiation Shielding Materials, we discussed various radiation shielding material options including standard lead (lead vinyl composition), lead composite and non-lead shielding materials. Radiation shielding garments are generally used to protect medical patients and workers from direct and secondary radiation during diagnostic imaging in hospitals, clinics and dental offices. Radiation shielding garments include x-ray aprons, vests, kilts, skirts and thyroid shields. Now that we have a better understanding of the radiation shielding options available we can apply this knowledge in choosing the right x-ray apron material for your application.

The Three Types Of Radiation Shielding Materials

The first and most well-known radiation shielding material is standard lead. Manufactured with 100% lead, standard lead x-ray aprons are the heaviest x-ray aprons available. The second radiation shielding material is a lead-based composite; lead composite x-ray aprons use a mixture of lead and other light weight radiation attenuating metals, reducing the weight by up to 25% compared to standard lead aprons. The third and final option is the non-lead or lead-free shielding material which is made from other types of attenuating metals including antimony, tungsten, bismuth and tin.

Core Material Options

The three core material options discussed all have their own unique benefits and features. There are many factors you will want to consider when making your decision on which x-ray apron material is best for you including the specific procedure being performed, length of the procedure, and the frequency of the procedure. Following the ALARA principles of time, distance and shielding your radiation safety officer or radiation physicist can evaluate the level of radiation protection required for your specific procedure.

Before we continue this discussion further, it is important to understand the terminology related to protective clothing and radiological protective materials. When choosing x-ray aprons, lead equivalency is quite possibly the most important factor to consider.

Attenuation

The definition of attenuation according to the American Society for Testing and Materials is “For radiological protective material, the reduction in the intensity of the X-ray beam resulting from the interactions between the X-ray beam and the protective material that occur when the X-ray beam passes through the protective material.”

Lead (Pb) Equivalency

The definition of lead equivalency according to the American Society for Testing and Materials is “For radiological protective material, the thickness of in millimeters of lead (commonly designated mmPb) of greater than 99.9 percent purity that provides the same attenuation as a given protective material.”

Kilovolts, Peak (kVp)

The definition of (kVp) according to the American Society for Testing and Materials is “the maximum electrical potential across an x-ray tube during an exposure, expressed in kilovolts.”

Which X-Ray Apron Material Is Right For You?

Standard Lead

Standard lead X-ray aprons are manufactured using 100% lead are the most traditional and economical option. For example, the standard large lead plain back apron (Product Code: 790RL) offers frontal protection weighing in at 11 pounds. This particular apron offers a nominal lead equivalence of 0.5mm and 100% protection at 80 kVp. Standard lead x-ray aprons are well-suited for shorter procedures. The weight of the apron will increase depending on the level and areas of protection required.

Lead Composite

Lead composite x-ray aprons are a lead-based alloy and can achieve weight reductions of up to 25% compared to standard lead x-ray aprons of the same size, style and lead equivalency. The lead composite large male Xenolite Elastic Tab Apron (Product Code: 610E) offers frontal protection weighing in at 9 pounds. This Xenolite apron offers a nominal lead equivalence of 0.50mm and 100% frontal protection at 100 kVp. This lead composite x-ray apron incorporates a two element material; the lead is blended with an additional attenuating metal and is recyclable. The lightweight and ultra-lightweight lead composite x-ray aprons are good for short to medium-length procedures.

Non-Lead

Non-Lead or Lead-Free x-ray aprons are manufactured from a proprietary blend of attenuating heavy metals. Lead is not the only metal that protects you from an x-ray beam. These heavy metals may include barium, aluminum, tin, bismuth, tungsten and titanium. The Xenolite Non-Lead Elastic Tab Apron is 40% lighter than standard lead aprons and has a 0.50mm lead equivalency and 100% frontal protection at 100 kVp. The non-lead and lead-free aprons are recyclable and safe for non-hazardous disposal and are excellent for long procedures.

(Part 3) How To Choose The Right X-Ray Apron Style 

Now that we have discussed the different types of core materials and their benefits, you should have a better understanding of what to look for when selecting your next x-ray apron or radiation shielding garment. In our next post we will discuss the different types of x-ray apron styles that are available. If you have any questions or comments,  please feel free to leave them below or connect with us on twitter!

3 Different Types of Radiation Shielding Materials (Part 1)

What are the different types of radiation shielding materials?

Radiation shielding materials are used for a variety of radiologic applications. “The use of radiation in diagnosing and treating patients has significantly advanced the field of medicine and saved or extended countless lives¹.” Advances in technology and more sophisticated applications have improved standard treatments for the benefit of the patient. Radiation use does, however, come with risks. “Those who use radiation must be adequately trained in radiation safety, radiation physics, the biologic effects of radiation, and injury prevention to ensure patient safety¹.” One of the three major principles of mitigating external radiation exposure is shielding, “Using absorber material such as Plexiglas for beta particles and lead for X-rays and gamma rays is an effective way to reduce radiation exposure².”

Radiation Shielding Materials

Historically, radiation shielding materials have been manufactured from lead (Pb). Lead shielding, often used in a variety of applications including diagnostic imaging, radiation therapy, nuclear and industrial shielding. For the purpose of this post, we will focus on the three different types of materials used in manufacturing x-ray attenuating garments such as aprons, vests, and skirts.

Radiation Shielding Materials

Radiation shielding garments are commonly used to protect medical patients and workers from direct and secondary radiation during diagnostic imaging in hospitals, clinics and dental offices³. Historically, the attenuating qualities of lead made it “the element of choice” for radiation protection. However, advances in radiation shielding material technology have produced two alternative materials, lead composite and lead-free radiation shielding. Now medical professionals have several options when it comes to selecting their radiation shielding garments.

Traditional Lead (Pb) Shielding

Lead is a chemical element in the carbon group with the symbol Pb and atomic number 82. Lead is a soft, malleable and corrosion-resistant material³. The high density of lead (11.34 grams per cm³) makes it a useful shield against X-ray and gamma-ray radiation. Lead, in its pure form, is brittle and cannot be worn as apparel. To transform pure lead into a wearable radiation shielding material it’s mixed with binders and additives to make a flexible lead vinyl sheet. The lead sheets are then layered to the desired thickness to achieve the required lead equivalency and incorporated into the radiation shielding garment. There are typically three standard levels of lead equivalency protection for traditional lead radiation shielding garments including 0.25mm, 0.35mm and 0.5mm.

Lead (Pb) Composite Shielding

Lead composite shielding is a mixture of lead and other lighter weight metals. These lead-based composite blends are a proprietary mixture of lead and other heavy metals that attenuate radiation. The lead composite blend will vary by manufacturer as they have developed their own proprietary blends that may include a mixture of lead, tin, rubber, PVC vinyl and other proprietary attenuating metals. The lead-based composite blend radiation shielding garments are lighter (up to 25%) than regular grade lead and are available with the same lead equivalency protection levels.

Non-Lead (Pb) and Lead (Pb) Free Shielding

Similar to the proprietary blends of lead-based composite shielding materials the non-lead and lead-free shielding materials offer the same protection levels. Non-lead shielding materials are manufactured with additives and binders mixed with attenuating heavy metals that fall into the same category of materials as lead that also absorb or block radiation. These metals may include tin (Sn), antimony (Sb), tungsten (W) bismuth (Bi) or other elements. Non-lead aprons and lead-free aprons are recyclable and safe for non-hazardous disposal. The material blends are propriety to the specific manufacturer; therefore; the materials mentioned above are not representative of any specific manufacturer.

Benefits of Shielding Options

The three core material options discussed all have their own unique benefits and features. There are several factors you will want to consider when making your decision, including the specific procedure being performed, length of the procedure, and frequency of the procedure. To determine the proper amount of protection required in your working environment contact your radiation safety officer or radiation physicist. Selecting the right radiation shielding garment begins by identifying the core material option right for you.

(Part 2)  How to determine which x-ray apron material is right for you

In our next post, we will discuss how to determine which x-ray apron material is right for you. If you have any questions, please feel free to contact us.