British Institute of Radiology [BIR] & Royal College of Radiologists [RCR]
Comments on ICRP Draft ‘Patient and Staff Radiological Protection in Cardiology’
The British Institute of Radiology [BIR and the Royal College of Radiologists [RCR] welcome the opportunity to comment on the ICRP consultation regarding protection of staff and patients during Cardiology procedures. As the draft highlights, these procedures are often high dose procedures performed by professionals with considerably less training than most radiological professionals and, as such, this draft is a welcome addition to the advice on offer to such practices.
There are many aspects of the draft report that we support including the advice on practical radiation protection, the review of information concerning follow-up after high dose procedures and the emphasis on sound management of a radiation protection programme [system]. These issues require a higher profile and we support their thorough inclusion in your draft.
We are concerned, however, regarding two aspects of your draft report. Our first concern is the exclusion from your report of the positive impact that properly trained radiographers/technologists can make to the radiation protection QAP and to best practice in general, both in their development and also to the continuing adherence to best practice by advising/cajoling cardiologists on a day-to-day basis. This group of staff should not be overlooked.
It is also concerning to see the continual reference throughout your draft to the potential tissue reactions from complex EP procedures. These procedures, if properly managed, should not lead to tissue reactions. The document needs to emphasise this, rather than almost implying that they will. Although some screening times are long, the dose rate from fluoroscopy for these procedures can be kept very low.
Below are specific points raised during our organisations’ deliberations on your draft report;
Line 79; EP procedures should not be associated with high doses and this gives a misleading impression regarding the inevitability of high EP patient dose. At a large UK cardiac centre their 95%tile dose for pulmonary vein isolations [the most complex EP] is 52 Gycm2!
Line 169; same as above, and repeated throughout draft.
Line 171; The statement that these procedures cause an increased risk of cancer ‘in children’ is misleading. There is an increased risk in all patients, but children clearly have an elevated risk coefficient. This line requires qualification to make it clear.
Line 174; the use of the term ‘tool’ is unclear – does it refer to protective devices?
Line 185; We feel ICRP should decide whether to use the term ‘deterministic’ or ‘tissue reaction’ then stick to it.
Lines 215-218; It is unclear to us why you make the distinction between referrer and imager for nuclear medicine and Ct but not for PCIs. It is feasible for a non-imaging cardiologist to refer a patient to a imager. Differences in legislation around the world mean that this statement should be made more general.
Lines 310-315; The training required should be commensurate with role not staff group. Increasing skill mix may require that some nurses receive more training than others. Also, radiographers/technologists not mentioned.
Lines 317-334; It may be better to require that ‘management responsibility’ should lie with a senior cardiologist. The issue here is putting management ownership of safety in the right place. ‘In charge of’ is a potentially misleading term. Duties may then be delegated to appropriately qualified/trained staff to deliver the QAP. In some countries the medical physicist may have some of these duties, in others he/she may advise on all aspects of QAP.
Line 345; There is also a local role in developing acceptable use criteria to reflect the case mix presenting at any particular organisation. This is distinct from the role of national bodies that may set the overarching framework.
Line 347; Why limit optimisation to only these two modalities?
Lines 365-368; Depending upon their involvement, nurses may be required to ensure patient dose minimisation as well as other staff. Also, role of radiographers/technologists requires inclusion.
Lines 376-378; Change ‘in charge of’ to ‘have responsibility for’
Line 778; For completeness, this should include general radiography as well.
Line 839; Why the inclusion of the word ‘even’ in this statement. The reasons for numbers of examinations are complex but do include prevalence. Adult prevalence of heart disease relative to child cardiac structural issues will vary around the world, surely?
Line 851 & 856; Inclusion of information regarding skin recovery time would be most helpful here.
Line 885; As stressed previously, extended fluoroscopy screening times do not necessarily lead to high doses as one is able to reduce the fluoroscopy dose rate.
Lines 1238-1241; Another explanation is that cardiologists do understand radiation but never actually look for effects and when the patient presents to their physician with a skin complain the fluoro is not linked back.
Lines 1267-1269; Also, cardiac procedures are generally not high gonadal dose procedures anyway.
Lines 1300-1310; This sentence is unclear – is the ATM gene the most significant factor resulting in radio-sensitivity?
Lines 2006-2008; see previous comment regarding why differentiate the basic requirements between modalities.
Line 2032; error, should have ‘radiological’ not ‘radio –logical’
Line 2035; need to explain the term ‘RAND’
Para(71); same complaint as for line 2006-8
Para(74); The x-ray unit also requires ‘optimisation’ via correct setting of internal functions. This is achieved via a collaboration between local experts and manufacturers/service agents.
Line 2244; Optimisation during a procedure is often a collaborative affair between a cardiologist and another ‘imager’ operating the x-ray unit, such as a nurse, radiographer or technologist. This collaboration is crucial to good radiation hygiene in the catheterisation laboratory.
Line 2279; For obese patients it is possible to reduce dose by raising the table and imaging off-isocentre. This tip should be included in the ‘during procedure’ section.
Para(82); A radiographer/technologist in-room will also provide sound optimisation strategies for complex or repeated procedures. This should be included.
Para(86); These doses seem on the slightly high side for typical, which we feel are at the bottom end of your range.
Line 2356; To eliminate radiation field overlap, gantry may need to move by 30 degrees – this is not ‘slightly’ as referred to.
Para(94); Consistency is required in follow-up advice.
Line 2502; Error in reference – page numbers are 909-918, NOT 9090-918
Table 5.1; add – ‘Remove grid where possible’ + ‘Program low doses – do not rely on factory settings’
Line 2619; and fitted to both sides of the table
Section 6.2; The relevance of some of this is doubtful. The inclusion of references to radiotherapy is confusing as this has not been previously mentioned. Could this whole section be more succinctly written?
Lines 2689-2690; Notnecessarily true as the catheter may need to be held in position
Line 2701; Change ‘… are particularly well suited’ to ‘maybe’ as it depends upon design and size of room and what procedures are performed.
Line 2702; Depending upon the procedure, the interventionalist may not be protected by ceiling suspended shields.
Para(113); The restriction of use of thyroid collar to only younger staff would be confusing in practice – we prefer to request all relevant staff to wear such protection when indicated by a risk assessment, regardless of age.
Line 2803; It would be useful to explicitly state what ‘correct positioning’ is, e.g. as low on patient as possible, slightly tilted away from imager, casting largest shadow upon staff.
Table 6.3; Why are the kV’s restricted to those values, excluding 100 kVp and 110 kVp?
Line 4265; The use of ‘in-charge’ and the need for clear lines of ‘management responsibility’ have been commented on previously.
Line 4309; We have already commented generally on the need to include radiographers/technologists in your report. They would be invaluable participants in any procurement project
Line 4333; No mention is made of tests to determine to functionality of radiation safety features of an installation [the Critical Examination in UK]. This should be included.
Line 4348; This is another example of where a radiographer/technologist would play a key part
Para(211); We feel the intention of this paragraph should be to say all imaging professionals should have an understanding of expected dose levels in any relevant dose metric – could this para be reworded to better convey the message.
Line 4527; Although the intent of this statement is supported, it is an idea that has not had much discussion. Therefore, could more detail be provided as to how often etc.
Table 10.3, Line 4581; Include ‘the ability to optimise patient dose settings or protocol settings by user’ as #1.
Secretary, Radiation Protection Committee [BIR]
On behalf of BIR & RCR