Skip to Content

Introduction

The Guideline for Radiation Safety has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective June 15, 2015. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance for preventing patient and health care worker injury from ionizing radiation exposure during therapeutic, diagnostic, or interventional procedures performed in the perioperative environment. Guidance for low-dose-rate and high-dose-rate brachytherapy using ionizing radiation is included. This guidance applies to patients, perioperative team members, and the caregivers of patients who receive brachytherapy or other radioactive therapeutic implants.

A review of the literature provided evidence that perioperative team members and patients are exposed to radiation in nearly all perioperative specialties (eg, general surgery, urology, neurosurgery, peripheral vascular surgery, cardiac surgery, endoscopy, orthopedics).1,2  These procedures are performed in various settings (eg, operating rooms [ORs], ambulatory surgery centers, inpatient and outpatient endoscopy suites, physician offices). In some situations, such as when a patient has brachytherapy implants, radiation safety practices extend beyond the clinical setting into the community.3 

Studies have demonstrated that ionizing radiation can have adverse effects on the human body; therefore, patients and personnel should be protected from unsafe levels of ionizing radiation.4-8  The adverse effects of radiation are classified as deterministic or stochastic. The deterministic effects of radiation (eg, skin erythema, hair loss, cataract formation, infertility, circulatory disease) appear at various times after the exposure.9-13  There have been reports of deterministic effects appearing as soon as 24 to 48 hours after the exposure and as long as three to four years after the exposure.14,15  The deterministic effects frequently appear at the radiation entrance site (eg, back, neck, buttocks, anterior of the chest).1,4,6  The stochastic effects (eg, cancer, genetic effects) can appear at any time after the exposure, but usually appear after several years.13,15-17  The stochastic effects occur when radiation causes a mutation within the cell or cell death. For both the deterministic and stochastic classifications, the severity and type of damage are related to the dose received (ie, the greater the dose, the greater the damage). Several factors affect the radiation dose delivered to the patient and personnel, including

  • patient positioning,

  • image magnification,

  • fluoroscopy duration,

  • maintenance of a single beam angle,

  • use of high-intensity mode,

  • dose monitoring,

  • x-ray beam angulation, and

  • mechanical defects in the radiation source.

When these factors are controlled by the perioperative team, the dose of radiation received by the patient and the team members will be decreased.4,18 

The potential for some stochastic effects in patients may be low. Based on a 2009 literature review on ovarian radiation sensitivity and the genetic hazards of ionizing radiation in female mammals including humans, Adriaens et al19  concluded that much of the literature involved irradiated animals and that the probability of genetic effects in humans resulting from exposure to radiotherapy or radiological examinations and accidental exposure is lower than the risk of genetic effects resulting from spontaneous risks (eg, exposure to the sun). The authors reviewed international articles from the 1970s, articles published between 1990 and 2008 identified in a MEDLINE® search, and additional articles acquired from citations in the literature.

The amount of radiation received by perioperative team members is affected by the direction of the beam, the beam quality, the field size, the position of the operator according to the position of the beam originator, and the dose required to produce a clear image.20  The radiation dose required varies among procedures, among operators, and among patients undergoing the same procedure.4,6 

Radiation may be generated by various modalities (eg, C-arm [eg, standard, mini], O-arm, computed tomography [CT], mobile or fixed fluoroscopy, portable x-ray machine)16,21  or by direct delivery methods (eg, brachytherapy using seeds or balloons, intraoperative radiation therapy).1  The modality or method chosen for delivery of radiation depends on the procedure being performed.

Perioperative team members are exposed to radiation from three different sources, including

  • primary radiation, which is emitted directly from the source;

  • leakage radiation, which emanates from the x-ray machine housing; and

  • scatter radiation, which is reflected off of the patient, table top, and shielding material.22 

The main source of radiation for personnel in the perioperative setting is frequently scatter radiation, but the source depends on where the person is located in respect to the device generating the radiation.23 

The effects of radiation have been known for more than 100 years, and this knowledge has led to the creation of practices to help protect patients and personnel, including5 

  • minimizing time spent near a radiation source,22 

  • maximizing distance from a radiation source,22 

  • using effective shielding,5,22 

  • controlling contamination,22  and

  • participating in educational programs.5,22 

The following subjects are outside the scope of this document:

  • management of radioactive specimens (See the AORN Guideline for Specimen Management),24 

  • the informed consent process for examinations or procedures that involve radiation,

  • collimation (ie, determining the size of the area of the beam),

  • the principles of justification (ie, a risk-benefit assessment completed by the person requesting the exam),

  • precautions to be taken during magnetic resonance imaging (MRI) and positron emission tomography (PET)/CT scanning,

  • procedural equipment selection, and

  • measures to calculate or regulate the patient’s dose of radiation.

Evidence Review

A medical librarian conducted a systematic search of the MEDLINE® and CINAHL® databases and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized controlled and non-randomized trials and studies, case reports, letters, reviews, and guidelines. The librarian also searched the Scopus® database, although not systematically. The search was limited to literature published in English from January 2006 through January 2014.

Search terms included invasive procedures, interventional procedure, interventional radiography, interventional radiology, intraoperative radiotherapy, cardiac catheterization, heart catheterization, abdominal radiography, radiation, ionizing radiation, iodine radioisotopes, radioactive tracer, radiation safety officer, safety management, radiation safety procedures, risk assessment, occupational radiation dose, occupational diseases, occupational exposure, occupational health, occupational hazards, radioprotection, radiation protection, radiation safety precautions, protective clothing, protective gloves, protective devices, eye protective devices, goggles, glasses, lead shield, lead apron, leaded garment, equipment failure, radiation injuries, patient safety, radiation monitoring, radiopharmaceuticals, radioactive pollutants, radioactive waste, medical waste, medical waste disposal, radiation field, storage, handling, transport, hazardous waste, occupational accident, thermoluminescent dosimetry, dosimeter, radiometry, staff dose, fetus, fertility, gonads, pregnancy, and pregnancy outcomes. These terms were searched in combination with terms such as healthcare facility, health care facility, ambulatory care facility, surgicenter, ambulatory surgery, outpatient surgery, operating room personnel, interventionalist, surgeon, nurse, anesthesiologist, anaesthesiologist, operator, operating room, operating theater, operating suite, and surgical suite.

At the time of the search, the librarian established weekly alerts on the search topics and until July 2014, presented relevant results to the lead author. During the development of this document, the lead author also requested supplementary literature searches and additional literature that either did not fit the original search criteria or was discovered during the evidence-appraisal process. The time restriction was not considered in these subsequent searches. Relevant guidelines from government agencies and standards-setting bodies also were identified.

Inclusion criteria were research and non-research literature in English, complete publications, relevance to the key questions, and publication dates within the time restriction unless none were available. Excluded were non-peer-reviewed publications, literature that examined radiation safety measures that were determined to be beyond the scope of this document (eg, columnation, methods to decrease fluoroscopy time), and literature outside the time restriction when literature within the time restriction was available. Low-quality evidence was excluded when higher-quality evidence was available. In total, 1,397 research and non-research sources of evidence were identified for possible inclusion; of these, 248 were cited in this guidance document (Figure 1).

Figure 1.
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Articles identified by the search were provided to a project team that consisted of the lead author and four evidence appraisers. The lead author and the evidence appraisers reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference, as applicable.

The methodology of the research and non-research evidence used to support this guideline was critically evaluated by the authors for validity and generalizability to current practice. The collective evidence supporting each intervention within a specific recommendation was summarized, and the AORN Evidence-Rating Model was used to rate the strength of the collective evidence. Factors considered in the review of the collective evidence were the quality of the evidence, the quantity of similar evidence on a given topic, and the consistency of the evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

In the literature, various metrics were used to report the dose of radiation received; the abbreviations used are listed in Table 1.25  Additional dose-related definitions are provided in the glossary.

Table 1.

Radiation Dosagea Metrics1-3

Term  Abbreviation  Definition 
Roentgen equivalents (mammal)  rem  1 roentgen 
Millirem  mrem  0.001 rem 
Millirad  mrad  0.001 rad 
Sievertb  Sv  100 rem 
Millisievert  mSv  0.001 Sievert 
Microsievert  µSv  0.0001 Sievert 
Grayc  Gy  100 rad 
Milligray  mGy  0.001 gray 
Microgray  µGy  0.0001 gray 
Term  Abbreviation  Definition 
Roentgen equivalents (mammal)  rem  1 roentgen 
Millirem  mrem  0.001 rem 
Millirad  mrad  0.001 rad 
Sievertb  Sv  100 rem 
Millisievert  mSv  0.001 Sievert 
Microsievert  µSv  0.0001 Sievert 
Grayc  Gy  100 rad 
Milligray  mGy  0.001 gray 
Microgray  µGy  0.0001 gray 

a Radiation dose is usually expressed in standard international units (SI).

b Effective dose or equivalent dose of radiation received is usually expressed in Sieverts. Equivalent dose may be further defined as deep-dose equivalent or shallow-dose equivalent.

c Absorbed dose is usually expressed in Gray.

References

1.

Lakkireddy
D
,
Nadzam
G
,
Verma
A
, et al.  .
Impact of a comprehensive safety program on radiation exposure during catheter ablation of atrial fibrillation: a prospective study
.
J Interv Cardiac Electrophysiol
.
2009
;
24
(
2
):
105
112
.

2.

Weiss
EM
,
Thabit
O
.
Clinical considerations for allied professionals: radiation safety and protection in the electrophysiology lab
.
Heart Rhythm
.
2007
;
4
(
12
):
1583
1587
.

3.

29 CFR 1910.1096
.
Toxic and hazardous substances: Ionizing radiation
.
Occupational Safety and Health Administration
. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10098. Accessed April 13,
2015
.

Abbreviations for a number of organizations that author clinical guidelines are used throughout this document. All organization names are spelled out on first reference and the abbreviations are used in subsequent occurrences. Table 2 is provided for easy reference to those organizations that are cited multiple times in the document.

Table 2.

Abbreviations for Clinical Guideline Author Organizations

Abbreviation  Organization 
AAPM  American Association of Physicists in Medicine 
AAWR  American Association for Women Radiologists 
ACR  American College of Radiology 
AORN  Association of periOperative Registered Nurses 
APDR  Association of Program Directors in Radiology 
ASGE  American Society for Gastrointestinal Endoscopy 
CIRSE  Cardiovascular and Interventional Radiological Society of Europe 
ESGE  European Society of Gastrointestinal Endoscopy 
ICRP  International Commission on Radiological Protection 
NRC  US Nuclear Regulatory Commission 
SCAI  Society for Cardiovascular Angiography and Interventions 
SGNA  Society of Gastroenterology Nurses and Associates 
SIR  Society of Interventional Radiology 
SPR  Society for Pediatric Radiology 
Abbreviation  Organization 
AAPM  American Association of Physicists in Medicine 
AAWR  American Association for Women Radiologists 
ACR  American College of Radiology 
AORN  Association of periOperative Registered Nurses 
APDR  Association of Program Directors in Radiology 
ASGE  American Society for Gastrointestinal Endoscopy 
CIRSE  Cardiovascular and Interventional Radiological Society of Europe 
ESGE  European Society of Gastrointestinal Endoscopy 
ICRP  International Commission on Radiological Protection 
NRC  US Nuclear Regulatory Commission 
SCAI  Society for Cardiovascular Angiography and Interventions 
SGNA  Society of Gastroenterology Nurses and Associates 
SIR  Society of Interventional Radiology 
SPR  Society for Pediatric Radiology 

 

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.

Read MoreShow Less

Access Options

If you would like to learn more about purchasing a subscription to this content, please click the appropriate button below.

Learn about facility access

Learn about individual access