The hazard of scattered radiation in a trauma intensive care unit

OBJECTIVE: Patients admitted to the trauma intensive care unit (TICU) often require bedside imaging procedures such as radiographs, fluoroscopic placement of enteral feeding tubes, and insertion of vena cava filters. The potential for scattered radiation exposure is a concern to healthcare workers. Our study's purpose was to measure the level of scattered ionizing radiation present in a TICU. DESIGN AND SETTING: This prospective study was conducted over 3 months in an open-design, ten-bed TICU of a Level I trauma center. INTERVENTIONS AND MEASUREMENTS: Fifteen dosimeters were placed in selected areas of the TICU to measure the amount of scattered radiation present. Standard radiation protection precautions were used throughout the study period. At the end of each month, data from the dosimeters were sent to the manufacturer for analysis. MAIN RESULTS: One thousand seventy-four radiologic studies were performed at the bedside during the study period (803 portable chest radiographs, 103 abdominal radiographs, 303 extremity radiographs, 223 spine radiographs, and 15 fluoroscopic procedures). Dosimetry analysis showed <5 mrem (1/1000 roentgen equivalent in man) scattered radiation per month (<60 mrem/year) in each of the monitored areas. All monitored areas measured <2 mrem per week of scattered radiation when adjusted for occupancy. CONCLUSIONS: The level of scattered radiation in our TICU is less than the recommended allowable exposure of <100 mrem/year, indicating that radiation exposure is not a significant occupational hazard in our TICU, even in the setting of frequent use of bedside imaging studies.     

Interventional musculoskeletal ultrasonography: Precautions and contraindications

In recent years ultrasonography (US) has emerged as the imaging technique of choice for guiding diagnostic and therapeutic procedures including those related to the musculoskeletal system. However, the absence of ionizing radiation and the elevated safety of the method must not lead us to forget that there are precautions and contraindications to keep in mind, which are crucial to the protection of both the patient and the physician.Among these precautions it is first of all essential to obtain the patient’s accurate clinical history including current medication, particularly if it involves drugs influencing the blood clotting, and information related to possible allergies. The patient should furthermore receive detailed information concerning the procedure (sterile precautions as well as possible side-effects of the drugs which will be injected). In addition to this, there must be a close contact between the radiologist and the patient’s general physician (GP) in order to obtain the best possible result of the procedure.     

Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation

MACLE, L., et al. : Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation. RF catheter ablation of paroxysmal atrial fibrillation (PAF) is associated with prolonged fluoroscopy. The procedural duration and fluoroscopic exposure to patients and medical staff were recorded and compared among 43 ablation procedures for PAF, 20 for common atrial flutter, and 16 for accessory pathways. Patient radiation exposure was measured by dosimeters placed over the xyphoid, while that of physicians and nurses was measured by dosimeters placed outside and inside the lead apron. The mean fluoroscopy time was   57 ± 30   minutes for PAF,   20 ± 10   minutes for common flutter, and   22 ± 21   minutes for accessory pathway ablation. The patient median radiation exposure was 1110μSv for PAF, compared with 500 μSv for common flutter and 560 μSv for accessory pathway ablation (P < 0.01). The median radiation exposure to physician and nurse inside the lead apron were, respectively, 2 μSv and 3 μSv for PAF, 1 μSv and 2 μSv for common flutter, and <0.5 μSv and 3 μSv for accessory pathway ablations. RF catheter ablation for PAF was associated with prolonged fluoroscopy times and a twofold higher radiation exposure to the patient and physician compared with other ablation procedures. Assuming 300 procedures/year, radiation exposure to the medical staff was below the upper recommended annual dose limit. (PACE 2003; 26[Pt. II]:288–291)     

The American Society of Anesthesiologists' national endorsement program for simulation centers

Anesthesiologists pioneered the use of simulation for health care years ago, and expanded the use of the technology in the 1980s and 1990s. Now, the American Society of Anesthesiologists is supporting an accreditation process for simulation programs to ensure that practicing anesthesiologists and their patients benefit from innovative, experiential training that has the potential to improve care and foster a higher level of patient safety. The development of this accreditation process is discussed along with its anticipated benefits.     

Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use in these complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.     

Simulator training to minimize ionizing radiation exposure in the catheterization laboratory

To learn about radiation and how to lower it. Patients and operators are routinely exposed to high doses of ionizing radiation during catheterization procedures. This increased exposure to ionizing radiation is partially due to a lack of awareness to the effects of ionizing radiation, and lack of knowledge on the distribution and behavior of scattered radiation. A simulator, which incorporates data on scattered ionizing radiation, was built based on multiple phantom measurements and used for teaching radiation safety. The validity of the simulator was confirmed in three catheterization laboratories and tested by 20 interventional cardiologists. All evaluators were tested by an objective knowledge examination before, immediately following, and 12 weeks after simulator-based learning and training. A subjective Likert questionnaire on satisfaction with simulation-based learning and training was also completed. The 20 evaluators learned and retained the knowledge that they gained from using the simulator: the average scores of the knowledge examination pre-simulator training was 54?±?15% (mean?±?standard deviation), and this score significantly increased after training to 94?±?10% (p?<?0.001). The evaluators also reported high levels of satisfaction following simulation-based learning and training according to the results of the subjective Likert questionnaire. Simulators can be used to train cardiology staff and fellows and to further educate experienced personnel on radiation safety. As a result of simulator training, the operator gains knowledge, which can then be applied in the catheterization laboratory in order to reduce radiation doses to the patient and to the operator, thereby improving the safety of the intervention.     

临床护理人员标准防护措施实施状况分析

目的：对临床护理人员标准防护措施实施状况进行描述。方法：采用问卷调查方法抽样调查了北京市某三级甲等医院142名临床护理人员标准防护措施的实施状况。结果：临床护理人员标准防护措施实施状况不好。标准防护措施各个层面、各单项要求执行的偏差较大。结论；对临床护理人员进行标准防护措施的有效培训、提高遵从率十分必要。     

MR fluoroscopy in vascular and cardiac interventions (review)

Vascular and cardiac disease remains a leading cause of morbidity and mortality in developed and emerging countries. Vascular and cardiac interventions require extensive fluoroscopic guidance to navigate endovascular catheters. X-ray fluoroscopy is considered the current modality for real time imaging. It provides excellent spatial and temporal resolution, but is limited by exposure of patients and staff to ionizing radiation, poor soft tissue characterization and lack of quantitative physiologic information. MR fluoroscopy has been introduced with substantial progress during the last decade. Clinical and experimental studies performed under MR fluoroscopy have indicated the suitability of this modality for: delivery of ASD closure, aortic valves, and endovascular stents (aortic, carotid, iliac, renal arteries, inferior vena cava). It aids in performing ablation, creation of hepatic shunts and local delivery of therapies. Development of more MR compatible equipment and devices will widen the applications of MR-guided procedures. At post-intervention, MR imaging aids in assessing the efficacy of therapies, success of interventions. It also provides information on vascular flow and cardiac morphology, function, perfusion and viability. MR fluoroscopy has the potential to form the basis for minimally invasive image–guided surgeries that offer improved patient management and cost effectiveness.     

Radiation exposure of the spinal interventionalist performing fluoroscopically guided lumbar transforaminal epidural steroid injections

OBJECTIVE: To evaluate radiation exposure to spinal interventionalists while performing transforaminal epidural steroid injections (TFESIs). DESIGN: Prospective study. SETTING: Multidisciplinary spine center. PARTICIPANTS: One hundred consecutive patients with either herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS). INTERVENTION: Fluroscopically guided lumbar TFESIs. MAIN OUTCOME MEASURE: Radiation exposure was monitored by radiography technologists who allocated 4 dosimetry badges to all spinal interventionalists performing fluroscopically guided lumbar TFESIs on patients being treated for radicular pain. Badges were placed on the ring finger, glasses, and the inside and outside of the lead apron worn by the interventionalists. The radiography technologists also wore marked badges outside their lead aprons. One control badge was placed 67in away from the fluoroscopy table and a second badge was placed in a desk more than 500ft away from the procedure to monitor ambient radiation. RESULTS: The average fluoroscopy time per procedure was 15.16 seconds. The average exposure per procedure was 0.7mrem at the ring badge, 0.4mrem at the glasses badge, and 0.3mrem at the outside apron badge. No radiation was detectable at the inside apron or at the outside room control badge. The cumulative exposure to the interventionalists from all 100 procedures was 70mrem at the ring badge, 40mrem at the glasses badge, and 30mrem at the outside apron badge. The radiography technologists' average exposure during these procedures was below the limit of detectablility. Radiation time under fluoroscopy ranged from 5 to 38 seconds. The interventionalist's exposure to radiation was significantly greater during procedures conducted on patients with LSS then during procedures on patients with HNP. CONCLUSION: Adhering to a radiation safety program that includes maximizing the distance the spinal interventionalist is from the radiation source, decreasing exposure time, and proper shielding is essential when performing fluoroscopically guided lumbar TFESIs. Our study shows that exposure to radiation of the spinal interventionalist performing fluoroscopically guided lumbar TFESIs was well within safety limits when proper techniques were followed.     

Risk of Radiation Induced Skin Injuries from Arrhythmia Ablation Procedures

Catheter guided ablation of cardiac arrhythmias is an effective and safe procedure for the treatment of most supraventricular and selected ventricular tachycardias. Because catheter manipulation is fluoroscopically guided, there is risk of radiation induced injury, especially during prolonged procedures. The Food and Drug Administration has recently issued a bulletin warning of the risks of acute skin injury occurring during fluoroscopically guided procedures that result in an exposure level exceeding 2 Gray units (Gy). This study was performed as an investigation into the risk of radiation induced skin injury during arrhythmia ablation procedures. The amount of radiation exposure for 500 patients who underwent ablation was calculated based upon fluoroscopy times and the entrance dose of radiation (0.02 Gy/min). The mean radiation exposure was 0.93 ± 0.62 Gy. Although 5.6% of patients (n = 28) received enough radiation exposure to reach the threshold dose (2 Gy) for early transient erythema, no clinical manifestations of acute radiation induced skin injury were observed. No patients achieved the threshold dose for irreversible skin injury. Patients undergoing AV node ablation or modification received significantly less radiation (0.39 ± 0.40 Gy and 0.79 ± 0.44 Gy, respectively) than patients undergoing other ablation procedures (0.94–1.45 Gy, P < 0.05). There was no association between the magnitude of radiation exposure and the presence of underlying heart disease. Patients undergoing ablation of accessory pathways were exposed to more radiation if there was a right-sided pathway (1.69 ± 0.93 Gy) compared to other sites (0.87–1.24 Gy, P < 0.05). This study demonstrates that the risk of significant radiation induced skin injury during arrhythmia ablation procedures is low provided that precautions are taken to minimize radiation exposure.     

Clinical handover in acute psychiatric and community mental health settings

This study collected an area-wide snapshot of current handover practice in psychiatric settings which included acute care units and community mental health centres. The study was conducted in two stages. Firstly, a questionnaire was sent to all clinical mental health staff within an area-wide health service regarding normal handover procedures and processes. The second part of the study used non-participant observers to evaluate actual handovers in inpatient and community settings. Of the 1125 surveys distributed in stage one, 380 (34%) were returned completed. Of the 40 handovers observed in stage two in which 637 patients were discussed, 40% included at least one consultant psychiatrist or registrar as a participant. Almost all the handovers were completed face-to-face in a specific location with a set time and duration. Eighty-six per cent of respondents reported that deteriorating patients were escalated for rapid response. The results of the survey and structured observations support the issues emerging from the literature from medical, surgical and clinical team handovers. Additionally, the issue of identifiers for deterioration of a psychiatric patient emerged as an area worthy of further investigation and incorporation into clinical handover education and training for psychiatric services.     

MRI for electrophysiology

Catheter ablation is a first-line treatment for many cardiac arrhythmias and is generally performed under x-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with suboptimal success rates and prolonged radiation exposure. Pre-procedure three-dimensional (3-D) MRI has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of MRI compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure MRI is now being applied to assess ablation lesion location and permanence, with the goal of indentifying factors leading to procedure success and failure. In the future, real-time MRI, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation.     

实习生在护理技术操作中标准预防执行情况的调查

目的了解实习生在护理技术操作中标准预防的执行情况。方法采用问卷调查和现场查看考核的方法,对2所医院124名实习生在技术操作中标准预防的执行情况进行了调查。结果多数实习生在临床护理操作前基本不洗手,操作后洗手和戴手套者比较少。实习生执行六步洗手法者仅为12.31%,戴手套的执行率为13.83%。有89.39%的实习生有针头刺伤史,70.07%的实习生没有接受过职业暴露保护教育,有57.35%的实习生不直接将污染针头放入利器盒。结论实习生在临床护理操作中,没有严格执行标准预防隔离措施,主要是没有严格进行教育和不执行操作规范。     

Healthcare workers' knowledge of inoculation injuries and glove use

Healthcare workers' (HCWs') occupational risk of exposure to blood-borne pathogens has been well documented. Subsequent educational programmes, awareness campaigns and policy implementation made limited impact on HCWs' level of knowledge of these risks and compliance with universal precautions. Two hundred HCWs completed a questionnaire to evaluate their level of knowledge. Results demonstrated that despite a comprehensive educational programme for nurses and training for medical staff, knowledge of inoculation injuries and associated issues remained inadequate. Indeed, policies and procedures were not followed. Furthermore, gloves were not routinely worn in the clinical setting. Educational programmes ware essential to inform HCWs of occupational risk of exposure to blood-borne pathogens and guide practice following an inoculation injury. However, efficacy of such programmes must be reviewed, alternative strategies evaluated, and the cause of HCWs' limited knowledge determined.     

A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions

Aims. The review examines from international research: the extent to which practitioners comply with infection control precautions; the pertinent issues that are considered influential in compliance; what strategies have been evaluated to instigate positive behaviour changes amongst practitioners and the effect of these interventions. Background. Internationally, standard/universal precautions (UP) are regarded as fundamental in the prevention and control of infection, and effective in protecting practitioners and patients. However, adherence has been problematic and the practice of standard/UPs is globally suboptimal. Design and methods. Literature review where relevant evidence was identified using several electronic databases, from 1994 to 2006, with number of key terms utilized. Data were extracted by using key headings, which facilitated analysis. Results. Thirty‐seven studies were appraised. Twenty‐four related to measuring practitioner compliance and 13 studies that evaluated the effect of a research intervention on compliance. In addition, other studies were included which examined the specific reasons for suboptimal compliance, or discussed infection control precautions generally. Conclusions. Compliance to infection control precautions is internationally suboptimal. The evidence confirms that compliance to specific aspects of standard/UPs varies, and practitioners are selective in their application of recommended practice. Compliance does improve following a structured intervention; however, research fails to indicate for how long the intervention affects practitioner compliance, or whether compliance after a period of time returns to the norm. Several reasons for non‐compliance are discussed, and recommendations for future research are suggested. Relevance to clinical practice. Suboptimal compliance has significant implications for staff safety, patient protection and the care environment. Infection control teams and researchers need to consider the reasons for non‐compliance and provide a supportive environment that is conducive to the routine, long‐term application of standard precautions.     

手术安全核查表的应用与效果

目的:探讨手术安全核查表的应用效果。方法:构建手术安全核查表,组织医务人员培训,组织督导人员现场督促检查,比较应用手术安全核查表前后手术核查正确率、准时率、护理缺陷发生率的差异情况。结果:应用手术安全核查表后,手术室接患者、麻醉开始、手术开始准时率分别为100%,99%,96%,均高于实施前的90%,85%,80%;手术医师、麻醉医师、手术室护士核查的正确执行率分别为98.46%,95.00%,98.00%,均高于实施前的70.00%,65.00%,84.00%;护理缺陷的发生率均低于实施前,除患者皮肤、患者管道、病理标本及非注册护士签名外,其余各项差异均有统计学意义(P<0.05)。结论:手术安全核查表应用后,有效提高了手术人员安全核查的依从性,护理缺陷率下降,确保手术患者安全。     

Ultrasound and chronic pain

Ultrasound (US) is an increasingly used imaging technique in interventional pain management. It allows the identification of soft tissues, vessels and nerves, without exposing patients and personnel to radiation. Imaging can be performed continuously and the fluid injected is visualized in a real time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal and paravertebral nerve blocks, inguinal nerve blocks, occipital nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger/tender points. Due to direct nerve visualization, US has a potential application for destructive procedures, such as cryoanalgesia, radiofrequency lesions or chemical neurolysis. Limitations are the poor resolution of narrow-gauge needles, the loss of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of the target area. US opens new perspectives in interventional pain management. However, there is a need for more clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are completed, US can not replace fluoroscopy or computed tomography in most interventional pain procedures and remains the domain of well-trained and experienced physicians. The limited evidence supporting the clinical utility of nerve blocks remains a problem, irrespective of the imaging technique employed.     

Inter-professional differences in compliance with standard precautions in operating theatres: a multi-site, mixed methods study

BackgroundOccupational acquisition of blood-borne infections has been reported following exposure to blood or body fluids. Consistent adherence to standard precautions will reduce the risk of infection.ObjectivesTo identify: the frequency of self-reported adverse exposure to blood and body fluids among surgeons and scrub nurses during surgical procedures; contributory factors to such injuries; the extent of compliance with standard precautions; and factors influencing compliance with precautions.DesignA multi-site mixed methods study incorporating a cross-sectional survey and interviews.SettingsSix NHS trusts in Wales between January 2006 and August 2008.ParticipantsSurgeons and scrub nurses and Senior Infection Control Nurses.MethodsA postal survey to all surgeons and scrub nurses, who engaged in exposure prone procedures, followed by face to face interviews with surgeons and scrub nurses, and telephone interviews with Infection Control Nurses.ResultsResponse rate was 51.47% (315/612). Most 219/315 (69.5%) respondents reported sustaining an inoculation injury in the last five years: 183/315 (58.1%) reported sharps’ injuries and 40/315 (12.7%) splashes. Being a surgeon and believing injuries to be an occupational hazard were significantly associated with increased risk of sharps’ injuries (adjusted odds ratio 1.73, 95% confidence interval 1.04–2.88 and adjusted odds ratio 2.0, 1.11–3.5, respectively). Compliance was incomplete: 31/315 (10%) respondents always complied with all available precautions, 1/315 (0.003%) claimed never to comply with any precautions; 64/293 (21.8%) always used safety devices, 141/310 (45.5%) eye protection, 72 (23.2%) double gloves, and 259/307 (84.4%) avoided passing sharps from hand to hand. Others selected precautions according to their own assessment of risk. Surgeons were less likely to adopt eye protection (adjusted odds ratio 0.28, 0.11–0.71) and to attend training sessions (odds ratio 0.111, 0.061–0.19). The professions viewed the risks associated with their roles differently, with nurses being more willing to follow protocols.ConclusionInter-professional differences in experiencing adverse exposures must be addressed to improve safety and reduce infection risks. This requires new training initiatives to alter risk perception and promote compliance with policies and procedures.     

Perceptions of CRNAs: current and future roles--Part II

The purpose of this study was twofold. First, to identify current roles and future role perceptions for Certified Registered Nurse Anesthetists (CRNAs) using the delphi methodology. Second, to analyze the level of agreement or disagreement of anesthesiologists and CRNAs with the identified roles. A survey instrument was developed using the delphi methodology which involved five CRNAs and five anesthesiologists. The instruments with a dimensional rating scale were labeled "Current Roles for CRNAs" and "Future Role Perceptions for CRNAs." The former instrument contained 26 items and the latter contained 28 items. Participants in this study were randomly selected from the active memberships of the American Association of Nurse Anesthetists and the American Society of Anesthesiologists. Usable responses were obtained from 369 of the 684 CRNAs and 354 of the 1,400 anesthesiologists. Analysis of the data revealed there were significant differences between the two professions on all roles. There was evidence of extreme polarity on roles relating to expanded practice, independent practice, the role of CRNAs on the anesthesia care team, and nontraditional practice settings. CRNAs differed from anesthesiologists in their role as nurse anesthesia educators. Anesthesiologists who worked with CRNAs were influenced in their support of CRNA roles, except for roles in independent and expanded practice, and responded differently from anesthesiologists who did not work with CRNAs. The conclusions were as follows: 1. CRNAs and anesthesiologists differ in support for expanded practice in both current and future perceptions. 2. CRNAs and anesthesiologists differ on the issue of independent practice. 3. The perception of anesthesiologists relative to the anesthesia care team appeared to be influenced by a working relationship with CRNAs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Review of personal protection equipment used in practice

Standard precautions offer a consistent approach to infection control that does not rely on knowledge or suspicion of infection, and contributes to staff and patient safety by reducing the risk of exposure to potentially infectious material. One of the cornerstones of standard precautions is the appropriate use of personal protective equipment (PPE) whenever contact with blood or body fluids is anticipated. However, evidence suggests that compliance with standard precautions including correct use of PPE is inadequate. Demographic and epidemiological changes in the U.K., and the drive to provide more complex patient care outside acute hospitals may lead to increased infection risks for both patients and community healthcare workers. This review examines the importance and use of PPE by community nurses and discusses the implications for practice of poor compliance with standard precautions. Recommendations for practice will be made aimed at improving compliance with this important element of standard precautions.