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Fluoroscopy Credentialing

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Title: Fluoroscopy Credentialing


1
Fluoroscopy Credentialing
  • William Robeson, Radiation Safety Officer
  • North Shore University Hospital
  • Radiology/Radiation Safety Office
  • (516) 562- 3895
  • Presentation created by Miyuki Yoshida-Hay

2
Objectives
  • The Joint Commission accreditation requires
    physicians who use or operate fluoroscopic x-ray
    systems be properly credentialed. This training
    shall include radiation safety, management of
    fluoroscopic radiation and operation of
    fluoroscopic x-ray system(s) used by the
    physician. Training in radiation safety and
    fluoroscopic radiation management is in addition
    to any clinical training or qualifications
    required to perform the specific clinical
    diagnostic or therapeutic procedures for which
    the fluoroscopic systems are used.

3
Credentialing Requirements
  • The hospital requires documentation of
    appropriate training before granting fluoroscopic
    privileges.
  • In order to become credentialed, a physician must
    do the following
  • View this powerpoint presentation
  • Complete the self-assessment quiz
  • Upon completing the training, each physician will
    need to complete an attestation. The attestation
    certificate is available for printing.
  • Present this certificate to the department
    chairperson for recording the successful
    completion of the fluoroscopy safety requirement.
  • It is up to the each department to establish
    other training and education requirements needed
    to obtain fluoroscopy privileges.

4
TOPICS
  • X-ray Production
  • Units of Radiation Exposure and Absorbed Dose
  • Dose Equivalent and Effective Dose Equivalent
  • Mobile C-arms
  • Factors Influencing Fluoroscopy Exposure Rate
  • Sources of Radiation Exposure
  • Radiation Protection
  • Personnel Monitoring
  • Basic Radiation Biology
  • Example of a Skin Injury from Fluoroscopy
  • Radiation and Pregnancy
  • Summary

5
X-ray Production
X-rays are produced in an x-ray tube when
electrons are accelerated through a high voltage
(50,000 150,000 volts or 50 - 150 kVp) and
allowed to hit a target composed of high atomic
number materials such as tungsten.
6
X-ray Production (cont.)
  • Electrons are released from an electrically
    heated filament and are accelerated to the target
    by the high voltage. This flow of electrons from
    the filament to the target is known as the tube
    current (mA). Fluoroscopy is usually performed
    using 2 to 6 (mA) and an accelerating voltage of
    75 to 125 kVp.
  • The amount of x-rays produced is determined by
    the tube current (mA) and the high voltage (kVp).
    X-ray production is directly proportional to the
    tube current therefore doubling the tube current
    (mA) doubles the of x-rays produced at a
    particular kVp.
  • However, x-ray production increases more rapidly
    with kVp than mA therefore increasing the kVp by
    15 is equivalent to doubling the mA. NOTE
    Higher kVp values also provides a more
    penetrating x-ray beam

7
Units of Radiation Exposure Absorbed Dose
  • Exposure
  • The quantity of x-rays or gamma radiation
    required to produce an amount of ionization
    (electric charge) in air at standard temperature
    and pressure
  • Units Roentgen (R)
  • 1R 2.58x10-4 C/kg (coulombs/kilogram)
  • Usually expressed in terms of exposure rate
    i.e., R/hr or fluoroscopy output measured as
    R/min.
  • Absorbed Dose
  • The amount of ionizing radiation energy absorbed
    per unit mass of tissue.
  • Units rad (radiation absorbed dose) 1 rad
    0.01 Joules/kg 1 rad 0.01 Gray
  • For x-rays used in fluoroscopy an exposure of 1R
    results in an absorbed dose of approximately 1
    rad.

8
Dose Equivalent and Effective Dose Equivalent
  • Dose Equivalent
  • Used to account for differences in the biological
    effectiveness of different types of ionizing
    radiation.
  • Defined as (the absorbed dose) x (radiation
    quality factor) specific to the type of radiation
    to which an individual was exposed.
  • Units rem (roentgen equivalent in man)or
    Sievert (Sv) 1 Sv 100 rem
  • For diagnostic medical x-rays the quality factor
    is 1, therefore an absorbed dose of 1 rad is
    equal to a dose equivalent of 1 rem
  • Effective Dose Equivalent (EDE)
  • The risk of potential health effects when only
    part of the body is irradiated is smaller than
    when the whole body is exposed.
  • The EDE is a calculation of risk to an individual
    posed by a partial body irradiation.
  • The EDE is also used to estimate the equivalent
    whole body exposure for fluoroscopy staff wearing
    protective aprons for comparison to annual
    personnel dose limits for radiation exposure

9
Mobile C-arms
  • Moved around ORs to visualize anatomy during
    surgery
  • Metallic c-arm contains x-ray tube at one end and
    image receptor at the other
  • An associated unit contains the display

10
Factors Influencing Fluoroscopy Exposure Rate
  • Modern fluoroscopy units produce images with an
    image intensifier (II) which brightens the image
    level sufficiently so that the image may be
    displayed on a TV screen. Fluoroscopy units are
    usually operated in an automatic brightness
    control (ABC) mode.
  • These units will automatically adjust the
    brightness by first increasing the kVp to
    increase x-ray penetration and then adjusts the
    mA to increase intensity.
  • Note Exposure to a thick patient will be
    greater than to a thin patient and also abdominal
    fluoro will require a greater exposure than a
    chest fluoro due to increased thickness and
    tissue density in the abdomen.

11
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 1 The image intensifier input
should be positioned as close to the patient as
practicable. This results in a lower patient
dose and sharper image.
12
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 2 Use the exposure pedal as
sparingly as possible. Radiation exposure
during fluoroscopy is also directly proportional
to the length of time the unit is activated by
the foot pedal. Depression of the foot pedal
determines the length of exposure. The
fluoroscopy time is an important determinant of
patient and staff radiation dose. Fluoroscopy
units are equipped with a timer and an alarm
which sounds at the end of 5 minutes. The alarm
serves as a reminder of the elapsed time.
13
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 3 Use last-image hold and
pulsed fluoro whenever possible. Most modern
fluoro units are equipped with last-image hold,
which stores the last fluoro image and allows
viewing without having to expose the patient
again. Many fluoro units also offer a pulsed
fluoro mode, in which the x-ray beam is pulsed
rapidly on and off and results in a lower
radiation dose without significantly degrading
the appearance of the image on the display.
14
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15
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 4 Use the smallest field of
view practicable. Radiation exposure also depends
on x-ray field size and keeping the x-ray field
as small as possible (by using collimators) which
will decrease the dose to BOTH the patient and
staff in the fluoroscopy suite. Restricting the
field size not only decreases radiation dose but
will also produce a better image. The contrast
in the image between various tissue types will be
greater for the smallest field of view that
encompasses the desired anatomy.
16
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 5 High dose or detail modes
should be used only sparingly. Many fluoro units
will have various dose modes, such as low dose,
medium dose and high dose mode. It is
important to recognize that fluoroscopic image
quality can be adversely affected by too few
x-rays in the image the image is noisy for low
dose. More tissue contrast is produced by the
high dose mode which will improve the image
quality at the expense however of increased
patient dose.
17
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 6 Magnification should be used
only when necessary. Fluoroscopy units are
capable of using different magnification modes.
Image resolution is improved with magnification
but field size is reduced and patient radiation
dose is increased. Patient dose is minimized by
using the lowest magnification (largest field
size) appropriate for the image procedure being
performed.
Under Normal mode, there is little magnification
with the whole beam used to generate a bright
image. Under Mag 1 mode, a smaller beam area is
projected to the same II output.  The resulting
object size is larger, but the image is dimmer
due to the less beam input.   The ABC system
senses the brightness loss and either boosts
machine X-ray output, increases tube voltage, or
a combination of both.
18
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19
6 inch mag FOV increases dose by a factor of 4
over non-mag image
20
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
Recommendation 7 For C-arm type fluoroscopy
units the patient should be positioned as far
from the x-ray tube as practicable to minimize
patient entrance dose. To reduce personnel
exposure the x-ray tube should be positioned
beneath the patient.
21
In the case of portable C-Arm systems,
eliminating the air gap between the I-I and the
patient ensures that the table top is as far away
as possible from the X-ray tube, minimizing
radiation exposure to the patients skin. Note
The separator cone should always be utilized
before commencing fluoroscopy on portable C-arm
systems, as depicted below on the image at right.
   
22
Factors Influencing Fluoroscopy Exposure Rate
(cont.)
In conventional under-table x-ray tube
fluoroscopic units, the x-ray tube is located at
a fixed distance from the patients skin. In
C-arm fluoroscopy, where the distance between the
x-ray tube and image intensifier is fixed, the
patient can be positioned in close proximity to
the x-ray tube which increases the entrance skin
dose and reduces image sharpness. It is
preferable to locate the C-arm x-ray tube
underneath the patient. Since the radiation
transmitted through the patient is typically only
5 10 of the entrance dose, inadvertent
exposure to the operator hand on the exit side of
the patient will result in a smaller dose
compared to the dose to the hand on the entrance
side of the patient. Also the amount of scatter
radiation the operator is exposed to on the beam
exit side of the patient is significantly less
than on the beam entrance side.
23
X-ray tube
X-ray tube
Sorenson, 2000.
Note The benefit is exaggerated - some operator
dose occurs on the image intensifier
(I-I) side.
24
Sorenson, 2000.
Care should be taken whenever the image view
angle is changed during the procedure (e.g,
changing from an ANT to a steep LAO). The I-I is
often moved away from the patient while changing
X-ray tube position. Large air gaps can result if
the table or I-I height remains unadjusted.
25
Sources of Radiation Exposure
  • DIRECT EXPOSURE
  • Entrance Skin Exposure (ESE) rates (where the
    x-rays enter the patient) are limited to less
    than 10 R/minute(NOTE At ESE rates of 10 R/min,
    30 minutes of fluoroscopy can deliver 300 R in
    skin dose.)
  • ESE rates for typical fluoroscopy procedures are
    usually less than 5 R/min.
  • On some machines an operator can deliberately
    choose a setting that will increase the output.
    The use of higher radiation rates or "boost"
    modes are useful in situations requiring high
    video image resolution. ESE of up to 20 R/min is
    permitted for short duration. Special operator
    reminders, such as audible alarms, are activated
    during "boost" modes.


26
Sources of Radiation Exposure
  • SCATTER EXPOSURE TO PERSONNEL
  • Most of the radiation exposure received by the
    operator or other personnel in the fluoroscopy
    suite is due to scatter radiation from the
    patient.
  • The operator will be exposed to a dose rate of
    approximately one one-thousandth (1/1000) of the
    ESE rate at a distance of 1 meter from the center
    of the fluoroscopy field.


Sorenson, 2000.
27
Sources of Radiation Exposure
  • Factors which increase the dose from scatter
    radiation
  • Large patients which will cause the automatic
    brightness control (ABC) to adjust the kVp and mA
    to higher values causing greater amounts of
    scatter radiation.
  • A large x-ray field, a result of not restricting
    field size will increase scatter radiation
  • The length of time the fluoroscopy unit is on.
    Complex interventional cases will require greater
    procedure time, increasing dose to both the
    patient and operator


28
Sources of Radiation Exposure
  • Other sources of exposure to the operator may be
    associated with the following
  • A small percentage of exposure to the operator
    may be due to leakage radiation through the x-ray
    tube housing.
  • C-arm operators should be aware that the
    shielding built in to fixed fluoroscopy systems
    is not available for protection against
    backscatter. This may be of greater concern if
    the C-arm is rotated out of the normal vertical
    plane.

29
Radiation Protection
  • The three most productive means of reducing
    radiation dose is
  • Time Minimize time spent in the radiation
    field. Use of last-image-hold
    and pulse fluoro features are technical
    advantages in reducing the total time x-rays
    are produced
  • Distance Radiation dose rates increase or
    decrease according to the
    inverse square law Ex Double your distance
    from the source and decrease your
    exposure by a factor of 4
  • Shielding Use of lead garments, lead gloves,
    thyroid shields, leaded eyeglasses, lead
    drapes and clear leaded glass barriers
    between the patient and operator

30
PPE and Radiation Monitoring

31
 
           
 
Sorenson, 2000.
32
Personnel Monitoring
  • Even when radiation protection techniques and
    engineering controls are in place to reduce
    personnel exposure, individual dose monitoring is
    required.
  • Various types of dosimeters are available (i.e.,
    film badges, thermo-luminescent (TLD) and
    optically-stimulated luminescent (OSL) badges).
  • Badges are assigned to an individual and must
    never be shared.
  • A badge designed to measure the whole body (torso
    including head) should be worn at the collar
    OUTSIDE the lead apron.

33
Monthly Investigational Levels (mrems)
Level I Level II Body Badge (DDE)
50 150 Collar Badge 150 450 Eye (LDE)
150 450 Ring/Wrist (SDE) or Extremity
500 1,500 DDE Deep Dose
Equivalent LDE Lens Dose Equivalent SDE
Shallow Dose Equivalent
34
Monthly Investigational Levels
  • Level I Each incident will be noted on the
    personnel badge report by the Radiation Safety
    Office. A notification letter is sent to the
    employee.
  • Level II The Radiation Safety Office will
    investigate each such incident. A report will be
    generated and the results of each investigation
    will be presented to the hospital radiation
    safety committee.
  • Physicians performing fluoroscopy that receive
    Level II collar badge readings will get a
    notification letter that includes their effective
    dose.

35
Personnel Monitoring (cont.)
  • The effective dose equivalent (EDE) may be
    calculated in the following manner
  • A two-badge system (waist and collar badges) is
    used to calculate an individuals EDE by taking
    into account the protective factor of the lead
    apron. In this situation, one badge is worn
    OUTSIDE the lead apron (collar) and a second
    badge is worn UNDERNEATH the lead apron (waist).
    The EDE is calculated as follows EDE
    1.5 x (waist) 0.04 x (collar)
  • A one-badge system (collar badge ONLY) is where
    one badge is worn on the OUTSIDE of the lead
    apron. The EDE is calculated as follows
    EDE 0.3 x (collar)

36
Personnel Monitoring (cont.)
  • Dosimeters must be promptly turned in and
    exchanged each month to give accurate
    assessments.
  • Badge reports are reviewed by the Radiation
    Safety Office. Notification letters are sent to
    individuals who exceed monthly Level I
    exposure limits. Investigational letters are
    sent to those who exceed monthly Level II
    exposures limits. A written response to the
    letter is required, which includes an
    acknowledgement and an explanation of the Level
    II exposure, if known. The letter is to be
    returned to the Radiation Safety Office within
    one week of receipt.
  • Copies of badge reports (3 months) must be posted
    in each department for individuals to review.
  • Badges are susceptible to heat and moisture
    damage. Badges not in use should be stored in a
    cool, dry place, away from any sources of
    radiation. Do not take dosimeters home or travel
    on a plane with a dosimeter or wear a dosimeter
    during a medical radiological procedure.

37
OCCUPATIONAL DOSE LIMITS (NRC)
For hospital radiation workers, annual doses
rarely exceed 10 of these values.
38
Basic Radiation Biology
  • X-rays from fluoroscopy interact with biological
    materials by transferring their energy to an
    electron which subsequently interacts with the
    target molecule to produce an ion or a free
    radical.
  • Indirect action is the creation of free radicals
    from interactions with water molecules. Free
    radicals may then chemically interact with
    biologically sensitive molecules (DNA, RNA,
    proteins) causing damage
  • Direct action is the interaction of ionizing
    radiation with biologically sensitive molecules
    such as DNA causing direct destruction or
    mutation
  • Since water molecules are much more numerous than
    biologically sensitive molecules, indirect action
    is the most common form of biological damage.

39
Basic Radiation Biology (cont.)
  • Cells can sustain a variable amount of radiation
    and still repair themselves from sub-lethal
    damage.
  • Continuous high intensity radiation will produce
    greater damage than an equivalent fractionated
    (multiple smaller) dose since fractionation
    allows for cell repair.

40
Basic Radiation Biology (cont.)
  • A given organs response to radiation depends on
  • Total dose
  • Dose rate
  • Fractionated scheme
  • Volume of irradiated tissue
  • Inherent tissue radiation sensitivity
  • A large total dose, high dose rate and small
    fractionated schedule (which is all possible in
    fluoroscopy) will cause a greater degree of
    damage.
  • Major concern in fluoroscopy is the possibility
    of acute, direct or deterministic, radiation
    damage which manifests as a skin injury. The
    severity of skin injury is dose-dependent more
    dose means more severe symptoms

41
FDA Specification of Radiation-Induced Skin Injuries FDA Specification of Radiation-Induced Skin Injuries FDA Specification of Radiation-Induced Skin Injuries FDA Specification of Radiation-Induced Skin Injuries FDA Specification of Radiation-Induced Skin Injuries FDA Specification of Radiation-Induced Skin Injuries
Threshold Dose Threshold Dose Typical Fluoro-On Time in Minutes Typical Fluoro-On Time in Minutes
Skin Effect rem Sv Normal mode _at_ 10 R/min High Dose mode _at_ 20 R/min Time to Onset
Early Transient Erythema 200 2 20 minutes 10 minutes Hours
Temporary Epilation 300 3 30 minutes 15 minutes 20 days
Basal Cell Erythema 600 6 60 minutes 30 minutes 10 days
Permanent Epilation 700 7 70 minutes 35 minutes 20 days
Dry Desquamation 1000 10 100 minutes 50 minutes 30 days
  • Note that the time to expression of symptoms is
    long enough that the patient may no longer be in
    the hospital when symptoms appear. The physician
    performing the fluoroscopy cannot discern the
    damage by observing the patient immediately
    following the procedure.

42
Basic Radiation Biology (cont.)
  • These threshold doses to cause an effect cannot
    be considered exact due to many variables such as
    individual biological response, age,
    characteristics of the individual exposed and the
    area exposed.
  • A patient may exceed the threshold dose without
    showing symptoms. This may be due to
  • The x-ray beam may not have been concentrated on
    a single area of the skin for the entire time and
    because 10 R/min or 20 R/min are maximum outputs
    for very thick patients.

43
Example of a Skin Injury from Fluoroscopy
  • This case, patient A is that of a 40-year-old
    male who underwent coronary angiography, coronary
    angioplasty and a second angiography procedure
    due to complications, followed by a coronary
    artery by-pass graft, all on March 29, 1990. The
    area of injury six to eight weeks following the
    procedures. The injury was described as "turning
    red about one month after the procedure and
    peeling a week later."

44
Example of a Skin Injury from Fluoroscopy (cont.)
  • In mid-May 1990, it had the appearance of a
    second-degree burn. The condition in late summer
    1990, exact date unknown, with the appearance of
    a healed burn, except for a small ulcerated area
    present near the center.

45
Example of a Skin Injury from Fluoroscopy (cont.)
  • Skin breakdown continued over the following
    months with progressive necrosis.

46
Example of a Skin Injury from Fluoroscopy (cont.)
  • The injury eventually required a skin graft.
  • The magnitude of the skin dose received by this
    patient is not known. However, from the nature of
    the injury, it is probable that the dose exceeded
    20 Gy.

Wagner LK, Eifel PJ, Geise RA. Potential
Biological Effects Following High X-ray Dose
Interventional Procedures. JVIR 1994 571-8
47
Deterministic Effects
  • Threshold dose below which no effect is observed
  • Severity increases with dose
  • Examples skin erythema, dermatitis,
    desquamation cataracts

48
Stochastic Effects
  • Incidence increases with dose
  • No dose threshold assumed
  • Basis for ALARA principle of radiation protection
  • Example cancer

49
Pregnancy and Radiation
  • The decision to perform a radiological procedure
    on a patient who may be pregnant is a medical
    decision and shall be made by a physician in
    consultation with the patient. If the procedure
    is to be performed, the physician must explain
    the risks to the patient, provide informed
    consent and the appropriate consent form shall be
    signed.
  • Shielding shall be used to shield the abdomen
    from radiation provided it does not interfere
    with the procedure.
  • Every attempt must be made to minimize direct
    exposure to the fetus according to the principles
    described in this presentation.
  • Medical emergency radiological procedures however
    take precedence over pregnancy status.

50
Principles for Fluoroscopy
  • PAUSE to properly plan and prepare for study
  • Activate dose saving features of equipment
  • No exposures unless necessary
  • Depress last image hold and last image grab
    instead
  • PULSE at lowest possible rate

51
PAUSE Clinical indication, appropriateness of
study, questions to be answered, unusual anatomy
or prior surgery, and type of study to be
performed should be clarified as much as
possible. Explain procedure, risks and required
immobilization to patient /or parents, a
cooperative and helpful patient /or parent can
greatly shorten study and exposure. Ensure that
fluoroscopic protective lead barriers on the
tower unit are in place and place upper and lower
lead shields under the patient as
appropriate. PULSE COLLIMATE / NO MAGNIFICATION
Bring the image intensifier tower as close as
possible to the patient. Preset the collimators
to the likely field of view and position the unit
over the anatomic location of interest prior to
beginning fluoroscopy STEP LIGHTLY Step lightly
on the fluoroscopy pedal. Hand or foot controls,
intermittent visualization only as needed. Most
images obtained during the study can be screen
saves without any additional radiation. If more
detail is needed some images can be camera spots
with no need for cine or cassette film
images. FLUOROSCOPY TIME Check fluoroscopic time
used, document time/dose information as per the
policy of hospital/ department
52
Radiation Safety Officer
  • Any institution that uses radiation for
    diagnostic and/or therapeutic purposes must name
    a radiation expert as their Radiation Safety
    Officer (RSO). This individual is responsible
    for the day-to-day safe use of radiation at the
    institution.
  • Find out who is the RSO at your facility and
    dont hesitate to contact the Radiation Safety
    Officer with any questions you may have.

53
Quiz
  • Which parameter effects the penetration of an
    x-ray beam through a patient?
  • kVp
  • mA
  • Both
  • Automatic brightness control (ABC) _______ the
    quantity of radiation for large patients
  • Increases
  • Decreases
  • Has no effect
  • Correct fluoroscopy technique requires which of
    the following to be close to the patient
  • X-ray tube
  • Image intensifier
  • Does not matter

54
Quiz
  • Which of the following reduces patient dose?
  • Last image hold
  • Pulsed fluoroscopy
  • Both of the above
  • Which of the following is better technique to
    reduce patient dose?
  • Use of collimation
  • Use of magnification mode
  • Neither has an effect on dose
  • For c-arm fluoroscopy, which is better?
  • Position x-ray tube under table
  • Position x-ray tube over table
  • It does not matter

55
Quiz
  • When wearing a single radiation badge during a
    fluoroscopy procedure, it must be worn
  • Attached to the thyroid collar
  • Underneath the lead apron at the waist
  • There is no need for radiation badges in
    fluoroscopy
  • The biggest concern for patients receiving high
    dose fluoroscopy is
  • Skin damage
  • Cancer induction
  • Both concerns are equal
  • Fluoroscopy procedures should never be performed
    on a pregnant woman.
  • True
  • False

56
Quiz
  • The most productive means of reducing radiation
    exposure during fluoroscopy is
  • Wearing lead garments
  • Reducing fluoroscopy time
  • Both of the above

57
PHYSICIAN ATTESTATION FLUOROSCOPY CREDENTIALING
I have read the material on radiation safety and
fluoroscopy and understand the operation and
radiation safety features of the fluoroscopic
units that I will use. Print Name
___________________________ Department
____________________________ The information
presented in this training document is designed
to give a practitioner a basic knowledge of
radiation safety principles as they apply to the
use of fluoroscopy. In addition, the practitioner
must have knowledge and experience in the use of
the specific radiographic systems which they will
utilizing. This attestation must be submitted and
filed with the department chairman who privileges
physicians to perform specific fluoroscopic
procedures. The responsibility for delineation
of clinical privileges ultimately lies with the
department chairman. Signature
_______________________________________ Date
___________
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