literature review on radiation protection in radiology department

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Importance of establishing radiation protection culture in Radiology Department.

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• Ploussi A 1
• Efstathopoulos EP 1

World Journal of Radiology , 01 Feb 2016 , 8(2): 142-147 https://doi.org/10.4329/wjr.v8.i2.142   PMID: 26981223  PMCID: PMC4770176

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Abstract 

Free full text , importance of establishing radiation protection culture in radiology department.

Correspondence to: Efstathios P Efstathopoulos, PhD, 2 nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, 1 Rimini St, 12462 Athens, Greece. rg.aou.dem@esihtats

Telephone: +30-210-5831818 Fax: +30-210-5831831

The increased use of ionization radiation for diagnostic and therapeutic purposes, the rapid advances in computed tomography as well as the high radiation doses delivered by interventional procedures have raised serious safety and health concerns for both patients and medical staff and have necessitated the establishment of a radiation protection culture (RPC) in every Radiology Department. RPC is a newly introduced concept. The term culture describes the combination of attitudes, beliefs, practices and rules among the professionals, staff and patients regarding to radiation protection. Most of the time, the challenge is to improve rather than to build a RPC. The establishment of a RPC requires continuing education of the staff and professional, effective communication among stakeholders of all levels and implementation of quality assurance programs. The RPC creation is being driven from the highest level. Leadership, professionals and associate societies are recognized to play a vital role in the embedding and promotion of RPC in a Medical Unit. The establishment of a RPC enables the reduction of the radiation dose, enhances radiation risk awareness, minimizes unsafe practices, and improves the quality of a radiation protection program. The purpose of this review paper is to describe the role and highlight the importance of establishing a strong RPC in Radiology Departments with an emphasis on promoting RPC in the Interventional Radiology environment.

Core tip: Radiation protection culture (RPC) is a combination of knowledge, beliefs and practices related to radiation safety. The establishment of a RPC in a Radiology Department demands substantial knowledge of radiation risks, safety rules and active participation of all stakeholders. Professionals have the key role in the creation of a RPC. A strong RPC provides more effective diagnosis and treatment, improves patient and staff safety and reduces radiation exposure. The objective of our study is to highlight the role of RPC in a Radiology Department with an emphasis on promoting RPC in the Interventional Radiology environment.

• INTRODUCTION

Culture is one of the most complicated and obscure concepts. Among the many definitions one may find in the literature, the most attractive one for the purpose of this text is that culture is “…the total range of activities and ideas of a group of people with shared traditions, which are transmitted and reinforced by members of the group…”[ 1 ]. The term culture is not only associated with a high level of art, civilization and religion but also strongly affects business, communication, marketing and safety.

During the recent years the concept of safety culture has been gaining ground in organizations mainly due to the rapid advancement of technology and the concern about employees’ health and safety. Safety culture reflects attitudes, values, norms and practices that professional and employees share concerning risk and safety. Safety culture is often used in conjunction with terms like “nuclear safety culture”, “patient safety culture”, “health safety culture”, “occupational safety culture”, “organization safety culture” and “environment safety culture”.

Regarding the safe use of ionizing radiation in the medical field and nuclear industry, International Radiation Protection Association (IRPA) first established the concept of radiation protection culture (RPC) in 2008 following the proposal of the French Society for Radiation Protection. The proposal was favourably greeted by the participating Associate Societies, the World Health Organisation (WHO) and the European ALARA Network. At the first Workshop of IRPA on RPC in 2009, professionals proposed a number of definitions for RPC and prepared the action plan for the development of a strong RPC. Two years later, after a series of meetings, the Association published the final draft on Guiding Principles for Establishing a RPC and very recently, in June 2014, the draft was issued in its final form and published in the website of IRPA[ 2 ].

Hence, the RPC is a newly introduced concept for professionals, staff and patients. The goal of this paper is to provide the role of RPC with an emphasis on promoting RPC in the Interventional Radiology environment.

• A DEFINITION FOR RPC

A thorough understanding of the term RPC is the first step towards developing a strong RPC in a Radiology Department. According to IRPA, RPC is defined as “The combination of knowledge, values, behaviours and experience of radiation protection in all its aspects for patients, workers, population and environment, and in all exposure situations, combining scientific and social dimensions”[ 2 ]. In other words, RPC is the assembly of attitudes, strategies and practices among staff and leaders that should be emphasized in radiation protection safety. As it is obvious, RPC is a part of safety culture oriented on the effects and risks of ionization radiation.

Each Radiology Department has guidelines and practical rules for the safe use of ionizing radiation even if not all members of the department are aware of that. Does this actual mean that every Radiology Department has a RPC program? On this question, opinions diverge. Some support that RPC exists in every Radiology Department; however this culture can be positive or negative, strong or weak. Others recognize that culture is a combination of attitudes and regulations and claim that RPC is either present or absent within a Radiology Department. In authors’ opinion, RPC exists in most Radiology Departments. The challenge is to improve rather than to build a RPC. Most often, it proves to be more difficult to improve an existing culture rather than to create a new one as workers and all stakeholders must unlearn the old behaviors and practices before they adopt the new ones.

The objectives of RPC are to provide a safe working environment, promote knowledge of radiation risks, minimize unsafe practices, control radiation risks, share responsibility among workers and improve the quality of an already existing radiation protection program. All the aforementioned objectives are achieved through the active participation and interaction of all the workers inside the department.

• WHY THE ESTABLISHMENT OF RPC IS IMPORTANT IN A RADIOLOGY DEPARTMENT

The increasing use of ionization radiation for diagnostic and therapeutic purposes especially in higher dose procedures such as computed tomography (CT) and interventional radiology have raised serious safety and health concerns for both patients and medical staff.

During the last 15-year period the number of CT examinations has almost tripled and now contribute to more than 60% of the total collective dose from X-ray examinations[ 3 , 4 ]. A typical head CT scan, which is the most frequent CT examination in adults and children, delivers an effective dose of about 4 mSv whereas the effective doses for abdomen and coronary angiography CT examinations can reach 25 and 32 mSv, respectively (Figure ​ (Figure1 1 )[ 5 , 6 ].

Effective dose from various computed tomography examinations[ 5 , 6 ]. CT: Computed tomography.

The concern for the increased use of CT exams is more pronounced for pediatric patients. A recent survey revealed that the frequency of CT examinations has doubled in children under 5 years old while it has tripled in older children the last 20 years[ 7 ]. Pediatric patients are more sensitive to radiation-induced risks compared to adults due to their longer post-exposure life expectancy and their rapidly dividing cells. Two recent epidemiological studies on large pediatric populations demonstrated positive association between radiation exposures received from CT scans and cancer incidence[ 8 , 9 ]. It is worth mentioning that even today there is lack of optimized, size-based protocols for pediatric procedures in clinical routine and therefore children may be over-exposed to radiation.

Concerning the field of interventional radiology (IR), the new advances in fluoroscopy imaging equipment as well as the development of new interventional tools and devices (balloon, catheters, stents) led to a significant increase of 78% in interventional (non-CT) procedures the period between 1998-2008[ 3 ].

Radiation protection and safety is an extremely important issue for IR medical staff. IR procedures are usually complex, demands high fluoroscopy times, high dose rates and a large number of cine acquisitions. Therefore, they deliver high radiation doses both to patients and medical staff. Figure ​ Figure2 2 presents the effective dose from various IR examinations for patients and medical staff[ 5 , 10 , 11 ]. IR procedures deliver effective dose to the patients ranging from 5 to 160 mSv[ 5 ] and contribute about 8% to collective dose[ 3 ] even though they consist of a small percentage in the total number of X-ray examinations performed in a given population. Variations in the value of occupational doses for the same type of procedure are largely due variations in the X-ray equipment, the technique, the training of health professionals on radiation protection issues, the optimization of protocols as well as to the availability and use of protection tools.

Effective doses from various interventional radiology procedures. A: Patients[ 5 ]; B: Occupational[ 10 , 11 ]. TIPS: Transjugular intrahepatic portosystemic shunt; CPTA: Carotid percutaneous transluminal angioplasty; ERCP: Endoscopic retrograde cholangiopancreatography; PCNL: Percutaneous nephrolithotomy; PCI: Percutaneous coronary intervention; IR: Interventional radiology.

There are several reports in the literature concerning radiation-induced deterministic effects on both patients and medical staff during IR procedures[ 12 , 13 ]. The most common deterministic effects in patients are erythema, skin necrosis, hair loss and permanent epilation as well as cataract formation in occupational settings. Most of the time, the deterministic injuries arise from the poor knowledge on radiation protection rules, the lack of quality assurance programs, the performance of wrong practices and the improper or no use of radiation protection tools.

• WAYS OF ESTABLISHMENT A RPC

The key role for the implementation of RPC in a Radiology Department is initially the development of a strategic plan where every decision and process takes into account radiation safety of staff and patients. Then this strategic plan must be turned into an action plan in order to create the conditions for the incorporation of radiation safety in the routine work of the department. But how we can achieve the establishment of a RPC program in Radiology Departments and how easy is it to apply a “culture” on a daily basis?

The most important factor contributing to the creation of a RPC is the continuous education and training of the staff and professionals with the attendance of courses, workshops, seminars and electronic-learning programs in a normal periodical basis. Theoretical education and practical training in radiation protection aim to ensure that healthcare professionals will obtain a strong foundation in radiation protection and a basic knowledge of the technology of each modality. Education is an essential aspect for the optimization of clinical protocols and the reduction of radiation exposure. Physicians, radiographers, nurses and other medical staff need to have a substantial knowledge of radiation protection regulations and a comprehensive understanding of the factors that affect patient and occupational dose in order to minimize the harmful effects of ionizing radiation. Medical staff should be adequately trained in order to keep the dose as low as reasonably achievable (ALARA principle), be familiar with radiation quantity units, pay special attention to radiation protection of pregnant and pediatric patients and proper use of the radiation protection equipment.

Literature review revealed that there is poor education in radiation protection of medical staff. A study from Salerno et al[ 14 ] on the evaluation of radiation risks knowledge in pediatric fellows and resident demonstrated that only 35% of medical staff have sufficient knowledge for radiation risk from common radiological examinations. Furthermore, it is impressive to be noted that a multicenter study conducted by Vano et al[ 15 ] in pediatric interventional cardiology departments in Latin America revealed that only 64% of the physicians used their personnel dosimeter and only 36% were aware of the doses received. European Commission[ 16 ] and more recently the International Commission of Radiation Protection[ 17 ] published guidelines highlighting the need for education and training of medical staff on radiation protection. It is important to understand that education does not only offer new knowledge but also facilitates the development of new skills and attitudes.

The active stakeholder engagement of all levels including health authorities, researchers, medical staff and patients is the second milestone for the establishment of a RPC. In a Radiology Department, multi-disciplinary collaboration is needed. Radiologists, medical physicists, radiographers, nurses and other specialists must collaborate closely one to each other, in order to ensure patient safety and best clinical outcome. RPC is strongly dependent on the behavior of all stakeholders. The effective communication among workers leads to the creation of a supportive and motivating work environment where everyone has a clear role. A positive workplace is characterized by trust and respect among stakeholders and allows the exchange of experience and knowledge. A strong leadership increases the radiation risk awareness and allows the performance of safer practices, which prompts minimizing errors.

Quality assurance (QA) program is another essential step in the implementation of RPC. According to WHO, the QA program in diagnostic radiology is defined as “an organized effort by the staff operating a facility to ensure that the diagnostic images produced are of sufficiently high quality so that they consistently provide adequate diagnostic information at the lowest possible cost and with the least possible exposure of the patient to radiation’’[ 18 ]. The objectives of a QA program is to improve patient care and comfort, ensure accurate diagnosis and proper function of the equipment, produce high quality images following the ALARA principle, ensure patient and staff safety and minimize cost. A QA program should include the following major elements[ 19 , 20 ]: (1) Responsibility: There should be an assignment of the responsibility with specific duties for the performance of QA procedures. Both managers and employee are responsible for the implementation and improvement of QA programs in clinical routine; (2) Equipment specifications: Accurate specifications must be provided for each modality according to the facilities needs; (3) Standards for image quality: Standards, criteria and limits for diagnostic acceptable images should be documented and accessible; (4) Monitoring and maintenance: Monitoring, testing and maintenance of radiology equipment should be established and performed on a regular basis; (5) Evaluation: There must be regularly recurring evaluation of the adequacy and effectiveness of the X-ray equipment performance and the QA program itself; (6) Records: Every department should keep records about the equipment, quality control tests, dosimetry data, maintenance and repair of the modalities. The records must be easily accessible to the staff; (7) Manual: The manual must include list of duties and responsibilities of the staff as well as a list of the tests to be performed; (8) Education: QA specialists shall have continuing education and training in order to be qualified and up-to-date; (9) Committee: Each department should establish a committee composed of radiologists, medical physicists and radiographers with the top priority being the QA and the radiation safety; and (10) Review: Ongoing review of the QA program is important in order to assess the effectiveness of the QA procedures.

• THE ROLE OF PROFESSIONALS AND STAFF

The implementation of a RPC should be driven from the highest level. Managers, medical professionals and workers should be directly involved and have a key role in the execution of RPC in every department. Radiation protection experts enhance safety culture, provide leadership, develop relationships with the administration and the employees and are responsible for the staff training and the creation of guidelines and recommendations under the guidance of radiation protection associates ( e.g ., IRPA). Managers should be able to change unsafe practices and behavioral hazards, recognize safe practices and report accidents in order to prevent recurrence. Furthermore, the healthcare staff should implement the guidelines and the recommendations, ensure the proper practice of examinations, improve patient health care and build trust between patients and staff.

• THE IMPACT OF RPC

The direct impact of the implementation of RPC is the substantial reduction of radiation dose on both patients and staff. Fetterly et al[ 21 ] showed a significant reduction of about 40% on cumulative skin dose of patients in an invasive cardiovascular laboratory after the establishment of a safety culture. The ways in which the safety culture was achieved included a number of practical and technical changes such as reporting of high air-kerma procedures, training for fellows on radiation exposure safety issues, maximum distance between the X-ray source and patient, increased use of X-ray beam spectral filters and reduced fluoroscopy frame rates. A strong RPC enables more efficient diagnosis and treatment and helps minimize harmful effects. The foundation of a RPC program has an important effect on the operation of the Radiology Department: It improves the efficiency and service quality, reduces cost and incorrect practices and promotes a good reputation.

RPC is a combination of attitudes, priorities, policies and practices concerning radiation safety. The foundation of a RPC program is a dynamic process that needs continuous evaluation and systematic improvement with the use of quantitative and qualitative tools in order to examine how well the RPC is being implemented and to check whether the program is achieving the desired goals. RPC should be an integral part of clinical routine and demands deep knowledge of radiation risks, safety rules and active participation of all stakeholders. Insufficient knowledge and lack of collaboration are the most significant barriers in the implementation of RPC. For the successful establishment of a strong RPC program, authorities, professionals, employee and patients must fully comprehend the role and the impact of RPC in a Radiology Department and fill the gap between theory and practice.

Conflict-of-interest statement: None declared.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Peer-review started: August 31, 2015

First decision: September 8, 2015

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P- Reviewer: Chow J, Faasse T, Landrigan-Ossar M S- Editor: Kong JX L- Editor: A E- Editor: Liu SQ

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Open Access

Peer-reviewed

Research Article

Infection control and radiation safety practices in the radiology department during the COVID-19 outbreak

Roles Conceptualization, Data curation, Investigation, Project administration, Writing – original draft

* E-mail: [email protected]

Affiliation Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah, UAE

Roles Investigation, Methodology, Writing – review & editing

Roles Resources, Software, Validation, Visualization

Affiliations Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah, UAE, Istinye University, Faculty of Engineering and Natural Sciences, Computer Engineering Department, Istanbul, Turkey

• Mohamed M. Abuzaid, 
• Wiam Elshami, 
• H. O. Tekin

• Published: December 27, 2022
• https://doi.org/10.1371/journal.pone.0279607
• Reader Comments

Rationale and objectives

Radiology personnel must have good knowledge, experience and adherence to radiation protection and infection control practices to ensure patient safety and prevent the further spread of the COVID-19 virus. This study analysed compliance and adherence to radiation protection and infection control during COVID-19 mobile radiography.

A cross-sectional using online survey was conducted from September to December 2021. Data on demographic characteristics, adherence to radiation protection and infection control practice were collected during mobile radiography for COVID-19 patients in the study. A random sample of the radiographers working in COVID-19 centres in the United Arab Emirates.

Responses were received from 140 participants, with a response rate of 87.5%. Females were the predominant participants (n = 81; 58%). Participants aged ages between 18–25 years (n = 46; 33%) and 26–35 years (n = 42; 30%), (n = 57; 41%) had less than five years of experience, followed by participants who had more than 15 years (n = 38; 27%). Most participants (n = 81; 57.9%) stated that they performed approximately 1–5 suspected or confirmed COVID-19 cases daily. The participants had moderate to high adherence to radiation protection, with a mean and standard deviation of 42.3 ± 6.28. Additionally, infection control adherence was high, with 82% of the participants showing high adherence.

Continuous guidance, training and follow-up are recommended to increase adherence and compliance to radiation protection and infection control compliance. Educational institutions and professional organisations must collaborate to provide structured training programmes for radiology practitioners to overcome the practice and knowledge gap.

Citation: Abuzaid MM, Elshami W, Tekin HO (2022) Infection control and radiation safety practices in the radiology department during the COVID-19 outbreak. PLoS ONE 17(12): e0279607. https://doi.org/10.1371/journal.pone.0279607

Editor: Suhairul Hashim, Universiti Teknologi Malaysia - Main Campus Skudai: Universiti Teknologi Malaysia, MALAYSIA

Received: June 22, 2022; Accepted: December 10, 2022; Published: December 27, 2022

Copyright: © 2022 Abuzaid et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The author(s) received no specific funding for this work

Competing interests: The authors have declared that no competing interests exist.

Introduction

Radiology personnel are at the frontline of the fight against COVID-19. Still, most of them have little experience working with COVID-19 patients [ 1 ]. Additionally, nonstandard preventative techniques used during radiological investigations increase the danger of hospital cross-infection in the radiology department [ 2 ].

The (COVID-19).-19 outbreak was reported in Wuhan, Hubei province, in late December 2019, quickly spreading throughout China and worldwide by March 2020 [ 3 ]. Radiology professionals are near in touch with suspected and confirmed patients and are at significant risk of occupational exposure to the disease. Previous studies have shown that front-liners account for about 10–20% of all COVID-19 cases [ 4 ]. The risk of positive COVID-19 tests was 3–4 times higher among healthcare workers compared to the general community [ 5 ]. The spread of COVID-19 among healthcare workers contributed to further spread in the community, directly affecting healthcare services.

Radiological examinations play a critical role in diagnosing and managing COVID-19 cases [ 1 , 6 – 8 ]. Chest X-ray and computed tomography (CT) examinations are the most effective imaging procedures for COVID-19 screening and diagnosis. Standard infection prevention techniques should be followed strictly to prevent hospital cross-infection from radiological studies. Detailed infection control measures were prepared internationally for radiology professionals for the disinfection of equipment, auxiliary instruments, and the workplace to reduce infection risk among workers, visitors and patients [ 2 , 9 ].

Mobile chest X-ray (CXR) is performed as a daily routine procedure for COVID-19 patients admitted to intensive care units. During radiology examinations, radiology professionals must provide radiation protection to patients. During mobile examinations, implement workers must perform the ‘as low as reasonably achievable’ (ALARA) procedures by employing the shortest possible exposure time, ensuring the optimum distance between the radiation source and the patient and applying proper patient, self and staff shielding [ 10 , 11 ]. The study was distinctive since it was the first to examine how radiation protection and infection control were practiced during the COVID-19 pandemic in the radiology department. The sudden outbreak of COVID-19 required quick recommendations about the roles and responsibilities of healthcare practitioners involved in managing COVI-19 cases. Radiographers are specifically trained to use imaging to benefit patients; they are aware of potential risks from ionising radiation and need to minimise the harm from inappropriate or excessive radiation use. In addition, other aspects of radiographer practice encompass elements of infection control. In this paper, we attempt to investigate the adherence to patient safety that forms part of normal practice for radiographers during the COVID-19 pandemic.

Study design and setting

A descriptive cross-sectional study using an online survey was conducted among radiographers working in in hospitals and health centres affiliated with COVID-19 cases in the United Arab Emirates (UAE). Radiographers who practice in the “Northern Emirates,” the five emirates located in the North of the country, were invited to participate in the study. The data collection duration was four months (August to December), with regular reminders to maximize response. This study followed the Strengthening the Re- porting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Participants

Radiographers who worked in the hospitals and clinics under the Ministry of Health and Prevention (MOHAP) authority and were willing to participate during the study period provided the data. Radiographers who failed to complete the survey by the deadline were not included.

Sample size

Random sample based on MOHAP records, there were 272 radiographers worked in different location [ 11 ]. A sample size of 140 was determined to have appropriate power based on a confidence level of 95% and margin of error of 5%.

Instrument for data collection

A self-administrated questionnaire was designed in English language, reviewed and piloted by a group of five senior radiographers and three infection control officers. The survey’s readability and appropriateness, as well as the questions’ definition, comprehension, and consistency were all tested during the pilot. The information statements and permission forms was also evaluated [ 11 ]. Additionally, the reviewer responses were used to improve the order and layout of the questions to reduce dropout rates. A pilot study was conducted on 15 systematic randomly selected participants whose results were excluded from the main study. A pilot study was conducted to ensure the understandability of the questionnaire. Internal consistency reliability of the questionnaire conducted using Cronbach’s Alpha.

The first part of the questionnaire consisted of demographic characteristics (e.g. age, academic qualification, work experience, the average number of COVID-19 cases performed daily and any special training or allowance during the pandemic). In the second part, it was investigated whether the radiation protection practices of participants minimise radiation exposure for workers staff and patients. Compliance with the following measures was assessed; wearing thermoluminescence dosimeter (TLD), lead aprons, thyroid collars, collimation, distance shielding, gonad shielding and proper exposure parameter. Finally, compliance with infection control practices was evaluated in the third part: personal protective equipment (PPE), infection precaution, equipment disinfection, hand hygiene and following the standard documentation protocol.

A 4-point Likert scale was used in the survey with the following scores: (4) always, (3) often, (2) sometimes and (1) never. The higher the score, the better the practice. The score was transformed into a percentage scale by dividing the total score by the maximum possible score multiplied by 100. Accordingly, the score was categorised as poor adherence (<60%), moderate adherence; (60–80%) and good adherence: (>80%) (11). A research assistant handed out hard copies of the survey to 160 radiographers, information papers, consent forms and explanations of the objectives of the study.

Ethical considerations

The research was approved by the Institutional Research Unit in University of Sharjah. The objectives of the study were explained and participants’ privacy was guaranteed. The participants were informed that they were free to withdraw at any time during the data collection process. Written informed consent was also obtained from all respondents prior to their involvement in the study, using an online consent form in google form, those who provided consent then completed a secure online survey.

Statistical methods

Data were collected, and graphs were created with Microsoft Office Excel 2016 (Microsoft Corporation CA, USA) and analysed in the Statistical Package for Social Sciences (SPSS) IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM. The descriptive statistics for the questions in all four sections were completed. ANOVA was conducted to understand the differences between radiation protection and infection control practices based on demographic differences. Jarque-Bera test of normality of distribution was conducted and the level of statistical significance used is α = 0.05.

Demographics and background of participants

Responses were received from 140 participants, making the response rate 87.5%, predominantly females (58%). Most of the participants were aged between 18–25 years (33%). Most respondents had a bachelor’s degree (77%) and Most had less than five years of experience (41%). Around (56%) of the respondents stated that they received special training related to COVID-19, while (24%) stated they received special allowances/incentives during the COVID-19 pandemic “ Table 1 ”.

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https://doi.org/10.1371/journal.pone.0279607.t001

Radiation protection practice during COVID-19 mobile cases

This section of the questionnaire had 10 sub-questions on a 4-point Likert scale. Responses were scored 1–4 as (1) never, (2) sometimes, (3) most of the time and (4) always. The frequencies of the responses and the distribution are given in “Tables 2 and 3 ”. When the participants were asked if they wore TLD, most (61.4%) stated they always wore it. Less than half (45%) of the respondents stated they always wore a lead apron and most (55%) participants never wear thyroid collars when performing mobile imaging procedures. Many respondents stated that they practised proper collimation always (46%) and most of the time (37%). Most participants (44%) responded ’always’ for using proper SID/FFD during imaging. Around (36%) of the participants responded ‘sometimes’ when asked if they applied patient gonad shielding and 30% (n = 42) for applying patient lead shielding during procedures. The minimum exposure time was applied most of the time, as stated by most participants (43%). A total of (37%) of participants stated that they use the lead apron for all co-patients or staff most of the time. Closing the door was a predominant practice, as most participants (57%) stated that they always performed this procedure.

https://doi.org/10.1371/journal.pone.0279607.t002

https://doi.org/10.1371/journal.pone.0279607.t003

Infection control practice during COVID-19 mobile cases

This section of the questionnaire had five sub-questions in which responses were recorded on a 4-point Likert scale, which were scored as never (1), sometimes (2), most of the time (3), and always (4). The majority of the respondents (70%) stated they always wore personal protective gear, such as a facemask, gloves and face shield. Nearly (59%) of the participants “always” used appropriate isolation precaution practices, and (57%) “always” disinfected the equipment according to infection control policies and procedures. Regarding personal hygiene, around (65.7%) of the participants always maintained hand hygiene and (66%) always followed standardised hospital protocols for decontaminating imaging equipment after the imaging procedure.

Knowledge and special training

Most of the respondents (71%) stated that they were up-to-date and aware of the latest information regarding COVID-19. Around (69%) of them attended the COVID-19 awareness course. Additionally, half of the respondents (50%) stated that they obtained support from the radiology department.

The participants were asked to what extent they have confidence in handling suspected COVID-19 patients and most participants (49%) stated they were confident to a great extent. Additionally, most respondents (66%) indicated that health organisations were the primary sources of information about COVID-19.

Comparison of demographics and responses

The demographics of the participants and their responses were analysed through ANOVA. The responses of radiation protection practices and infection control practices were summed, with the lowest possible score of 15, which meant that the worker did not adhere to best practices and the highest possible score of 60, which meant that the worker followed best practices.

A significant association was found between the educational qualifications of the respondents and their best practices (p = 0.0009, α = 0.05). The mean score of the respondents with Master degree (μ = 43.5) and Bachelor degree (μ = 48.1) were higher than those with a diploma (μ = 40.7). There was no significant association revealed among the radiographers’ best practises and the training provided (p = 0.10, α = 0.05), age (p = 0.34, α = 0.05), gender (p = 0.59, α = 0.05), number of COVID-19 cases they handled (p = 0.35, α = 0.05), and their experiences (p = 0.35, α = 0.05).

Adherence to radiation protection and infection control

The adherence of the participants to radiation protection and infection control is shown in “ Table 4 ”. The lowest score in the study was 21, and the maximum score was 57 in terms of radiation protection practices. The mean and standard deviation (SD) was 42.3 ± 6.28. The study found a minimum score of seven and a maximum score of 20 in infection control practices, with a mean and SD of 17.3 ± 3.49. The percentage of participants who adhered to good radiation protection was 50%, while that of those who adhered to infection control was 82%.

https://doi.org/10.1371/journal.pone.0279607.t004

During the COVID-19 pandemic, there was a need for rapid and accurate diagnostic procedures. The importance of medical imaging (chest radiography and computed tomography) in the fight against COVID-19 has been confirmed [ 6 , 8 ]. Patients, professionals and public safety are crucial during medical imaging investigations. Medical imaging professionals must gain knowledge and abilities to ensure patient safety and up-to-date information while the pandemic continues. Various studies and papers have been published emphasising patient safety in medical imaging during COVID-19 [ 2 , 9 , 12 – 14 ] and the challenges and optimisation strategies in radiology service during the COVID-19 pandemic [ 15 ] but no studies investigated the practice during mobile radiography. Increased utilisation of mobile radiography during the COVID-19 pandemic required more attention to occupational and patient doses [ 1 ]. Therefore, in April 2020, the International Society of Radiographer and Radiologic Technologist (ISRRT) released a response paper to ensure patient safety and radiation protection during medical imaging procedures during COVID-19 cases [ 9 ].

During mobile radiography, the radiation safety goals were determined not to exceed occupational exposure limits for workers or the general public, perform optimisations, use protective garments, monitor occupational exposure, request justification, correct patient identification and reduce repeats. Established radiation protection rules and practices must be followed by radiology departments to ensure the safety of workers, patients and the environment.

It was revealed in the results that most participants (81%) had high to moderate adherence to radiation protection practices during mobile radiography. Regarding personal safety, the findings are both surprising and alarming, as radiology professionals should be aware of the importance of wearing TLDs, lead aprons and thyroid collars during their practice. The participants who never wore TLD (15%) or lead apron (12%) showed an indication of negligence or a low awareness level. Wearing TLDs is critical for personal safety and is used to alert workers and hospitals when radiation levels exceed acceptable limits to avoid the danger of radiation exposure [ 16 ]. Additionally, the lead apron is a critical element of personal radiation protection [ 17 ].

The results of wearing the thyroid collar are linked to its unavailability and a lack of knowledge about the importance of wearing it during mobile radiography. These results are similar to those obtained in other studies [ 11 – 15 ]. Therefore, additional specialised radiation safety training is required, focusing on the risk of radiation exposure in the workplace and the significance of wearing TLDs while working.

Regarding patient protection, moderate to high adherence concerning collimation, distance, exposure time and gonad shield was shown in the results “ Table 2 ”. A fundamental concept to reduce radiation exposure is (ALARA). According to ALARA, minimum exposure time, distance to radiation and radiation shielding are the three key parameters to decrease occupational exposure to scatter radiation.

Concerning infection control, PPE is based on the risk of exposure by the activity being performed and the transmission dynamic of the virus considering the three types of transmission of diseases: contact, droplet and aerosol. Therefore, appropriate PPE for droplets is mandatory to reduce the spread of COVID-19, including eye protection, either goggles or a face shield and a facemask, depending on the procedures being performed [ 14 – 18 ]. During mobile radiography, infection prevention measures include the imaging room and equipment. This must be regular cleaning and decontamination [ 19 ].

High to moderate adherence to infection control practices was shown in this study. The participants indicated good adherence to PPE during mobile radiography, with 70% always answering and 14% answering most of the time. However, no total adherence of 100% during COVID-19 cases has been shown in other studies [ 20 ].

The percentage of 2% of staff workers who indicated never using PPE could be justified either by poor practice or PPE shortage. Hand hygiene adherence was up to the international level and accepted, with 66% of the workers answering ‘always’, 24% answering ‘most of the time’, 9% answering ‘sometimes’ and only 1% stating ‘never’. Better hand hygiene adherence and performance compared to PPE adherence could be related to knowledge and risk awareness.

Only 50% of those polled said they obtained support from the radiology department, and only 24% said they received incentives throughout the pandemic. The payment system for healthcare providers was adjusted by many healthcare systems worldwide during the pandemic [ 21 ]. Personnel motivation and support are processes with significant economic and societal implications.

This work focused on radiographers’ practice during mobile radiography. We acknowledge some limitations. First, we did not collect full details of radiation and occupational dose during the COVID-19 period. Second, we investigated only the radiographer’s practice, whereas many healthcare professionals such as nurses and radiologists are involved in mobile radiography. In future studies, we plan to target a larger population, other professionals and collect qualitative data.

The delivery of medical imaging services faces tremendous challenges in an exceptional pandemic. The delivery of healthcare is continuing despite the crisis, and given the crucial role that medical imaging services play in the ongoing battle against COVID-19, the standard and safety of care are becoming increasingly crucial. The current study highlights the current level of radiographer adherence to patient safety during COVID-19, which still has room for improvement to meet its goal of complete COVID-19 eradication. Mobile radiography examinations have an essential role in diagnosing and following COVID-19 patients. Therefore, radiology personnel must have good knowledge, experience and adherence to radiation protection and infection control practices to ensure patient safety and prevent the further spread of the virus. Based on ALARA and infection control practices, such as hand hygiene and PPE, proper radiation protection measures are among the most critical infection control and prevention measures. Continuous guidance, training and follow-up are recommended to ensure increased compliance and, as a result, a decreased rate of cross-infection and probable fatalities. The health organization should invest in a variety of COVID-19 prevention initiatives, such as health education, increase community awareness, the implementation of artificial intelligence applications, and improvements to its preventative procedures, in order to achieve the highest level of patient safety during mobile radiography.

Supporting information

https://doi.org/10.1371/journal.pone.0279607.s001

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The Importance of Radiation Protection Education and Training for Medical Professionals of All Specialties

• Radiation Protection
• Published: 14 May 2021
• Volume 44 , pages 829–834, ( 2021 )

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• Agapi Ploussi 1 ,
• Efstathios P. Efstathopoulos 1 &
• Elias Brountzos   ORCID: orcid.org/0000-0002-7504-2016 2  

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The article is part of the series of articles on radiation protection. You can find further articles in the special section of the CVIR issue. Lately, more advanced techniques have been introduced in medical imaging expanding the diagnostic and therapeutic applications of ionizing radiation. Among the various strategies that have been proposed for the management of radiation exposure, education and training seem to have a strong impact on radiation protection and dose reduction. However, according to several studies, medical professionals appear to lack knowledge on basic radiation protection aspects. Therefore, the establishment of an accreditation and certification system in radiation protection for all medical professionals employing ionizing radiation is considered as high priority. The purpose of this review article is to highlight the importance of education and training in radiation protection, provide recommendations for an effective educational program and propose an educational program structure for the different medical specialties.

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Ploussi, A., Efstathopoulos, E.P. & Brountzos, E. The Importance of Radiation Protection Education and Training for Medical Professionals of All Specialties. Cardiovasc Intervent Radiol 44 , 829–834 (2021). https://doi.org/10.1007/s00270-020-02744-7

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Radiation protection among health care workers: knowledge, attitude, practice, and clinical recommendations: a systematic review

This study was performed to determine the knowledge, attitude, and practice (KAP) of health care workers (HCWs) towards radiation protection.

In this systematic review study, three international databases (Web of Science, PubMed, Scopus) were searched for related published articles in the English language from 1 January 2000 to 1 February 2020. The quality of the included studies was evaluated using the Hoy et al. tool.

Out of the 1,848 studies examined, 41 studies that were performed on 11,050 HCWs were included in the final stage. The results indicated that in most studies, more than half (50%) of the participants had average knowledge. Furthermore, 60% of the participants had a positive attitude, but in most studies, they had average practice regarding radiation protection. The most important recommendation for improving KAP among the participants was incorporating radiation protection standards in the student curriculum.

Considering the results of the study, further attention should be paid to proper education regarding radiation protection standards and improvement of HCW performance.

Introduction

Daily, healthcare workers (HCWs) are exposed to occupational contacts with various diagnostic and therapeutic radiology interventions [ 1 ]. The HCWs’ exposure to various radiology waves results in acute complications (dermatitis, mucositis, and hair loss) as well as long-term complications (cataracts, skin problems, genetic problems, and cancer) through impairment in the normal DNA functioning [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ].

Specifically, the HCWs exposed to radiation develop cancer by approximately more than 40% compared to patients and other groups [ 7 ]. To prevent the side effects of radiation, the International Radiation Protection Association (IRPA) has designed some guidelines to limit the dose received by the HCWs, and it is periodically reviewed [ 8 ], [ 9 ]. The most important method of proper radiation protection principle implementation is education [ 10 ]. Today, with the increase in the number of radiology procedures, all healthcare workers exposed to radiology waves should know how these procedures are performed and how they can better protect themselves [ 11 ], [ 12 ]. The extent of awareness of the healthcare workforce about radiation protection has a considerable impact on the proper attitude and performance regarding protection against radiology waves [ 13 ].

Current evidence suggests different results about the level of awareness, attitude, and performance of healthcare workers about radiation protection across different countries [ 14 ], [ 15 ], [ 16 ]. Further, many studies have shown that HCWs with good knowledge may lack a good attitude about radiation protection [ 17 ], [ 18 ], [ 19 ]. Also, many individual studies have found poor knowledge about radiation protection [ 14 ], [ 20 ], [ 21 ]. Precise determination of awareness, attitude, and performance of HCWs about radiation protection across different fields can help healthcare policymakers in the better management and improvement of awareness, attitude modification, and their performance. To the best of our knowledge, so far, no study has been performed in this regard and with this scope. Accordingly, this systematic review study was conducted to determine the knowledge, attitude, and practice (KAP) of healthcare workers towards radiation protection.

Materials and Methods

This systematic review study was performed based on the Cochrane book and reported using preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist [ 22 ]. A prepared protocol was used to conducting the study but was not published in English. Protocol registration was not conducted. In this study, cross-sectional studies conducted to investigate the knowledge, attitude, or practice of healthcare workers about radiation protection published in the English language was included. Review studies, letter to the editor, qualitative, and poor quality studies performed before 2000 published in non-English language were excluded. The health care workers based on included studies were included: radiologists, dentists, radiographers, medical students, surgeons, nurses, cardiologists, and anesthesiologists.

Search strategy

In this study, three international databases (Web of Science, Scopus, and PubMed) were searched from 1 January 2000 until 1 February 2020. The PubMed search strategy used for search in other databases. To develop a search strategy, a librarian specialist with an experience of working in systematic review studies was employed. The keywords were determined based on Boolean operators (AND, OR, and NOT), Medical Subject Headings (MeSH), EMTREE, and keywords in relevant studies. The keywords were: “Radiation protection”, “health care workers”, “knowledge”, “attitude”, “practice”, and “KAP”.

Selection of studies and data extraction

The search results across the databases were entered into Endnote. Next, the included studies were screened, and duplicate articles were removed. The title of the remaining studies was evaluated, and irrelevant cases were excluded. According to the inclusion criteria, the abstract of the studies was evaluated, and the relevant studies proceeded to the next stage. In the last stage, the full texts of the remaining studies were examined. Screening and selection of the studies were performed by two persons. Any disagreement between the authors was resolved by a third person. In some papers where the information was incomplete, their authors were contacted to acquire the necessary information. Extracted data items included: first author, year, country, sample size, participants, target population, age, gender, sampling method, method of data collection and risk of bias, outcome measures, knowledge, attitude, practice, and improvement recommendations.

Quality assessment

The quality studies were evaluated by Hoy et al. scale [ 23 ]. This scale included 10 items which checked the external and internal validity of studies. The quality of included studies was assessed by two researchers separately. The disagreement between researchers was resolved by the third researcher.

Study selection

A total of 1,848 articles from initial searches were retrieved in three databases. Out of 1,471 non-duplicated studies in the title and abstract screening process, 1,406 studies were excluded. Out of 65 studies, 41 had eligibility criteria. Out of 24 excluded studies, four studies were reviews, six studies had no full text, seven studies were published in a non-English language, and three studies did not meet the minimum quality requirements for inclusion in the study, and four studies were qualitative ( Figure 1 ).

Study selection process.

Study characteristics

Forty-one studies conducted on 11050 HCWs were included, which had been performed from 2002 to 2019. All of the studies were cross-sectional. The most common method of sampling was convenience sampling (n=19). In more than 98% of studies (n=40), the instrument was a researcher-made tool. In all of the studies, the information had been collected as a self-report. Most studies had a low risk of bias (n=36). The mean age of the participants had been mentioned only in 11 studies. The age range of the participants was 29.4–45 years. The studies had been conducted in 22 countries. Most of the studies had been performed in the US (n=5) and Italy (n=4) ( Table 1 ).

Knowledge, attitude, practice and recommendations for the practice among health care workers (HCWs) towards Radiation protection.

Main results

Instruments.

In most studies (n=40), the researcher-made instrument had been used for data collection. Only one study had used a standard tool. In five studies, the number of questionnaire items used was not clear. The number of items in different questionnaires ranged from 5 to 63. The content of items was different from study to study. Nevertheless, overall they examined the KAP of HCWS regarding radiation protection.

Knowledge of HCWs towards radiation protection

Out of the 41 studies, most of them (n=33, 80.4%) had examined knowledge of HCWs about radiation protection. Knowledge in different studies had been measured with various numbers of items and about different protection tools. Moreover, knowledge had been classified as poor, average, and sufficient in most studies. In the present study, the level of sufficient knowledge in the included studies was reported. The minimum level of knowledge was 2%, while the maximum was 95%. More than 50% of the participants in most studies (18 out of 33) had sufficient knowledge of radiation protection. In some studies (n=6), the level of knowledge had been mentioned as average (5.6–12.1). The level of knowledge of radiation protection among the dentists was 39.1–75.98%. For the radiologists, it was 59–95%, and among the medical students was 10–94%.

Attitude, practice, and clinical recommendations of HCWs about radiation protection

Out of the 41 studies included, six studies had examined the attitude of HCWs about radiation protection. In four studies, the level of awareness had been classified as negative and positive. The minimum level of positive attitude was 61.2%, while the maximum was 88%. The results indicated that more than 60% of the HCWs had a positive attitude about adhering to radiation protection precautions. In two studies, awareness had been reported as average (6–8.6). Out of 41 studies, 15 studies had examined the practice of HCWs about radiation protection. In 13 studies, the level of proper practice of HCWs had been mentioned. The practice in the studies had been classified as poor, average, and good, and is defined as the extent of applying protective equipment for radiation protection. The level of high practice across different studies was 14.3–99%. In most studies (n=7), HCWs had an average practice of radiation protection. In some studies, the mean score was 3.2–13.1. The most important recommendations in the included studies to enhance the KAP of HCWs regarding radiation protection were: including radiation protection topics in curricula (n=13), implementing periodic practical training course in hospitals (n = 12), providing continuing education programs (n=11), and providing sufficient radiation protective devices (n=8) ( Table 2 ).

Practical recommendations to improve nurses’ knowledge, attitude and practice towards radiation protection among health care workers (HCW S ).

The present study was performed to investigate the KAP as well as clinical recommendations of HCWs regarding radiation protection. A total of 41 studies performed on 11,050 individuals were entered into the final stage. The instrument utilized in most studies was researcher-made. The HCWs are the most relevant people dealing with daily exposure to radiology procedures. Thus, following safety rules and protection against radiation are crucial in HCWs. Regarding the knowledge, the study results showed that generally, the participants had average knowledge about radiation protection. The level of knowledge was 2–95%. Among the HCWs, radiologists had greater knowledge about standard precautions, which can be due to greater familiarity has given that they receive more education due to the nature of their profession, experience of the type of studied population, sample size as well as previous knowledge among radiologists who have more awareness in this regard. No previous study was found examining the KAP of HCWs about radiation protection using a systematic review. Nevertheless, individual studies on the general population have shown that only 24.7% of the participants had adequate knowledge about radiation protection [ 24 ], which was in contrast to the present study. This can be due to the differences in the target population, studied sample size, and examined country. Having proper knowledge about radiation protection is vital given its short-term and long-term complications [ 25 ]. The essential principles in proper knowledge are knowing the duration, distance, and use of suitable personal equipment [ 26 ], [ 27 ].

Regarding attitude, the study results showed that in most studies, more than 60% of participants had a positive attitude to radiation protection. Positive attitude Development about radiation protection leads to motivation for enhancing the knowledge; hence, more proper practice. Developing a positive attitude is time-consuming, and mostly occurs over the long run and based on experience [ 18 ]. Regarding performance, most studies revealed an average performance of HCWs concerning radiation protection. The average practice can be due to differences in the methodology, sample size, type of the target population studied, and the country where the studies had been performed. Indeed, a different approach may exist in any country for training HCWs regarding radiation protection. Further, the content of educational courses held in different countries can have a different impact on their performance. The basis for creating a proper knowledge, positive attitude, and thus, the right practice is the use of the same approach with a standard content regarding radiation protection among HCWs. Clinical guidelines prepared by the IRPA [ 28 ], and the International Society of Radiology (ISR) [ 29 ] are the best sources. Besides, the study showed that the best methods for increasing awareness, attitude, and performance of HCWs about radiology protection were as follows: including radiation protection topics in curricula (n=13), implementing periodic practical training courses in hospitals (n=12), and providing continuing education programs (n=11).

These recommendations highlight the importance of systematic and step-by-step attention to enhance HCWs awareness from the studentship period. The creation of a standard curriculum based on international standards, which is also regularly updated, is essential for the students’ curriculum. Also, after the studentship period, at the beginning of working in hospitals, again internship and practical as well as theoretical courses as in-service training are necessary to establish a proper performance atmosphere for them. It is because improper performance leads to many complications for HCWs and patients as well as increased costs incurred to the healthcare system.

Limitations and strengths

The most important limitations were as follows. All included studies were cross-sectional; thus, special limitations of these studies when interpreting the results should be considered. Also, the instruments in different studies examined special parts of precautions; thus, it was not possible to examine their awareness, attitude, and performance given the type of precaution adopted. As well as instruments had been researcher-made. Hence, it was not possible to do a meta-analysis. In some studies, the KAP had been stated in a general form. Consequently, it was not possible to examine them in terms of occupation, and only English published studies were included.

Despite the above limitations, this study had some strength as well. To the best of the authors’ knowledge, this is the first study performed in this area. Also, the standard systematic review approach and Cochrane guidelines have been used for conducting and reporting of the study. In this study, in addition to awareness, attitude, and performance of HCWs, clinical recommendations were also examined to improve KAP.

This systematic review indicted that HCWs have average knowledge, positive attitude, and average awareness towards radiation protection, respectively. This study suggests the importance of using standard clinical guidelines and approaches to prepare educational curriculum, internship education in hospitals, and educational courses in hospitals. The findings of this study can be used as a suitable guideline for HCWs especially radiology staff and healthcare policymakers.

Research funding: No funding received.

Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Informed consent: Not applicable.

Ethical approval: Not applicable.

Competing interests: Authors state no conflict of interest.

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© 2020 Razieh Behzadmehr et al., published by De Gruyter, Berlin/Boston

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Importance of establishing radiation protection culture in Radiology Department

Affiliation.

• 1 Agapi Ploussi, Efstathios P Efstathopoulos, 2 Department of Radiology, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece.
• PMID: 26981223
• PMCID: PMC4770176
• DOI: 10.4329/wjr.v8.i2.142

The increased use of ionization radiation for diagnostic and therapeutic purposes, the rapid advances in computed tomography as well as the high radiation doses delivered by interventional procedures have raised serious safety and health concerns for both patients and medical staff and have necessitated the establishment of a radiation protection culture (RPC) in every Radiology Department. RPC is a newly introduced concept. The term culture describes the combination of attitudes, beliefs, practices and rules among the professionals, staff and patients regarding to radiation protection. Most of the time, the challenge is to improve rather than to build a RPC. The establishment of a RPC requires continuing education of the staff and professional, effective communication among stakeholders of all levels and implementation of quality assurance programs. The RPC creation is being driven from the highest level. Leadership, professionals and associate societies are recognized to play a vital role in the embedding and promotion of RPC in a Medical Unit. The establishment of a RPC enables the reduction of the radiation dose, enhances radiation risk awareness, minimizes unsafe practices, and improves the quality of a radiation protection program. The purpose of this review paper is to describe the role and highlight the importance of establishing a strong RPC in Radiology Departments with an emphasis on promoting RPC in the Interventional Radiology environment.

Keywords: Interventional radiology; Radiation protection culture; Radiation safety; Radiology Department.

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Recommendations for reducing exposure to medical X-ray irradiation (Review)

Hai-min shi.

1 Department of Gynecology and Obstetrics Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, P.R. China

2 Department of Gynecology and Obstetrics Medicine, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang 310006, P.R. China

Zhi-Chao Sun

3 Department of Medical Imaging, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, P.R. China

4 Department of Medical Imaging, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang 310006, P.R. China

5 Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310006, P.R. China

6 Department of Respiratory Medicine, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang 310006, P.R. China

Associated Data

Not applicable.

With the increasing frequency of X-ray examinations in clinical medicine, public concern regarding the harm caused by exposure to X-ray radiation is also increasing. However, some physicians are not completely aware of the dangers of exposure to X-ray irradiation. Individuals specialized in this field, including physicians, have a better understanding of these dangers, which limits the use of X-rays in medicine. The present study aimed to address strategies for reducing the harm caused by exposure to medical X-rays and increase public awareness regarding X-ray radiation. Through a literature search and review, combined with the current status of clinical X-ray examination and the authors' professional experience, the present study highlights the importance of reducing X-ray exposure, and proposes several specific recommendations and measures for reducing the frequency or dose of X-ray irradiation. On the whole, the finding discussed in the present review suggest the minimal use of medical X-ray examinations and that alternative tests should be selected whenever possible. When medical X-ray screening and treatments are necessary, the risk-benefit ratio should be assessed, possibly aiming to achieve avoidable exposure. Further attention should be paid to protect sensitive glands and reduce the risks in children.

1. Introduction

On a daily basis, humans are subjected to natural background radiation ( 1-8 ), which is the largest source of human radiation exposure, with a global average dose of 2.4 mSv ( 9 ).

Medical diagnostic techniques, such as routine conventional radiography or computed tomography (CT) scans, which are also based on X-ray irradiation, are vital for the diagnosis of certain diseases. Simultaneously, the possible damage caused by radiation has attracted increasing attention and has become a subject of public concern and a potential healthcare issue ( 10 ).

X-rays are one of the most widely used forms of radiation in medical diagnosis and treatment. In the United States, 13 million patients underwent CT examinations in 1990( 11 ). This number increased to ~62 million in 2006( 12 ) and to >84 million after accounting for multiple scans in 2016( 13 ). Following the discovery of X-rays, it was found that frequent exposure experienced by physicians increased their risk of developing cancer ( 13-18 ). Studies on atomic bomb survivors ( 19-24 ) and patients with cancer receiving radiation therapy ( 25-35 ) have found that the risk of tumorigenesis is associated with acute or fractionated high-dose radiation exposure. Although opinions differ as regards the harm of low-dose radiation to the human body, the impact of low-dose radiation on cancer risk has gained scientific attention. For example, a study reported that in the United States, 1.5-2.0% of all cancers are considered to be attributable to radiation from CT scans ( 12 ). Radiation can damage DNA by direct and indirect mechanisms that may lead to cancer development ( 36 ). Direct damage is caused by breaks in the DNA molecule caused by radiation energy, while reactive species, which may be produced from the ionization of water, can induce indirect damage to the DNA molecule.

Despite the differing opinions on the exposure threshold required to induce carcinogenesis, including the risk of both single-acute dose and recurrent small-dose exposure, the most popular accepted model of cancer risk associated with radiation is a linear no-threshold dose-response curve ( 37 ). This risk model is the reason that the current guiding principle of radiation safety is ‘as low as reasonably achievable’ (ALARA), which indicates that radiation should be avoid as much as possible, even if the dose is minimal, if it has no direct benefit ( 38 ).

As numerous individuals undergo radiographic examinations each year ( 12 , 39-43 ), raising awareness concerning the risk of X-ray irradiation is particularly important ( 39 ). However, to date, at least to the best of our knowledge, no specific literature has addressed methods with which to reduce X-ray exposure in China. To fill this gap in knowledge, a literature review was conducted to discuss some practical strategies that may be applicable in China to reduce the bodily harm caused by medical X-ray exposure and to increase awareness regarding X-ray radiation.

2. Literature selection and search criteria

The present narrative review focused on reducing X-ray radiation exposure. First, based on the current status of X-ray use in clinical practice, the authors' medical knowledge and experience regarding X-ray radiation was combined with existing literature resources to outline measures and suggestions for reducing X-ray exposure. According to this outline, relevant topics in the literature were identified for the search. Various literature databases were searched, including PubMed, Web of Science, Wanfang Data and China National Knowledge Infrastructure. The Baidu search engine was also used. The present study was a review and did not require informed patient consent or ethics committee approval.

Inclusion and exclusion criteria

The selected literature was required to be published in the English or Chinese language, or translated into English, for inclusion in the study. The literature included professional medical textbooks, professional medical journals, and medical reports with content on radiographic or CT radiation. The following literature studies were excluded: Non-English and non-Chinese studies.

Literature selection

Two authors selected the literature independently, first reviewing the title and abstract, followed by selecting references for complete review, and finally including the literature deemed most suitable.

Data extraction

The authors read the titles preliminarily and selected the literature after extracting the entire text. The authors then compared and discussed the selected items. For the literature screened, those items for which an agreement could not be reached, were discussed and excluded.

3. The importance of reducing X-ray exposure

The harmful effects of X-ray radiation exposure, such as cancer induction, have been well established ( 12 ). As aforementioned, in the United States, 1.5-2.0% of all cancers are considered to be attributable to radiation from CT scans ( 12 ). According to the Chinese National Central Cancer Registry, the average incidence of cancer in the Chinese population is 285.91/100,000 (317.97/100,000 for males and 253.09/100,000 for females), with an average mortality rate of 80.54/100,000 (224.20/100,000 for males and 135.85/100,000 for females). These values suggest that the Chinese population may be one of the highest risk groups for cancer worldwide ( 44 ). Hence, further focus on the rational use of X-rays and the prevention of harm caused by medical X-ray radiation is warranted.

Medical X-ray use needs to be economized to reduce risks associated with radiation exposure. The aim of the present study was to propose methods with which to reduce unnecessary radiation exposure based on the authors' professional experience and to promote the dissemination of scientific knowledge throughout medical staff and the general public.

4. Specific recommendations and measures for reducing X-ray radiation exposure

Specific recommendations and measures for reducing unnecessary exposure to medical X-ray radiation are presented in Table I .

Measures suggested for the reduction of medical X-ray radiation.

Enhancing medical knowledge and education regarding radiation within the general population (including physicians) Radiologists and technicians require comprehensive knowledge of radiation hazards

Radiologists and technicians perform radiographic examinations of patients. Their understanding of radiation hazards involves the following: The radiation doses that patients receive; radiation protection for patients, themselves, and those in the vicinity while a scan is ongoing; scientific recommendations for clinicians; and the education of clinicians and patients regarding radiology. This also affects their self-preservation. The International Commission on Radiological Protection advises that the occupational dose limit for radiation exposure should be 100 mSv over a period of 5 years, with a maximum of 50 mSv in any single year ( 45 ). According to a survey performed in Saudi Arabia, a number of radiologists have limited knowledge regarding the harmfulness and carcinogenicity of X-ray radiation ( 46 ). The same study found that only 65±13.5% of radiologists had clearer comprehension of the carcinogenicity of CT scans than the patient ( 46 ). Approximately 80% of radiologists presumed that CT scans were associated with an elevated risk of developing cancer; however, only 56.5, 48.5 and 65% of the radiologists were aware of the specific risks from radiation involved in the head, chest and abdominal pediatric examinations, respectively ( 46 ). Regular, frequent and specific training courses are suggested to improve the fundamental knowledge of radiologists and other physicians regarding radiation exposure from CT scans ( 46 ). It is thus suggested that the further training of radiologists, technicians and other medical professionals may also be required in China.

The knowledge of general healthcare workers about radiation hazards needs to be enhanced

Medical staff provide care to patients, prescriptions for radiological examinations and protective care during examinations. Hence, they should have extensive knowledge of the harmful effects of radiation. Radiology should be applied only when necessary, and appropriate protection must be provided to the patient. From a radiologist's perspective, unnecessary radiological examinations occur due to insufficient knowledge and training of physicians when referring patients for radiological examinations, according to previous a study conducted in Pakistan ( 47 ). Physicians in different countries may have varying degrees of understanding of the radiological hazards; however, all physicians must enhance their training and education in radiological protection.

Patients and the public need to be provided with more information regarding radiation hazards

Individuals may require medical X-ray examinations or may be exposed to radiation from other sources during their lifetimes. Further knowledge in this area will help individuals avoid unnecessary radiation sources, including unnecessary screenings or higher-than-necessary radiation doses during screenings.

Reducing excessive radiation doses in screenings

The use of appropriate doses is required to minimize the radiation exposure from each X-ray examination. It has been demonstrated that the radiation dose is proportional to the risk of developing tumors ( 40 ). The radiation doses differ depending on the target body parts, the body part being examined and scan parameters, such as kilovoltage (kVp), tube current (mA), slice thickness (mm), examination type, volume CT dose index, dose-length product and scan model ( 15 ). For routine conventional radiography, digital X-ray equipment is used, which has high detective quantum efficiency detectors, uses special image-processing and noise-reduction software, and optimizes the exposure chart with detectors which can reduce the radiation dose ( 48 , 49 ). For CT scans, there are several techniques, including the reduction of tube voltage, the use of dual-source CT for high-pitch helical scanning, modulation of the tube current and optimization of the scan length which have been used to reduce radiation doses ( 50 ). For example, a previous study found that by reducing the peak potential from 120 to 80 kVp, multidetector-row computed tomography may reduce the effective radiation dose by 68.58% and can maintain uncompromising image quality in pediatric neck CT examinations ( 51 ). Another study demonstrated that automatic current selection setup was more effective than the fix tube current according to the ALARA principle. These findings suggest that the automatic current selection with iterative reconstruction technique can reduce the effective dose to an average of 0.71 mSv (reduction of radiation dose by ~50%), whereas it can maintain an image quality comparable to that obtained with the fixed-tube-current of 35 mAs with iterative reconstruction technique in individuals with a normal body mass index ( 52 ). It is noteworthy that different organs have different risks of radiation-induced cancer. For example, the extremities have a low risk of radiation-induced carcinogenesis, whereas solid organs, including the lungs, and particularly glandular organs, such as the thyroid and mammary glands, have a much higher risk ( 45 ). The same exposed body part may even receive varying radiation doses depending on the effective dose when undergoing a CT scan ( 53-55 ). To reduce the harm of radiation to the human body, the dose in each X-ray examination needs to be minimized. Therefore, X-ray device settings are crucial as they directly relate to the amount of radiation dose.

Reduction of unnecessary radiation exposure Alternative techniques, such as magnetic resonance imaging or ultrasonography, should be used whenever possible

In 2016, radiographic examinations and CT scans were performed for 42,027,701 (523 per 1,000) and 17,897,944 (223 per 1,000) individuals, respectively, in Jiangsu Province, China ( 39 ). In light of the large numbers of radiographic and CT studies being performed, other methods, such as magnetic resonance imaging and ultrasonography, need to be considered whenever possible to reduce X-ray radiation exposure.

For patients requiring follow-up scans, the follow-up duration should be extended whenever possible

Diseases, such as lung cancer or infections, often require re-examination post-treatment; therefore, when conducting radiological re-examinations, the risk-benefit ratio should be weighed, and a radiological review should be conducted as late as possible while still meeting the clinical requirements. Frequent and inappropriate re-examinations may increase radiation-related risks in patients. We should strengthen the training and test of medical professionals with the authority to prescribe radiology, which may maximally change practice among medical professionals.

Increasing protection when performing radiological studies Increasing protection for non-inspected body parts

During radiological examinations and treatments, it is recommended that only the areas necessary for inspection are exposed. Particular attention should be paid to protect children and sensitive glands, such as the thyroid ( 54 ). Children are the most radiosensitive subgroup, with a lifetime risk of developing cancer induced by radiation exposure two or three times higher than that in the general population ( 45 ).

Radiology examination and treatment rooms should comply with protective requirements

Radiological examination and treatment rooms receive numerous patients daily. The radiation hazards to outside personnel should be monitored. There is a significant risk of occupational exposure if protection requirements are not met.

For bedside or other mobile inspections, protective measures should be taken, including the protection of surrounding personnel

Radiological studies may be performed in an operating room or ward. However, these areas often lack adequate protection systems. Therefore, radiation damage is likely to affect medical personnel or other people in such environments ( 56 ). The protection of these individuals should be prioritized.

Development of helpful information technology

A patient's radiology images in one hospital can be used easily and safely in another hospital, thereby reducing unnecessarily repeated tests. Due to high mobility rates in the Chinese population, patients have the option to pursue quality medical care and tend to move from one hospital to another or from one city to another. During this process, if radiology data are lost or if the data obtained in a previous radiology examination are not adequately clear, the patient may require additional scans. Therefore, it is crucial to develop robust information technology networks whereby patients can retain high-quality imaging data available in different hospitals and avoid unnecessary, repeated radiological tests.

Establishing social guidance Reducing repeated and unnecessary radiological screenings for occupational entry purposes or admission to academic institutions

As is known in China, for certain entry-level reasons, radiological examinations are often performed to assess the fitness of a candidate in China. However, in some cases, if a candidate has undergone a recent scan, an additional scan is not required for the entry examination. Certain entry level requirements include the irrational request of asking healthy, young job seekers to obtain a CT scan, which could easily be replaced by a conventional, routine radiological examination. A CT scan has effective radiation doses that may be 5-20-fold higher than those of routine conventional radiology ( 57 ). There are several radiological assessments for occupational entry purposes or for entry into academic institutions each year, and unreasonable or unnecessary examinations should be minimized.

Reducing unnecessary and unreasonable radiological check-ups due to health-benefit packages

As is known in China, a number of employers offer annual health check-ups, which often include a routine chest radiography or chest CT scan. However, it is not necessary for all individuals to undergo such an annual radiological examination, particularly if they are young and healthy. However, owing to the lack of knowledge regarding radiation, a number of individuals choose free radiological screenings without considering the actual risk-benefit ratio.

Building a more trusting relationship between doctors and patients

A trusting doctor-patient relationship helps physicians make more confident, reasonable, and scientifically sound decisions as regards the use of radiation. The physician-patient relationship in China is an important topic ( 58 ). A healthy physician-patient relationship, based on trust, will facilitate physicians in making proper scientific decisions. Theoretically, if the physician-patient relationship is unhealthy or not trustworthy, the physician may then inappropriately apply radiology due to excessive concern for misdiagnosis.

Strengthening of scientific analysis and management of radiation applications

The scientific analysis of the rationality of radiation prescription benefits management. It is beneficial to analyze the rationality of radiation applications in medical management, including justification of examination types, doses, intervals between examinations, and whether an alternative examination can be selected, which is conducive to further scientific radiation application in the future. The over-prescription of X-rays causes the misuse of medical resources and increases the risk of radiation-induced cancers ( 12 ), thereby exerting serious economic burden on patients and society.

Special attention should be paid to the radiation-sensitive population

Women, children and patients with previous tumors may be more sensitive to radiation damage and may require special attention. Females have a higher risk of developing cancer induced by radiation than males. This may be attributed to the increased risk of thyroid and breast cancers in women. In addition, the effects of estrogen and cytochrome P450 enzymes may promote radiocarcinogenesis in women ( 59 , 60 ). Children are more sensitive to radiation damage than the general population. Patients with tumors are more sensitive to X-ray radiation injury than the general population and require special consideration ( 61 ). Older adults have reduced organ function and less actively dividing cells compared with children, and they have a shorter lifespan, which is the reason why older adults have a lower risk of most of the radiation-induced cancers ( 45 ).

With the increase in the average life expectancy and with the improvement of medical conditions in China ( 62 ), as well as the increasing number of health check-ups, individuals have increased opportunities to undergo medical X-ray examinations throughout their lives. Therefore, the cumulative effects of radiation on individuals should also be considered.

Enhanced establishment and dissemination of radiological protection guidelines, consensuses and laws

Radiological protection guidelines, consensuses and laws can guide medical workers and the general population in using radiological examinations and therapy more rationally. Currently, in China, laws and regulations, such as ‘Law of the People's Republic of China on Prevention and Control of Radioactive Pollution’ ( www.gov.cn/bumenfuwu/2012-11/13/content_2601283.htm ), ‘Regulations of the People's Republic of China on Health Protection of Medical Treatment X-ray’ ( http://www.law-lib.com/law/law_view.asp?id=2158 ), ‘Basic Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources’ ( http://www.nirp.cn/userfiles/file/GB18871-2002.pdf ), and others, which are critical for medical X-ray radiation exposure protection, are in place. The aforementioned laws and regulations put forward basic requirements and principles for the use and protection of radioactive radiation, including medical X-radiation. Therefore, these laws and regulations need to be followed. The establishment and dissemination of radiological protection guidelines, consensuses and laws needs to be strengthened. Relevant guidelines should establish dose standards for various radiological examinations or therapy techniques, with updates as techniques develop. There should also be a consensus regarding the dose standards. Professional personnel involved in radiological protection can further strengthen their pre-job training. This is crucial in order to improve general awareness of radiation protection. Medical physicists and radiobiologists should strengthen the training of medical staff and the dissemination of scientific knowledge among the general population. At the same time, the importance of departmental record keeping needs to be emphasized, as it is beneficial for scientific research and helps physicians better understand the dangers of radiation.

5. Conclusions and future perspectives

The authors acknowledge that the present review has several limitations. The present review was based on the authors' professional experience and primary understanding of radiation, and some suggestions are put forward in combination with ideas from the literature, which may not be well-rounded.

In the present study, it is emphasized that the intention was not to prescribe dose limits and constraints for individual patients, as these may cause more harm than good by reducing the effectiveness for a particular diagnosis or treatment ( 45 ). Instead, the present study aims to emphasize the legitimacy and optimization of medical procedures, and the application of diagnostic reference levels to diagnostic procedures ( 45 ).

In conclusion, the use of medical X-ray examinations needs to be minimized, and alternative tests should be used whenever possible. If medical X-ray screening and treatment are necessary, the risk-benefit ratio should be weighed to determine the most effective dose, while protecting other areas from avoidable exposure. Particular attention should be paid to the increased radiation risk in children and the protection of sensitive glands ( 45 , 54 ).

Acknowledgements

Funding statement.

Funding: The present study was supported by Zhejiang Provincial Natural Science Foundation of China (grant no. LY18H270011) and Zhejiang Chinese Medical University (grant no. KC201928).

Availability of data and materials

Authors' contributions.

HMS and FHJ performed the analysis, including the literature selection and search. HMS and ZCS were involved in the writing of the original draft. FHJ was involved in the writing, reviewing and editing of the manuscript. All authors have read and approved the final manuscript. Data authentication is not applicable.

Ethics approval and consent to participate

Patient consent for publication, competing interests.

The authors declare that they have no competing interests.

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