Radiation is used in outpatient surgery more than ever these days, for everything from fluoroscopic guidance for orthopedic surgery to barium enemas to urological procedures such as retrograde pyelography. C-arms are standard fluoroscopic equipment in most surgical facilities. Depending on the type of procedure, patients are often exposed to high amounts of radiation during fluoroscopy. Likewise, healthcare workers who perform the procedures are also exposed because of scattered radiation from the patient. Here are seven essentials to protecting your staff.

Know the risks
Of course, protecting patients from overexposure is the first priority in a surgical facility. However, protecting healthcare workers — whether they're a few feet away or in the next room — is just as important. The biologic effects of exposure to radiation are classified as either stochastic (as a result of exposure to radiation regardless of the dose) or deterministic, in which the severity of the effects correlate with the amount of exposure. Burns, cataract formation and hair loss are deterministic effects. Patients are more likely to suffer these effects than healthcare workers, who are at risk from long-term exposure. Stochastic effects include cancer (leukemia, breast cancer and skin cancer) and fetal deformities, especially between the fourth and 15th weeks, when the fetus's organs are forming.

Comply with radiation rules and regulations
It's important to know your local regulations as well as national safety guidelines. You might need to do a little bit of research to find out which local and state agencies have jurisdiction over radiation in healthcare facilities. It may be the department of health or environmental services. Some states have a department of radiation safety. Contacting another local facility or a professional society such as the American College of Radiology (www.acr.org) or American Association of Physicists in Medicine (www.aapm.org) are other possibilities. Don't count on your equipment manufacturer's rep to know. It's your facility's responsibility to comply with all the regulations. If you're not up to code, local regulators can shut down your facility immediately.

For patient safety, the Joint Commission calls for facilities to have methods of tracking patient radiation exposure during fluoroscopy procedures that have the potential to generate high doses of radiation. I suggest working with a medical physicist to create a tracking method for all procedures that generally run longer than 75 minutes or those with a cumulative dose of more than 3,000 mGy.

Wear safety garments
The amount of radiation an employee is exposed to is a function of time, distance and shielding. Whenever possible, shielding should be used to lessen the exposure. AORN calls for personnel to use lead aprons, vests, skirts, thyroid shields and leaded glasses.

Team members who sometimes stand with their backs to the radiation beam should wear wrap-around lead aprons. In order to encourage compliance, consider purchasing lightweight composite (non-lead) aprons with comparable absorption capabilities. Many people find composite aprons more comfortable. Aprons should be as long as necessary in order to provide the appropriate protection to the legs.

A note about thin lead protective gloves: They don't provide complete protection. In fact, in the July 1996 issue of Radiology researchers from the University of Texas Medical School at Houston reported that gloves provided "moderate to insubstantial" reduction in dose to the hand. When viewed through a fluoroscope, the glove's protection is exaggerated because the display shows the two layers of the glove. When the worker wears a glove, the hand is actually protected by just one layer, writes safety expert Louis K. Wagner, PhD. For this reason, don't let employees become cavalier with their hands around the X-ray beam. The best defense for reducing exposure is to keep the hands out of the beam, even those of mini C-arms used for hand surgery.

Test safety garments
New leaded aprons and other garments should be X-rayed under the C-arm before their first use to test for defects or cracks that might have developed during shipping. Before each procedure, surgical team members should inspect safety items before putting them on. At least once a year, these items should be tested under X-rays in order to identify cracks or deterioration, according to the CDC's Recommended Guidelines for Controlling Noninfectious Health Hazards in Hospitals.

Monitor employees' exposure
The OSHA regulated maximum annual dose that a healthcare worker may receive is 50 mSv (5 rem), based on a quarterly limit of 12.5 mSv (1.25 rem). Staff must wear a dosimeter film badge outside their clothing to monitor the amount of radiation the unprotected parts of the body receive. Radiation from gamma and beta rays can be monitored with a dosimeter ring worn under gloves. Be sure to keep the ring's label on the inside of the hand. Staff shouldn't wear badges outside the facility; store badges away from radiation, heat and moisture.

Pregnant workers must wear two badges: one outside the apron at the collar level and one under the apron at the abdomen level. Employees who wear two badges should make sure that they don't confuse the badges. The outside badge needs to be worn outside always, and the abdomen badge needs to be under the apron always. Otherwise, the dose readings won't reflect the employees' true exposure. The dose that a pregnant worker may receive is much more restrictive. She may receive 5 mSv (0.5 rem) throughout gestation or 0.5 mSv (.05 rem) per month during gestation.

Protect your neighbors
If your C-arm is fixed to the building, the facility is required to have a mobile shield or one hanging from the ceiling. Walls must be constructed with drywall impregnated with lead. The leaded drywall should be installed with no gaps between sheets. Mobile C-arms may require a mobile shield, depending on the state. Regardless of local regulations, I recommend using mobile shields in every facility to provide a flexible way to create a radiation-free zone inside surgical suites.

Use equipment safety features
Today's C-arms can create detailed images while emitting less radiation, thanks to technical advances and safety features that are becoming standard. If you get to know all the bells and whistles on your equipment, you'll be able to reduce exposure and create better images. To lessen the dose that patient and staff receive, most C-arms now have the following features that let you better use the ALARA (As Low As Reasonably Achievable) concept when using radiation to create an image:

• Last image hold. Freezes the image on the display so that you can turn off the beam.
• Pulse mode. Creates moving images with 15 frames per second rather than 30 frames. This can reduce patient's dose by as much as 50 percent.
• Beam collimation. Frames and shapes the beam to a more precise field with less scatter.

Limiting exposure
Exposure to radiation in the healthcare setting is getting more attention. In 2006, the Joint Commission declared that radiation overdosage and radiation therapy on the wrong site are sentinel events. Last year, AORN updated its Recommended Practices for Reducing Radiological Exposure in the Perioperative Practice Setting. The goal when using a C-arm is to create the best possible image with patients and staff receiving the least amount of radiation.