Radiation should not be feared, but must be respected, says Vivian Wisniewski, RN. Your staff would be wise to heed that advice when using C-arm fluoroscopy, which comes with inherent, invisible dangers. But there are basic, commonsense measures that can reduce radiation exposure risks. Here's how to protect your staff, surgeons and patients from the dangers of fluoroscopy exams.

1. Administer the lowest dose possible.
Achieving the lowest possible dose of radiation — As Low As Reasonably Achievable (ALARA) — should be the guiding principle for every C-arm procedure. Using the low-dose setting for the C-arm whenever possible is a simple step toward achieving the lowest reasonable dose, says Ms. Wisniewski, director of nursing at the Harrisburg (Pa.) Interventional Pain Manage-ment Center.

"Almost without fail, we image using the low-dose setting," she says, adding that using pulse fluoroscopy to capture intermittent images — as opposed to continually taking shots throughout the C-arm's range of motion — will also minimize exposure.

Dialing down the dose may affect image quality, but high-resolution images are typically not needed for the physician's purposes, notes John Dom-browski, MD, PC, anesthesiologist and pain management physician at the Washington Pain Center in Washington, D.C.

"Surgeons don't really need a crisp image to get the anatomical view they need," says Dr. Dombrowski. He adds that using a half-dose of radiation to obtain fluoroscopic images "minimizes radiation to both the patient and the physician." This is especially critical for the surgeon, who is "[exposed to radiation] all the time. That's what's even more concerning."

2. Regularly evaluate your unit.
C-arm units are required by law to be evaluated by a radiation physicist at least once a year in order to determine radiation output. Upon review, a service technician for the C-arm should make the necessary adjustments, says Ms. Wisniewski. One annual evaluation is required, but bi-annual reviews are a good idea, especially if your C-arm unit is getting on in years, she adds. "In order to get optimal images and keep everyone safe, testing your unit at least twice yearly is ideal," she says. "C-arm units will increase or decrease output as they age, and there's no need to turn out more radiation than necessary."

3. Protect patients and yourself.
Lead aprons should be a standard part of your X-ray team's attire. There are 2 types of aprons available, says Michael Schroeder, RN, BSN, ASC director at NovaMed Surgery Center of Baton Rouge in Louisiana. One type is designed to protect the front of the body and is worn much like a chef's apron, he explains. There are also shields that provide more full-body protection, consisting of a wrap-around, Velcro vest and a skirt of sorts, which give the wearer more freedom to move around the room during the procedure.

While lead aprons guard against a significant amount of radiation, these shields only protect part of the body. Protective eyewear — with lead lining— and thyroid shields are also recommended, adds Mr. Schroeder. Lead-based shields that can be mounted from the ceiling or tableside — positioned between the patient and physician — create another barrier that helps keep radiation from scattering.

"When the beam is emitted from the source to the patient, you always have the possibility of ionizing radiation spreading," says Mr. Schroeder. "If you think about where the patient is situated on the table, in a belly-down position, the C-arm is shooting radiation from top to bottom, right at the patient's spine area.

"As [radiation] leaves the source, some particles could bounce off the patient, so to speak, and spread," he adds. "Keep the patient as close to the image intensifier, the bottom piece of the C-arm, as possible, to reduce the scatter of radiation."

Using a C-arm drape also helps reduce the dangers of scatter, according to Mr. Schroeder. From an infection control standpoint, centers using fluoroscopy typically perform pain procedures, so there's generally not a lot of blood or fluids to deal with. Still, proper and frequent cleaning of the drape — ideally done with any type of spray or wipe used in a medical setting, with a 2- or 3-minute kill time — is important for preventing infections in staff and patients alike. C-arm drapes should be cleaned as you would clean any flat surface in the surgical setting, and stored flat as well.

4. Monitor exposure.
Providing monitoring tags for staff members to wear on their lead aprons is one way that NovaMed Surgery Center gauges its staff's levels of radiation exposure, says Mr. Schroeder. These tags consist of sensitive material that absorbs radiation, he explains. NovaMed sends the tags to a monitoring service on a monthly basis for reports on how much radiation surgical team members are being exposed to.

Internally, "your center's radiation safety officer would typically monitor employee exposure limits, looking for staff members who may be tracking on the high side," says Mr. Schroeder. This, however, is an area where you and your safety officer must be careful. "You want to make sure it's a valid jump, and not just something random," he explains. "For example, an X-ray technologist may have left their apron hanging in the room with the tag still on it." This would obviously cause a significant, one-time jump in the amount of radiation the tag absorbed, and would not signify that an individual is necessarily at risk.

Rather, what a radiation safety officer should look for are employees whose exposure is increasing from month to month. In this instance, you may consider removing that employee from settings where she would be exposed to radiation, or at least reduce her ongoing dosage, Mr. Schroeder advises.

By the very nature of their job function, X-ray technologists are bound to track higher, he says, which isn't a cause for concern as long as they are all in an acceptable range. High exposure on a staff level, however, may very well signal that your fluoroscopy unit is due for evaluation and possibly maintenance, adds Dr. Dombrowski. "That's a red flag," he says. "That's a clue that maybe you need to look at your fluoroscopy machine and recalibrate it."

5. Properly position patients and staff.
As Mr. Schroeder points out, positioning the patient as close to the image intensifier as possible will help cut down on radiation scatter. Positioning the patient is obviously critical to obtaining quality images and, moreover, ensuring the safest possible environment. The positioning of your staff, however, is equally important, and an aspect of C-arm safety that sometimes goes overlooked, says Mr. Schroeder.

"Always be aware of [caregivers'] movements within the room," he advises. "If, for example, a staff member is adjusting the oxygen tubing or administering medication to the patient — a task that requires them to be right next to the patient — then refrain from using fluoroscopy at that point." Or avoid taking images if a staff member wearing an apron that covers only the front of her body has her back to the unit. Staffers should also step away from the tableside before each image is taken, says Ms. Wisniewski. "The further you are from the source, the less you are exposed," she explains. "Unfortunately, the exposure is the same to the patient, but your staff is there all day."

Keeping a distance of about 6 feet is recommended, Mr. Schroeder says, comparing the effect of radiation leaving the C-arm to water being sprayed from a hose. The force of the water, he explains, is the most concentrated at the point where the water leaves the nozzle. "The further away from the hose the water gets, the less pressure there is," explains Mr. Schroeder. "That's why we talk about the 6-foot barrier. When you get past the 6-foot point, you have less exposure."