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Radiation Protection: What Does Your EP Program Use?

Compilation by Jodie Elrod

Compilation by Jodie Elrod

For this article, we asked various EP programs about what they use for radiation protection for lab staff. Providing their thoughts are Koroush Khalighi, MD, FACC, FACP, FHRS, CPE and Lori Jones, RN, BSN, RCIS, Director of Cardiovascular Services, from Easton Hospital in Easton, Pennsylvania; Steven Higgins, MD, Director of Cardiac EP, Scripps Health in La Jolla, California; Kristi Ramsey, BSN, RCIS, CVRN, Permanent Charge Nurse, from Medical Center of the Rockies in Loveland, Colorado; Devin Maher, RN, BSN, Clinical Supervisor, from French Hospital Medical Center in San Luis Obispo, California; Roxanne Gardner, Chief Electrophysiology Technologist, from Methodist University Hospital in Memphis, Tennessee; Esam Baryun, MD from St. Mary’s Medical Center in Huntington, West Virginia; and Stacy Shelto-Smith, RT(R), RCIS, MS from Concord Hospital in Concord, New Hampshire.

What type(s) of radiation protective shielding, aprons, eyewear, skullcaps, and technology does your EP program use?

Easton Hospital: Our hospital takes radiation protection very seriously for patients, physicians, and staff during procedures that require fluoroscopy. All staff wear protective lead aprons, including thyroid shielding and lead glasses. In the past, we have used several vendors for lead aprons and glasses, including Lite Tech, Inc. and Burlington Medical. We purchased lead aprons from Merry X-Ray, Bar Ray, and AADCO Medical, Inc. We have a new vendor, Infab Corporation, for future purchases.
A Zero-Gravity radiation protection system (BIOTRONIK) was chosen to increase whole-body radiation protection for our physicians as well as eliminate the weight of lead aprons during prolonged electrophysiology procedures.
When choosing equipment for our new EP lab, radiation protection figured into the decision. We chose the AlluraClarity with Clarity IQ technology (Philips). The system allows us to obtain excellent quality images with a more than 50% reduction in radiation exposure. The AlluraClarity technology also decreases scatter radiation, thereby reducing long-term health risks for physicians and staff. In addition, by reducing the x-ray dose, it also enables longer procedures to treat obese patients.
In general, the best way to protect against radiation is to minimize fluoroscopy time. In our EP lab, we use the CARTOUNIVU Module (Biosense Webster, Inc., a Johnson & Johnson company) to minimize fluoroscopy time. This technology allows integration of 3D mapping with real-time fluoroscopic imaging. Using this technology allows us to reduce fluoroscopy by greater than 50%.
Scripps Health: At Scripps, we have many options for radiation protection. This includes the standard lead aprons, thyroid collars, available eyewear, and skullcaps. We also use a lead drape attached to the table edge as well as two mobile shields in each lab. This includes a 6x3 foot mobile acrylic glass shield for use at the head by the anesthesiologist (who also wears a lead apron) and a ceiling-mounted protective shield (MAVIG), made of lead acrylic, for use by the operator.
In addition, we have purchased two mobile Zero-Gravity units this year for use in any of our 6 EP labs. These floor-mounted units provide radiation protection as well as orthopedic benefits from wearing traditional lead aprons. 
Medical Center of the Rockies: All of our EP labs have the following for radiation shielding and protection:
  1. Movable lower procedural table lead (from Philips) that can be placed on either side of the table or both sides if needed;
  2. A movable shield (Philips) attached by arm from the upper table to protect from the image intensifier;
  3. Each room has at least one if not two mobile 6-foot lead shields.
  4. All of our staff has been fitted for their own 2-piece lead aprons that are checked at least yearly;
  5. All staff has access to lead glasses (Infab Corporation), and a few have their very own;
  6. All of our rooms have accommodations for lower EP levels of 3.75 frames per second (fps) (Philips);
  7. All staff is asked to wear radiation film badges (Landauer). New ones are sent monthly;
  8. All staff is required to take a yearly competency on radiation safety;
  9. Hats, masks, and booties are all available for personal protection as the case requires.
  10. In the past 12 months, we have focused on increased staff education as well as easier access to exposure reports by having our own tracking group (rather than being part of the one for the whole region). This has shown significant improvement with the timeliness of the reports.
French Hospital Medical Center: We use lead glasses, aprons, skullcaps, moveable shields, and a shield that hangs off the EP lab table. We are going to be implementing the Bleeper Radiation Monitor (Fluke Biomedical), which we hope to get this September. 
Methodist University Hospital: In our lab, we use a variety of radiation protective devices. Staff members can choose to wear a 1- or 2-piece lead apron (Burlington Medical). Our physicians have also started wearing lead skull caps (Burlington Medical) and eyewear (AADCO Medical, Inc.). Some of our physicians use a lead skirt (GE Medical) on the procedure table as well. We are considering the potential role of using a frame-mounted overhead lead shield (AliMed) for complex ablation procedures in which fluoroscopy is still helpful for optimal safety and periprocedural efficacy. 
St. Mary’s Medical Center: We have always made radiation safety a priority. The EP program uses Zero-Gravity, a suspended radiation protection system from BIOTRONIK. We have one in each of our 3 EP labs. We also use ProGuard RR radiographic protection gloves (Protech Medical) and the latest 3D mapping technology, which has helped us minimize the use of fluoroscopy. For some procedures, RADPADs (Worldwide Innovations & Technologies, Inc.) are selectively used.
Concord Hospital: Our EP program uses the ALARA (As Low As Reasonably Achievable) principle to manage both patient and staff safety while administering radiation during electrophysiology procedures. All personnel in the procedure room wear protective lead aprons (Burlington Medical). The electrophysiologist and scrub assistant wear lead glasses for eye protection (Burlington Medical). Staff members use personal dosimeters (Mirion) to measure the amount of radiation exposure they receive, and these are monitored on a monthly basis. Positioning of additional ceiling-mounted lead shields (MAVIG) and RADPADs are utilized to reduce scatter radiation. Imaging equipment (Philips) techniques are defaulted to fluoro/cine 7.5 f/s, low detail, and we can adjust the techniques based on image quality. The use of ultrasound (GE) for vascular access and transseptal approaches has significantly helped reduce radiation levels by using less fluoroscopy. The use of EP mapping systems (EnSite by Abbott, and CARTO by Biosense Webster, Inc., a Johnson & Johnson company) has been integral in reducing both the use of fluoroscopy and the risk of radiation to both staff and patients.

How long has your EP program been using these radiation protection technologies?

Easton Hospital: The new Philips EP lab with AlluraClarity technology opened in July 2016, which is also when the Zero-Gravity system was purchased. The CARTOUNIVU technology was installed at the same time.
Medical Center of the Rockies: Our EP lab opened in February 2007 with a Philips biplane and the lower level of 3.75 fps. In 2016, we opened a second fully dedicated EP lab with newer technologies and better imaging capabilities and decreased exposure levels (still with 3.75 fps). All other radiation measures have been instituted since 2014.
French Hospital Medical Center: We have been using these technologies since our inception.
Methodist University Hospital: Our program has always used lead skirts on the procedure table, lead aprons, and lead eyeglasses, but our physicians have only recently started wearing the lead skullcaps.
St. Mary’s Medical Center: We have been using Zero-Gravity for 3 years. Before that, we were solely using traditional caps, glasses, smocks, and skirts, which we think are quite burdensome in comparison. We made sure Zero-Gravity was available in our new EP lab.
Concord Hospital: Our EP program has been using these devices since our lab opened in 2010.

Why were these radiation protection technologies chosen?

Easton Hospital: We want to protect our patients and staff members from exposure to radiation. The AlluraClarity and CARTOUNIVU systems allow us to decrease both overall time and the dose of radiation exposure for everyone in the EP procedure room. Cumulative radiation exposure for patients will also be tracked in the future. The Zero-Gravity system was chosen to eliminate the heavy weight of lead aprons during long procedures while providing excellent radiation protection.
Scripps Health: The Zero-Gravity purchase was a result of physician requests. In particular, younger EP physicians have recognized the lifelong risks of radiation as well as orthopedic injuries, and have become proactive with requests for products that should improve safety for physicians and staff. In 2014, I gave a presentation at the Heart Rhythm conference discussing these concerns, citing one paper that found a sixfold increased risk of brain cancer on the left brain among interventionalists (Roguin A, SOLACI 2014). 
Medical Center of the Rockies: Our labs in general are very proactive when it comes to radiation safety for ourselves and our patients. Our radiation physicist is very active in communication with our teams. We have been recording air kerma and dosing of patients for many years now, long before the state of Colorado required it. We have also upgraded to the Philips AlluraClarity technology in other rooms, which we have found has decreased exposure by 40-50%.
French Hospital Medical Center: They were chosen to maximize radiation protection of our patients and staff.
Methodist University Hospital: They were chosen so that the staff could get the least amount of radiation as possible.
St. Mary’s Medical Center: We chose to use Zero-Gravity because it provides superior protection in a single piece of equipment and enables remarkable freedom of movement during procedures. Most importantly, Zero-Gravity eliminates the weight burden of traditional protective shielding, which we know is proven to have long-term health consequences for physicians. St. Mary’s supports workplace wellness, and their decision to use Zero-Gravity shows me and my EP colleagues that our employer cares about our health and safety. Our lab is busy, so having Zero-Gravity technology also improves our efficiency as healthcare providers because it reduces fatigue.
Concord Hospital: The radiation protection technologies used here were chosen based on recommendations from the radiation safety committee and physician preferences.

In what ways are these technologies and equipment effective or beneficial?

Easton Hospital: The technologies are beneficial because they protect our patients, staff, and physicians from the harmful effects of radiation exposure. Radiation has known potential carcinogenic effects. Other potential health risks of chronic radiation exposure are cognitive dysfunction, atherosclerosis, and cataracts, among other untoward effects. Wearing heavy protective lead aprons may cause various orthopedic injuries. The Zero-Gravity system helps protect the physicians while avoiding repetitive injuries from wearing lead aprons. The radiation exposure was compared to the same amount of fluoroscopic time in our old lab versus in our new lab. Radiation exposure (mGys) was reduced by about tenfold (90% reduction) — a significant reduction.
Scripps Health: In addition to protective barriers, we have instituted a radiation reduction plan we euphemistically call TPCC, which stands for Table (raise the table, lower detector panel), Protocol (use the lowest possible frame rate of 3.75 or 7.5 frames/sec), Collimate (cone down the fluoro image), and Cine (actually, no cineangiography, instead using stored fluoroscopy imaging). Unfortunately, the benefit of radiation reduction is very difficult to measure, as it may take a lifetime to determine a reduction in orthopedic or neoplastic complications. 
Medical Center of the Rockies: These technologies are very beneficial, as they allow for significantly less risk to both patients and staff in the total amount of radiation a person receives over his or her lifetime. Harm from significant levels of radiation exposure can cause cancers and non-healing wounds; staff can also experience back problems from wearing heavy lead. The advancements in this area are greatly noticed, including the newer and lighter lead that still gives great protection. If you don’t look after your own health by being proactive in radiation safety, then don’t be surprised when you’re older and have a plethora of issues because you chose to ignore the basic safety precautions!
French Hospital Medical Center: Hopefully, the technologies not only protect the patient and the staff from harmful radiation, but also give feedback to the fluoroscopy operator about x-ray scatter. 
Methodist University Hospital: The benefits of these technologies is that they limit the amount of radiation that a staff member is exposed to, reducing the chance of a staff member getting certain cancers or eye diseases.
St. Mary’s Medical Center: Zero-Gravity minimizes risk by protecting my mind and body from dangerous radiation and weight-induced strain, circumventing the host of long-term effects caused by radiation exposure and heavy lead. Zero-Gravity offers better radiation protection than traditional equipment, and carries all the weight of the apron. I believe its protection of the head and neck is far superior to any of the other shields available.
Concord Hospital: These radiation protection technologies have been effective for our institution by reducing radiation exposure and protecting patients and staff. This is seen through extensive monitoring of radiation badges and patient dose levels.

How have these technologies changed the way you do procedures?

Easton Hospital: This new technology allows us to perform procedures with much less radiation exposure to the patients, which minimizes the risk of the procedures. We have greater quality images and a significant reduction in radiation exposure in our new EP lab compared to our old one. It makes for a smoother and quicker procedure, and it potentially minimizes complications.

Scripps Health: The attention to radiation risks has impacted the behavior of both our physicians and staff. In a team approach, we all strive to diminish radiation usage and maximize protection.
Medical Center of the Rockies: The area of radiation safety will continue to grow in technology. Leaded eyewear will continue to get lighter, and film badges will give more instant resulting or be easier for the user to keep and accommodate. Lighter lead aprons will come, and the advancements in imaging equipment will become so advanced that less and less scatter will occur, causing less threat to everyone. There is currently a team looking into other ways to improve radiation monitoring.  
French Hospital Medical Center: We have developed strategies to reduce fluoroscopy times based on feedback that we receive from our dosimetry reports. Based on these dosimetry reports, we have strategically placed additional lead shielding and have found ways of limiting the amount of time that we use fluoroscopy. 
Methodist University Hospital: They have allowed us to get a little closer to the x-ray equipment during certain procedures versus having to do some procedures from the control room. We are also increasingly depending more on electroanatomic mapping during ablation procedures.
St. Mary’s Medical Center: I no longer have to put on multiple pieces of protective equipment before a procedure, because I can step into Zero-Gravity and be well protected. This saves us time and energy. There is a learning curve, however. The suspension system and navigation within the apron took a little getting used to at first, but I was ready to adopt it knowing Zero-Gravity will protect my well-being and prolong my career.
Concord Hospital: The field of electrophysiology is evolving; we now rely on other imaging modalities such as EP mapping systems and ultrasound rather than using fluoroscopy. As a result of these alternate resources, we have successfully and significantly reduced our radiation exposure dosages to patients and staff by reducing the use of ionizing radiation.