University of California San Francisco SCAI Position Statement on Occupational Health Hazards of the Cath Lab Shifting the Paradigm for Healthcare Workers Protection Disclosures None Charles Chambers Memorial Symposium ID: 932613
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Lloyd W. Klein MDClinical Professor of MedicineUniversity of California, San Francisco
SCAI Position Statement on Occupational Health Hazards of the Cath Lab: Shifting the Paradigm for Healthcare Workers' Protection
Slide2DisclosuresNone
Slide3Charles Chambers Memorial Symposium
Dedicated to Dr Charles Chambers Who showed me that this was an interesting and important field And well worth the effort
Slide4The Interventional Laboratory Also Poses Workplace Hazards to Interventional Physicians & Staff Klein et al: Cath CV Intervent 2009; 73:432/J Vasc Intervent Radiol
2009; 20:147
Occupational Health Hazards in the Interventional Laboratory Time for a Safer Environment
Slide5Origin of Patient & Staff Safety RisksIonizing radiationScatterLack of attention to angulation and radiation parametersNon-mandatory and often uneducated use of shielding
Personal protection creates orthopedic problemsCost
Slide6Slide7X-rays Traverse the Patient
X-ray Tube
Generator
A few x-rays get through. Most are absorbed, attenuated or scattered.
Skin exposure greatest.
Much occupational scatter below table.
Image Intensifier
The x-ray beam diverges as it leaves the x-ray tube.
Patient
Slide8Radiation Exposure to Operator
Balter S. Categorical Course RSNA 1998, p226
mSv/
hr
lines
45 deg LAO, 20 deg cranial
30 deg RAO
X-ray tube
YOU
X-ray tube
YOU
Slide9Biologic Effects of Radiation
Deterministic injuries When large numbers of cells are damaged and die immediately or shortly after irradiation. Units of Gy. There is a defined threshold dose for visible post procedure injury from erythema to skin necrosis. Stochastic injuries Post radiation damage, cell descendants are clinically important. Higher dose, the more likely the process, and therefore based upon probability statistics. There is a linear non-threshold dose
identifiable for radiation-induced neoplasm and heritable genetic defects. This is defined in units of Sv.
Slide10Radiation Risks to the OperatorOrthopedic injury
: Interventionalists have high rates of orthopedic injury. Approximately 50 % of respondents reported at least one orthopedic problem.Brain tumors: Interventionalists are typically positioned with the left side of their body close to the patient’s chest and X-ray source, 86 % have been located on the left side of the brain. The average radiation exposure left side of the head is 4.7 times the dose of the right. Vascular aging: New research provides evidence that continued exposure to low-dose ionizing radiation also increases cardiovascular (CV) risk. Carotid intima-media thickness (CIMT) and leukocyte telomere length (LTL) are markers for atherosclerosis and biological aging, respectively.Cataracts: 50% of interventional cardiologists have lens changes that are a precursor to cataracts commonly associated with radiation exposure. Thyroid disease: includes malignant and benign thyroid tumors.
Slide11How do we minimize occupational risk?The (modified)
As Low As Reasonably Achievable principleTimeKeep the time per frame to a minimumKeep the number of shots to a minimumMinimize fluoroscopic timeShielding Use proper barriers to block or reduce ionizing radiation. Use all available shielding, barriers and eyewearPay close attention to the relationship between the patient, the x-ray source, the source to image distance, and you
DistanceInverse square law: radiation exposure decreases as a function of 1/d2Stay as far away from the x-ray source as possible
Enhanced Awareness
Slide12Incidence of Spine Problems (cervical & lumbar) Correlates with Years Worked
Goldstein JA et al. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice.
Catheter Cardiovasc
Interv 2004; 63 (4): 407-411.% Incidence
Slide13SCAI 2014 Survey
Klein et al. Occupational health hazards of interventional cardiologists in the current decade. Results of the 2014 SCAI membership survey. Catheterization and Cardiovascular Interventions 2015: 86(5): 913-24.
Slide14Work-Related Musculoskeletal Pain Among Employees Involved in Procedures With Radiation Exposure, Analyzed by Job Description (Mayo Clinic)
Slide15Andreassi et al JACC Cardiovasc Interv. 2015;8:616-27.
Relationship of Illness with Exposure to the Cath Lab
Slide16Carotid IMT & Cath Lab exposure
Andreassi et al JACC CV Int 2015; 8: 617-627.
Slide17Leukocyte Telomere Length
Andreassi et al JACC CV Int 2015; 8: 617-627.
Slide18Klein, Campos J Inv Card 2018; 35: 75-76
Slide19Management & Economics Dictate the ResultAccepting the profit motive as an authentic origin, and finding the courage to change business practice, is the only path to innovative cath lab design and shielding techniques that can prevent these occupational hazards.
The true economic cost of thinking of interventional staff as expendable is vastly underappreciated, but more importantly, as a principle of personnel management, disingenuous. Accepting the risks as part of a self-deceptive bargain should not be necessary. The time may come when this hazardous work environment may need to be actively regulated by federal and state agencies; and one can readily conceive of personal injury cases being brought, as has happened in many other occupations.Klein & Bazavan Circ Int 2016
Slide20Multi-Society Position Statement 2020
Klein LW et al. Catheterization and Cardiovascular Interventions 2020; https://doi.org/10.1002/ccd.28579. Journal of the American College of Cardiology 2020; 75: 1718-1724.
Slide21Klein LW et al. Catheterization and Cardiovascular Interventions 2020; https://
doi.org/10.1002/ccd.28579. Journal of the American College of Cardiology 2020; 75: 1718-1724.
Slide22Klein LW et al. Catheterization and Cardiovascular Interventions 2020; https://
doi.org/10.1002/ccd.28579. Journal of the American College of Cardiology 2020; 75: 1718-1724.
Slide23Under development
Digital Amplification of ImagesLess images/sec in each cine runRoboticsLead mounted on floor, suspended from ceilingsShielding mounted on and around the image intensifier
Slide24The Pathway Forward
Consistent application and adherence to established and procedural processes; Widespread adoption and utilization of novel commercially available protection systems; Encouragement and support to further develop even more effective equipment and processes that facilitate enhanced safety and protection in the workspace;Support individual physicians, teams and practices, especially those that are hospital owned; Clinician leaders should speak authoritatively to hospital administration and industry partners regarding these concerns without fear of reprisal;Consider formal Physician Labor OrganizationsKlein LW et al. Catheterization and Cardiovascular Interventions 2020. JACC pending.
Slide25“If the same level of ingenuity and commitment which produced the incredible innovations that have transformed the practice of interventional medicine were applied to enhancing workplace safety, then the career of an interventionist would undoubtedly be more comfortable, healthier and longer.
”Occupational Health Hazards in the Interventional Laboratory:Time for a Safer Environment:Klein et al Radiology 2009; 250: 538-544; Cath CV Int 2009; 73: 432-436
Conclusion