As fluoroscopy use grows, so do efforts to keep it safe

Fluoroscopy has become an increasingly used modality across a variety of specialties -- a trend that translates to improvements in patient care. 

But this trend is also prompting a need to ensure its safe use.

That's why experts from the American College of Radiology (ACR) are actively addressing the issue of fluoroscopy safety, particularly the need to standardize training, radiation doses, and to establish a strong "safety culture."

"Improving the wide variability in fluoroscopy safety culture requires intentional institutional support, including empowered safety champions, adequate staffing, routine protective‑equipment checks, and non-punitive reporting," wrote a team led by Dustin Gress of the ACR in a recommendation document created by the college's Blue Ribbon Panel on Fluoroscopy Safety (BRP-FS) and published in the Journal of the American College of Radiology. The panel included representation from 32 organizations.

"The recommendations of the Blue Ribbon Panel are rooted in principles that many organizations and experts have long supported," Gress and the college's CEO Dana Smetherman, MD, said in a statement to AuntMinnie.com. "What makes this effort unique is that the ACR created an inclusive, multidisciplinary forum in which representatives from across medicine, industry, regulatory bodies, and professional societies could collectively agree on those principles and identify practical, achievable actions to move the field forward. We believe that these recommendations are key to the future of patient and personnel safety, and the consensus behind them is extraordinary."

Fluoroscopy uses radiatDana Smetherman, MDDana Smethermanion to procure real-time images of moving anatomic structures; to guide interventional procedures such as cardiac catheterizations; and to install devices such as stents, catheters, and pacemakers. "Noninvasive and minimally invasive procedures that use fluoroscopy are an integral part of patient care," Gress and colleagues noted, writing that "[the procedures'] benefits greatly exceed the associated risks when used responsibly by appropriately trained individuals."

In fact, the modality is now used across a broad range of specialties, including radiology, cardiology, orthopedics, urology, pain management, vascular surgery, gastroenterology, neurology, and neurosurgery, coauthor Mahadevappa Mahesh, PhD, of Johns Hopkins Health Systems in Baltimore, told AuntMinnie.com.

"The advantage of visualizing objects without having to operate is the driving force behind the wide use of fluoroscopy," he said. "Also, the advances in digital detectors and capabilities of fluoroscopy devices to operate for a long time and the ease of their use has further driven the technology to all corners of medicine. Historically, fluoroscopy procedures were predominantly performed in radiology and later trickled into cardiology, but in the past 10 to 15 years, with the shift towards minimally invasive and image-guided procedures, fluoroscopy has become an essential tool across many specialties."

Mahadevappa Mahesh, PhDMahadevappa Mahesh

Yet this increasing number of specialties using the modality has prompted concerns about variations in training requirements and expectations, Mahesh said. He cautioned that "even though the use of fluoroscopy has expanded across various specialties, education, training and safety practices have not caught up or are not uniform."

"Fluoroscopy safety can be confounded by a number of challenges, including but not limited to inconsistent state, federal, and international regulatory requirements; concerns regarding scope of practice; and dose index monitoring," recommendation authors wrote.  

"One of the biggest challenges is the sheer diversity of fluoroscopy users," Mahesh noted. "Unlike some imaging modalities that are more concentrated within a single specialty (such as radiology), fluoroscopy is used by professionals with very different training backgrounds, procedural needs, and levels of experience with radiation physics and radiation safety. Historically, radiologists in the United States have to undergo rigorous radiation physics education during their residency training and are subsequently examined during the board certification process. This is not the case with other specialties."

As well, fluoroscopes from assorted manufacturers use controls that function differently, despite looking similar, "which can create confusion and increase the learning burden for user," he said.

Standardizing safety

The ACR panel offered the following recommendations to address fluoroscopy safety:

· Sufficient staffing. "Health systems, hospitals, and clinics in which fluoroscopy is used must ensure staffing is sufficient to fulfill clinical needs," according to the panel.

· Effective training. "The BRP-FS recommends that individual facilities in which fluoroscopy is used establish their own educational and training programs, tailored to each person's role in the fluoroscopy environment," the group wrote, adding that "initial training should occur during onboarding and recurrent training should occur at regular intervals to maintain competency in the safe use of fluoroscopic equipment."

· Provision of protective equipment. "Protective garments must be available for different body types and provide proper fit and coverage," the panel wrote. "A radiation safety champion should be appointed to oversee appropriate shielding for staff and operators, including proper fit and coverage of the protective garments."

· Clinical protocol and dose optimization tracking. "Facilities should establish agreed-upon imaging protocol settings for common clinical procedures, ideally customized to use minimal acceptable dose. Lower-dose protocols should be standard, with higher-dose protocols reserved for exceptional cases," recommendation authors noted.

· Intraprocedure actions. The panel recommended procedural time-outs to verify all staff have appropriate protective shielding; the use of appropriate imaging protocols; optimized collimation throughout the procedure; and a "radiation safety champion" in the procedure room.

· Establishment of a practice quality improvement program group. This group should include a range of practitioner types, including a medical physicist and should conduct regular meetings to assess any issues that arise regarding the use of fluoroscopy, Gress and colleagues wrote. 

Safety culture

It's clear that a strong safety culture for fluoroscopy is needed, according to Gress and colleagues, who stressed that there can be a "lack of empowerment of practitioners to speak up in favor of better [fluoroscopy] practices." 

Professional organizations can help distribute radiation safety information through social media campaigns, conferences, webinars, workshops, and publications and can "collaborate with governmental entities, industry stakeholders, and health care institutions to establish and enforce sensible safety regulations, standards, and guidance," to establish this kind of culture, they concluded.

In any case, "a safety culture encourages everyone involved in patient care to prioritize radiation protection, communicate openly, identify potential risks, and continuously improve practice," Mahesh told AuntMinnie.com.