We conducted a comprehensive study to assess radiation exposure in the Cardiac Catheterization Laboratory (Cath lab) for operators, nurses, technicians, and patients. This study represents the first of its kind in the Africa-Middle East region, shedding light on the critical role of radiation protection in reducing radiation exposure for patients and healthcare personnel in the Cardiac Catheterization Laboratory. Additionally, it evaluates the extent to which operators, nurses, and technicians adhere to radioprotective measures.

Understanding the importance of minimizing patient radiation exposure, which inherently reduces operator risk [9], is pivotal. It is essential to recognize the challenges associated with implementing radiation protection measures, given the invisible nature of radiation and its predominantly long-term effects [10]. These challenges became evident during the study, underscoring the significance of Phase II, aimed at heightening awareness among staff.

The Society for Cardiovascular Angiography and Interventions has consistently emphasized the importance of physicians possessing knowledge in radiation physics and X-ray machine operation, considering it their responsibility to comprehend this knowledge base. Simultaneously, hospitals are mandated to monitor and ensure worker safety, particularly regarding optimal occupational exposure to radiation [1]. Our initiative was prompted by the need to enhance radiation awareness and documentation.

An evaluation of radiation doses received by healthcare personnel revealed that the doses often exceeded annual radiation exposure limits. This observation may be attributed to our prevailing "Angiographic culture," which prioritizes the optimization of angiographic procedures while potentially overlooking radiation hazards for operators, patients, and the environment [11].

Numerous studies have highlighted the importance of incorporating shielding systems to primarily minimize the radiation dose received by operators [12, 13]. In a pre-clinical investigation conducted by Dixon et al. [12], a recently developed radiation shielding system demonstrated equivalent effectiveness to traditional lead aprons, leading to a notable decrease in scatter radiation doses.

In a recent publication, the cardiac catheterization team at the Cleveland Clinic shared their experience in radiation dose reduction. They implemented advanced protocols, including reducing the fluoroscopic frame rate to 7.5 frames per second, installing a low dose mode for acquisition on the foot switch, and introducing a pulse detector dose reduction. This protocol yielded a significant reduction in radiation exposure to patients, along with decreased air kerma and kerma area products [14].

Balancing the use of low radiation doses with the need for high-quality imaging for accurate diagnosis is crucial, aligning with the ALARA (As Low As Reasonably Achievable) and AHARA (As High As Reasonably Achievable) principles [15]. This implies that the goal is not to eliminate radiation exposure but to make it appropriate. Despite the absence of a statistically significant reduction in fluoroscopy time between Phases I and III, data from operator radiation exposure in these phases indicated a statistically significant reduction in the cumulative radiation dose in Phase III. This reduction could be attributed to the increased awareness fostered during Phase II, leading to greater utilization of radiation protection equipment, especially lead aprons and table protection shields.

Our findings revealed that the radiation dose exposure for nurses and technicians remained relatively unchanged between the two phases. Notably, nurses' exposure to radiation may surpass recommended limits and even exceed that of the operators [16]. This discrepancy may stem from a lack of awareness regarding factors influencing radiation dose, including proximity to the radiation source, tube geometry, procedure type, and time spent in the Cath lab [16]. Consequently, greater efforts are warranted to enhance awareness of radiation protection optimization among Cath lab personnel [17, 18].

Phase III unveiled a statistically significant correlation between the total radiation dose received by operators and both the total procedure time and fluoroscopy time. This correlation clarifies the elevated radiation dose received by operator number 9, who had the lengthiest procedural time, driven by a substantial caseload of complex coronary cases, including chronic total occlusion cases. This underscores the importance of implementing real-time radiation monitoring within the Cath lab, providing instantaneous auditory feedback and real-time reporting of operator radiation dose [10]. This technology's significance is supported by the results of the RadiCure randomized control trial, conducted by Christopoulos G. et al., which demonstrated a substantial reduction in operator radiation exposure in cardiac catheterization laboratories through the use of real-time radiation monitoring devices [10].

Our data further disclosed a noteworthy reduction in total radiation doses received by patients in Phase III, exhibiting a significant correlation with fluoroscopy time across both phases. This underscores the benefits of optimizing radiation protection practices for both healthcare personnel and patients. Patients are particularly susceptible to direct deterministic effects of radiation, rather than the long-term stochastic effects, with potential adverse effects on hair and skin, ranging from mild to severe [19].

The findings of our study revealed a significant challenge in terms of compliance with radiation protection measures among operators, nurses, and technicians in the Cardiac Catheterization Laboratory (Cath lab) at Cairo University Hospital. This challenge arose not only from a lack of awareness regarding radiation hazards but also from inadequate adherence to protective measures. Despite the suboptimal compliance observed, there was a notable reduction in radiation doses among operators when some attention was given to radiation protection measures. This juxtaposition suggests that while compliance may be an issue, the implementation of protective measures, even to a limited extent, can still yield positive outcomes in terms of reducing radiation exposure.

Our study's compliance results diverged from those reported by Abuzaid et al. in July 2017 at the University of Sharjah [20]. In our study, overall adherence scores ranged from 46.4 to 67.8%, with a mean score of 56.7 ± 7. In contrast, Abuzaid et al. [20] reported adherence scores ranging from 13.3 to 100.0%, with a mean score of 75.2% ± 18.5 in their study. These differences may be attributed to variations in the awareness programs, institutional policies, or cultural factors influencing compliance across different settings. The observed suboptimal compliance underscores the need for intensified efforts in educating and motivating healthcare personnel within the Cath lab about the importance of adhering to radiation protection measures. This includes raising awareness about the potential risks associated with radiation exposure, emphasizing the long-term benefits of compliance, and providing continuous training on the proper utilization of protective equipment.

Addressing the reasons behind the observed non-compliance is crucial for developing effective strategies. Possible contributing factors may include a lack of understanding about the potential harm caused by radiation, time constraints during procedures, or a perception that the protective measures may impede the efficiency of the cardiac catheterization processes. Interventions to enhance compliance could involve regular and targeted training sessions, incorporating real-life case scenarios to illustrate the impact of non-compliance on both healthcare personnel and patients. Additionally, fostering a culture of open communication within the Cath lab, where concerns and challenges related to radiation protection are openly discussed, can contribute to a collective commitment to compliance.

It is worth noting that achieving optimal compliance is an ongoing process that requires continuous monitoring, feedback, and reinforcement. Implementing a feedback loop that provides timely information on individual and collective compliance levels, coupled with recognition for adherence to protocols, can contribute to a positive shift in attitudes and behaviors regarding radiation protection within the Cardiac Catheterization Laboratory.

Clinical implications and learning points

This study constituted a foundational assessment of compliance with radiation safety standards; however, it transcended mere evaluation and spurred a commitment to enhance practices within our department. Several measures were undertaken to enhance our radiation safety protocols, including:

1.

Implementation of Personal Thermoluminescent Dosimeters (TLDs) The successful adoption of personal TLDs by most operators was a pivotal step in enhancing radiation monitoring and ensuring the safety of our team.

2.

Comprehensive Training Rigorous training programs were conducted for operators, nurses, and technicians, focusing on identified areas of improvement. This initiative provided a comprehensive understanding of our department's radiation safety practices, enabling us to align more closely with international standards.

3.

Knowledge Sharing Collaboration with other departments exposed to radiation was established to disseminate the insights gained from our study. This knowledge-sharing endeavor aimed to enhance quality control and improve outcomes across multiple departments.

Recommendations

Based on the findings from the study, several recommendations can be made to improve radiation safety for both medical staff and patients. These recommendations aim to address specific issues identified in the study:

A.

Recommendations for Cardiologists:

1.

Procedure Optimization Balance procedure distribution among cardiologists and evaluate and minimize procedural times to reduce cumulative radiation exposure. Also, limit the use of the acquisition (cine) to minimize the received radiation dose.

2.

Continuous Training Provide ongoing radiation safety training, and highlight the correlation between procedural times and radiation doses

3.

Equipment Maintenance Ensure regular calibration of fluoroscopy equipment

4.

Monitoring and Feedback Implement continuous monitoring of individual radiation doses and provide timely feedback to promote awareness and improvement.

5.

Adherence to Protective Measures Emphasize the importance of wearing protective lead aprons, and thyroid collars, using the protective glass shield all the time, and monitoring and enforcing protective measures during fluoroscopy.

6.

Environmental Protection Reinforce keeping doors closed throughout procedures.

B.

Recommendations for Nurses and Technicians:

1.

Training and Awareness Provide radiation safety training and encourage awareness and adherence to safety protocols.

2.

Regular Monitoring Implement a system to track and analyze radiation doses and establish thresholds for cumulative doses, triggering reviews or additional training.

C.

Recommendations for Patient Protection:

1.

Educational Initiatives Develop patient education programs on risks and benefits and encourage patient collaboration in safety.

2.

Optimize Imaging Techniques Explore and implement advanced imaging techniques.

3.

Utilize Protective Shields Promote routine use of shields to protect patients.

D.

Overall Quality Improvement:

1.

Conduct periodic audits of safety practices and use the audit results for continuous improvement.

2.

Foster a collaborative culture among staff members and support ongoing research in radiation reduction technologies.

Implementing these recommendations will enhance radiation safety, minimize occupational exposure, and optimize patient care outcomes in the cardiac catheterization unit. Regular reviews and adjustments to protocols will contribute to a culture that prioritizes the well-being of both staff and patients.

Limitations of the study

It is imperative to acknowledge certain limitations within our study including:

1.

Organ-Specific Radiation Impact This study did not evaluate the impact of radiation exposure on specific organs, including the thyroid, eyes, bone marrow, and brain. These organs can be susceptible to serious complications, including premature cataracts. Consequently, the involvement of specialized ophthalmologists and organ-specific assessments is imperative in future studies.

2.

The research is conducted at a single center, rather than multiple centers.

3.

The nature of the study is cross sectional, which carries inherent limitations. Cross-sectional studies cannot establish a cause-and-effect relationship, are susceptible to selection and information bias, and are prone to confounding.

4.

The study period was relatively short, leading to constraints on the selected sample size.

Potential future research directions

To advance radiation safety in cardiac catheterization units, future research should focus on enhancing safety protocols and conducting detailed organ-specific radiation impact assessments. Key areas for exploration include the development of advanced protocols using artificial intelligence for real-time monitoring, tailoring radiation doses based on individual patient characteristics, and evaluating emerging technologies for dose reduction; including comprehensive data collection for operators that encompass factors such as the operator's experience, the number of procedures conducted by each operator, and the nature of the procedures including but not limited to chronic total occlusions (CTOs), bifurcations, structural interventions, and electrophysiological procedures, such as pacemaker installations which would augment the data collection process, ensuring a more detailed understanding of operator-related variables in the study. In-depth studies on the organ-specific impact of radiation, long-term follow-up of healthcare professionals, and research on patient-centric approaches are essential. Collaborative multi-center initiatives, integration of quality improvement strategies, and ethical considerations in research practices are crucial aspects to explore. By looking into these research areas, the scientific community may make a significant contribution to the continued development of radiation safety in cardiac catheterization facilities, creating a safer and more effective healthcare environment for all the staff and the patients involved.