|Year : 2017 | Volume
| Issue : 4 | Page : 166-174
Safety measures among workers occupationally exposed to ionizing radiation in Tanta University Hospitals
Asmaa A El-Feky1, Rania M El-Sallamy1, Ali A El-Sherbeni2, Hagras El-Mursi Hagras1
1 Department of Occupational Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||11-Mar-2017|
|Date of Acceptance||26-Aug-2017|
|Date of Web Publication||12-Mar-2018|
Asmaa A El-Feky
Department of Occupational Medicine, Faculty of Medicine, Tanta University, Mahalet Marhoun, El Gharbia, Tanta
Background Nowadays, there are wide applications of ionizing radiation in medicine, which can lead to serious health hazards to healthcare workers (HCWs) and nearby environment if safety measures are not properly applied.
Aim The aim of the present work was to assess applied safety measures in workplace and the practice of HCWs occupationally exposed to ionizing radiation in Tanta University Hospitals.
Patients and methods This study was cross-sectional survey study conducted at Diagnostic Radiology Department (11 units), Radiotherapy Department (two units), and Nuclear Medicine Unit (two units) in Tanta University Hospitals. The study participants were 225 HCWs. The study tools included workplace observation checklist and observational checklist for the practice of HCWs toward safety measures.
Results Radiation safety measures were insufficient in 54.4 and 50% of diagnostic radiology units, and radiotherapy units, respectively, but were sufficient in all nuclear medicine units. The majority of HCWs did not wear personal protective clothes and equipment, but they used lead aprons more than any other personal protective clothes and equipment.
Conclusion There was an insufficient application of radiation safety measures in the workplace as well as insufficient protective practices by HCWs. Therefore, HCWs are more prone to the hazardous effects of ionizing radiation rendering us recommending an ongoing audit system to ensure that all aspects of safe work (radiation safety standards) are being strictly adhered to and holding more basic and refreshing training courses that are needed to raise staff safety practice and good performance.
Keywords: healthcare workers, ionizing radiation, safety measures, Tanta University Hospitals
|How to cite this article:|
El-Feky AA, El-Sallamy RM, El-Sherbeni AA, El-Mursi Hagras H. Safety measures among workers occupationally exposed to ionizing radiation in Tanta University Hospitals. Tanta Med J 2017;45:166-74
|How to cite this URL:|
El-Feky AA, El-Sallamy RM, El-Sherbeni AA, El-Mursi Hagras H. Safety measures among workers occupationally exposed to ionizing radiation in Tanta University Hospitals. Tanta Med J [serial online] 2017 [cited 2018 Oct 15];45:166-74. Available from: http://www.tdj.eg.net/text.asp?2017/45/4/166/227117
| Introduction|| |
Uses of ionizing radiation in the medical field continue to increase all over the world. Annually, an estimate of over 3000 million diagnostic imaging and over five million radiation therapy treatments are done worldwide . Recently, United Nations Scientific Committee on the Effects of Atomic Radiation estimated that there are about four billion radiographic examinations performed every year by medical personnel using radiation for diagnostic and therapeutic purposes exposing them to occupational radiation hazards if safety measures are not applied and regularly used . Nuclear medicine (NM) workers are continuously exposed to the risk of ionizing radiation in the workplace in spite using radiation protection (RP) equipment ,.
Overexposure and uncontrolled exposure to ionizing radiation are significant factors causing various cancers and genetic mutations ,,. It also has harmful effect on the entire body systems including the hematopoietic system, digestive system, skin, testicles, ovaries, central nervous system, and eye lens . The International Commission on Radiological Protection (ICRP) has recommended that the annual occupational exposure dose limit to ionizing radiation should not exceed 20 mSv. Therefore, the use of personal dosimeters is mandatory to measure the amount of radiation received by the healthcare workers (HCWs) .
In order to reduce hazardous effects of ionizing radiation certain measures should be strictly followed including continuous workplace radiation monitoring using survey meter to detect the level of radiation in workplace, preplacement and periodic clinical examinations, annual training courses for HCWs, and observing radiobiological standards must be simultaneously considered by radiology personnel ,.
To promote the level of RP, personal protective equipment should be utilized during radiographic processes. These RP devices include lead aprons, lead eye goggles, lead gloves, gonad shields, and thyroid shields. The personal protective equipment is one of the basic preventive measures. Regular use of lead aprons provides an average 75–80% protection of the bone marrow . Lead shielding is one of the primary protective measures to reduce the unnecessary exposure ,.
An audit system gives a clue and detects the gap to the justification of ionizing radiation safety measures standards and procedures .
In Egypt, RP is specified in the legislative Egyptian Law No. 59/1960, according to which both Ministry of Health and the Egyptian Atomic Energy Authority are competent authorities, each with specific jurisdictions, and regulate the licensing and use of radiation sources. Open sources are responsibilities of the Atomic Energy Organization, whereas closed sources and X-ray machines are responsibilities of the Ministry of Health .
Some studies in Egypt and nearby countries have shown inadequate RP in most X-ray facilities ,. In addition, some of them have also reported lack of RP instruments ,.
Hypothesis of the study
Occupational exposure to ionizing radiation in hospital has adverse health effects on HCWs. On prolonged exposure, it can lead to serious consequences on the blood picture such as leukemia and lymphoma and can lead to pancytopenia.
If workers regularly follow occupational health and safety instructions according to occupational health standards, the health hazards can be prevented.
The aim of the present study was to assess applied safety measures in workplace and practice of HCWs occupationally exposed to ionizing radiation in Tanta University Hospitals.
| Participants and methods|| |
Study design and settings
This cross-sectional study was carried out in diagnostic radiology (DR) department, radiotherapy (RT) department, and NM units of DR Department in Tanta University Hospitals during the period between October 2015 and October 2016.This study was conducted in this hospital because there is high work force and all diagnostic procedures and RT maneuvers are carried out leading to high level of exposure to ionizing radiation.
Diagnostic radiology department
The diagnostic radiology department includes 11 units as follows: four units of radiography, two units of mammography, three units of computed tomography, one unit of interventional radiology, and one unit of fluoroscopy.
Nuclear medicine units
NM unit, which is a part of DR Department, includes two units of PET.
Oncology radiotherapy department
Oncology RT department includes two units as following: one unit of linear accelerator and one radiography room.
All HCWs (technicians, nurses, resident physicians, and physicists) occupationally exposed to ionizing radiation in DR department, RT department, and NM units at Tanta University Hospitals available during the study period were included as study population. Thirty-two of 41 resident physicians, 109 of 127 of nursing staffs, 67 of 88 of technicians, and 17 physicists were the target population who accepted to participate in the study (225/273, with a response rate of 82.4%).
Physicians other than resident physicians were excluded from the study as their practice could not be detected because they were not in contact with the patients when they were being examined.
The study tools included Workplace Observation Checklist (tool I) and HCWs Observation Checklist (tool II). The observational checklist of the workplace was derived from the International Atomic Energy Agency (IAEA) standard. It was validated by the Nuclear Safety Standard Committee and was based on ICRP standard , to check the safety measures in the units of the studied departments with the following items: design of radiation working area, personal protective clothing and equipment, and registers and records. HCWs observation checklist (tool II) included the following items: utilizing personal protective clothes and using personal monitoring devices.
The observations were answered as ‘yes’ or ‘no’. Coding for the checklist was done as follows: each positive point was scored as 1 point and each negative point was scored as 0 point. Units that achieved equal or more than two-thirds of the total score (≥66.7%) was considered to have sufficient radiation safety measures, those that achieved from one-third to less than two-thirds (33.4 to <66.7%) were considered to have somewhat sufficient measures, and those that achieved less than one-third (<33.4%) were considered to have insufficient radiation safety measures according to IAEA standards .
Data were collected from mid of October 2015 to mid of April 2016 by direct observation of the workplace and the HCWs by the researcher who filled up tool I and tool II. Each participant was observed and registered by the researcher along their work shift by observing whether they are following the safety and the protective measures or not.
Data were presented and statistically analyzed by using statistical package for the social sciences (SPSS) version 19 (SPSS Inc., Chicago, Illinois, USA). Numerical data were presented as mean and SD and categorical data were presented as number and percentage. The χ2-test was used for statistical analysis. When the χ2-test was not appropriate, the likelihood ratio test was applied. The level of significance was considered at P value less than 0.05.
A formal approval from the dean of the Faculty of Medicine with an official permission letter was obtained and directed to the heads of the selected departments to acquaint them about the objectives of the study and to get their cooperation and facilitation throughout the study.
Approval from the Ethical Committee of Faculty of Medicine was obtained.
Participants were informed about the purpose and procedure of the study and benefits of sharing it. Ethical considerations of the study were in accordance with the Declaration of Helsinki .
| Results|| |
[Table 1] shows that the work force in DR was 121 HCWs, with a mean age of 31.7±7.62 years. 14.9% were resident physicians, 48.8% were nursing stuffs, and 36.3% were technicians. In the RT department, there were 67 HCWs, with a mean age of 33.7±9.82 years. 20.9% were resident physicians, 53.7% were nursing stuffs, 17.9% were technicians, and 7.5% were physicists. In NM units, the work force was 37 HCWs, with mean age of 30.05±5.83 years. 37.8% were nursing stuffs, 29.7% were technicians, and 32.5% were physicists. The majority of HCWs in the RD department, RT department, and NM units were women (74.4, 74.6, and 62.2% respectively). Also, the majority were high degree holders. The mean years of experience were 7.33±5.62, 9.29±10.23, and 5.8±5.4 in DR department, RT department, and NM units, respectively. Only 9.9 and 16.4% of HCWs in DR and RT departments, respectively, had received training programs on radiation safety, whereas 43.2% of HCWs in NM units had received training programs.
|Table 1 Sociodemographic and work related data of the studied healthcare workers in the studied units (n=225)|
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[Table 2]illustrates that the radiation working areas were properly designed for radiation work in the studied departments. The caution signs were present in 45.5% of DR and 50% of RT units compared with all units in NM. Copy of Ionizing Radiation Standard was not posted in all units. In DR departments neither automatically energized audible warning devices nor functioning survey instrument were available compared with 50% of RT department and NM units. However, survey meter instrument was present and used in 100% of NM units. About 80% of radiation equipment was in a special room in DR units compared with 100% in RT department and NM units. 54.5% of DR, 50% of RT, and 100% NM units had lead shielding in walls and doors and appropriate enclosures. All units were provided with air conditioning. All units of NM were provided with fume hood for volatile radionuclide work and were functioning properly. There were statistical significant differences between the studied departments as regard to audible warning devices and functioning survey instrument only.
|Table 2 Workplace design in diagnostic radiology, radiotherapy, and nuclear medicine units|
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[Table 3]shows that the lead aprons were present in 72.7, 50, and 100% of DR department, RT department, and NM units, respectively. About two-fifths of HCWs in DR (39.7%), NM (35.1%), and nearly half (53.8%) in RT units were using them. Gonad shields were not available in all units; hence, all HCWs were not using them. As regard to the thyroid shield and protective goggles, they were present in 27.3% of DR departments and in all NM units, whereas they were not available in RT department. Only 33.9 and 21.6% of HCWs in DR department and NM units, respectively, used the thyroid shield, whereas no one in the RT department used them. Also, only 27.3 and 21.6% of HCWs used the eye goggles in DR department and NM units, respectively. None of the HCWs used protective lead gloves. Regarding personal dosimeters, all NM units were provided with the personal monitoring devices compared with 54.5% of DR and 50% of RT departments. Only 9.1, 22.4, and 54.1% of HCWs received the personal dosimeters and used them in DR department, RT department, and NM units, respectively.
|Table 3 Availability and utilization of personal protective clothes and equipment by healthcare workers in the studied units in diagnostic radiology, radiotherapy, and nuclear medicine units|
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[Table 4]shows that there were written guidelines for emergency situations in only 36.4, 50, and 100% of DR department, RT department, and NM units, respectively. The studied departments notified all cases of accidents. There were no records for survey monitoring, personal monitoring, medical examination, and training program in all DR and RT department. However, all this records were present in all NM units.
[Table 5]shows that the workplace design was sufficient in 100% of NM units and 50% of RT department compared with 0% of DR department with significant difference in between. As regard to the personal protective clothing, it was insufficient in 72.7% in DR and 100% of RT departments, but it was totally sufficient for NM units with statistical significant differences in between. Regarding the personal monitoring devices, it was somewhat sufficient in 45.5 and 50% of DR and RT departments, respectively, compared with 100% sufficient in NM units with statistical significant differences in between. The records and registers were 100% sufficient in NM units compared with 50% in RT department, but insufficient in DR department with statistical significant differences between them. There were no statistically significant differences between the three departments with regards to the total score for safety levels of workplace (P=0.07).
|Table 5 The level of safety measures for different items in workplace in the studied departments|
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[Table 6]demonstrates the levels of safety practices among HCWs in DR department, RT department, and NM units. It revealed that 10.8% of HCWs in NM units had sufficient safety practice compared with 2.5 and 1.5% in RD and RT departments, respectively, with statistically significant differences between them.
|Table 6 The levels of safety practices among healthcare workers in diagnostic radiology, radiotherapy and Nuclear Medicine units|
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| Discussion|| |
The exposure to radiation in medical procedures has become a topic of recent public and scientific discussion. The present study revealed that only 9.9 and 14.4% of HCWs in DR and RT departments, respectively, received training programs about radiation safety ([Table 1]). The results of our study are in accordance with that of Abdellah et al.  (in Egypt), Salih et al.  (in Saudi Arabia), and Daniel et al.  (in Ethiopia). However, Rostamzadeh et al.  (in Iran), Borhani and Alizadeh  (in Iran), and Badawy et al.  (in Australia) found greater share of attendance for the training courses (60.4, 50, and 41%, respectively). In the present study in NM units, more than 40% of the HCWs received training programs ([Table 1]). However, Alotaibi et al.  (in Kuwaiti) found that there was a low proportion of attendance for training courses related to radiation safety measures.
As regard to the years of working experience in our study population, the means were 7.33±5.62, 9.29±10.23, and 5.8±5.4 years in DR department, RT department, and NM units, respectively ([Table 1]). In Egypt, Abdellah et al.  found that the mean duration of employment among the participating physicians was 5.85±3.84 and ranged from 1 to 16 years.
The current study revealed that the safety measures in diagnostic and therapeutic departments were not strictly adhered to the IAEA standards and guidelines for radiation safety and protection. However, they were adhered to IAEA standards and guidelines for radiation safety and protection in nuclear medicine units ([Table 5]). Nearly half of items related to radiation safety measures were insufficient in DR and RT departments, whereas all items of the safety measures were sufficient in NM units, as NM units are authorized and under supervision of Egyptian Atomic Energy Authority.
Mohamed  (in Sudan), Rostamzadeh et al.  (in Iran), and Eze et al.  (in Nigeria) reported that there was inadequate RP in most of the functional government and private X-ray facilities. Cletus et al.  (in Nigeria) in their study found that most modern RP instruments were lacking in all the centers, and the radiation safety measures were insufficient. In contrary, Dehghani et al.  (in Iran) reported that there was statistically significant difference in safety status among hospitals in Iran. However, Fawcett and Barter  confirmed that radiation safety devices were present in 70% of radiology centers, but only 38% of HCWs were using these devices.
ICRP and Radiation Protection Guidance for Hospital Staff recommended the use of caution sign above the radiography room entrance . The current study found that the caution signs were present only in about half of DR and RT departments. Whereas, all units in NM were posted with caution signs ([Table 2]). In DR departments, automatically audible warning devices were not present, whereas half of RT department and NM units had these warning devices ([Table 2]). This was in accordance with results of El-Hady et al.’s  study (in Egypt), who reported low availability of radiation warning signs. Also, Mohamed  (in Sudan), Rahimi et al.  (in Iran), and Tamjidi  (in Iran) showed that the majority of the studied hospitals did not have adequate) warning signs. In contrast, Farzaneh et al.  and Rostamzadeh et al.  (in Iran) reported that these signs were used in most of the diagnostic imaging centers.
The current study revealed that copy of Ionizing Radiation Standards was not posted in all DR department, RT department, and NM units ([Table 2]). Also, Mohamed  (in Sudan) reported that a written policy was present in only 6.9% of their studied hospitals. In contrary, Abdellah et al.  (in Egypt) reported that 65% of the policies for RP were posted and easily understood in their studied hospital.
The present study showed that about 80% of radiation equipment was present in a special room in DR units compared with all units in RT and NM ([Table 2]). In accordance with our results, El-Hady et al.  (in New Damietta, Egypt) and Farzaneh et al.  (in Iran) found that the radiation labs were in special room and secured against unauthorized access.
The current study found inadequate shielding of lead lining of walls and doors in 54.4% of DR and 50% of RT departments; however, the two units of NM had a good structural shielding and appropriate enclosures ([Table 2]). These findings go hand in hand with a study by Mohamed  (in Sudan), who showed poor lead shielding of walls and doors in Sudanese governmental and private medical facilities. However, Farzaneh et al.  reported that only 10% of the entrance door of the RT room in the Radiology Centers in Iran has lead shields .
The present study revealed that all units of DR, RT, and NM were provided with suitable ventilation and air conditioning. All units in NM department were provided with fume hood (leaden hoods) for volatile radionuclide work and all of them were functioning properly ([Table 2]). However, Farzaneh et al.  (in Iran) reported that only 20% of the radiology centers were not using air conditioning device and 60% of them had leaden hood.
The current study revealed that the lead aprons were present in 72.7, 50, and 100% of DR department, RT department, and NM units, respectively. However, only about two-fifths (39.7%), one-third (35.1%), and nearly half (53.7%) of HCWs in DR, NM and RT departments, respectively, were using them. There was a low availability of other personal protective clothes and equipment, and a significant percentage of different working categories did not use eye goggles, thyroid shield, and protective lead gloves. They justified their poor practice by various reasons such as nonavailability of enough numbers of lead aprons in their departments or increased weight of apron and some of them preferred to follow position–distance rule rather than using lead apron.
These findings were in accordance with a study by Salama et al.  (in Saudi Arabia), who found that most hospitals had lead aprons and thyroid shields, but only about 50% had lead eye goggles and lead shields. However, the majority (99%) of medical staff always used lead aprons, 37% used lead glasses, and 42% used thyroid shields. Also Ahmed et al.  (in Taif, Saudi Arabia) reported that 72% of the participants were using lead apron, 22.7% were using lead gloves, 25.3% were using gonad shields, and 36% were using thyroid shields . These results were in accordance with that of Abdellah et al.  (in Egypt), in which physicians were using lead aprons more than other personal protective clothes and equipment and 52.5% were using lead gloves. Sharma et al.  (in India) reported that lead aprons and thyroid shields were the most common devices used. Awosan et al.  (in Nigeria) reported that 75.5% of HCWs wear at least one type of personal protective device at work.
However, Mohamed  (in Sudan) found that all governmental and private hospitals are provided with the lead aprons but radiographers were poorly using these safety devices. Also, Eze et al.  (in Nigeria) and Bhatt et al.  (in Nepal) reported insufficient availability of lead aprons. Rahman et al.  (in Pakistan) and Luntsi et al.  (in Nigeria) reported that almost all the participants used lead apron (93 and 84.5%, respectively) to protect themselves during radiographic exposures.The present study found that all NM units were provided with personal monitoring devices compared with 54.5 and 50% of DR and RT departments, respectively. Most of HCWs (90.9%) in DR, 77.6% in RT, and 45.9% in NM units did not wear them ([Table 3]). Also, Eze et al.  (in Nigeria) reported that only 20% of the public and 62.5% of the private X-ray units have personal monitoring devices . In contrary, there was a low availability of the personal dosimeters in the studies conducted by Mohamed  (in Sudan) and Bhatt et al.  (in Nepal), in which only few numbers of the healthcare facilities had personal dosimeters.
The present study illustrated that there were records of written guideline plans for emergency situations in about one-third of DR department, 50% of RT department, and 100% of NM units. Records for notification of accidents were available in all units and they were reported to the regulatory bodies, but immediate notification was not done in all units. Abortions and cancer cases were reported as a type of radiation accidents ([Table 4]). The present study is in agreement with the study by Mohamed  (in Sudan), who found that 48% of radiation accidents were reported and recorded. Most accidents types were injuries and abortion cases.
The current study revealed that there were not any records of environmental monitoring, personal doses monitoring, medical examination, or training program records in all DR and RT departments, but all this records were present in all units of NM ([Table 4]). These results coincide with that of Eze et al.  (in Edo State, Nigeria). Also, Ameh and Shehu noticed that there was poor record keeping in both private and government hospital . In the contrary, Mohamed  (in Khartoum State) found better records for recording personal and environmental monitoring by hospitals. Mojiri and Moghimbeigi  showed that periodical examination was not done by 22.5% of the radiographers in hospitals in Hamadan city, in Iran. Also, Bhatt et al.  (in Nepal) reported that all dose data were kept in hospital records .
| Conclusion and recommendations|| |
The majority of DR and RT departments had insufficient workplace design, personal protective clothing, personal monitoring devices, registers and record, but they were sufficient in NM units. A significant percentage of HCWs were neither using personal protective clothes nor personal dosimeters.
Hence, developing an ongoing audit program to ensure that all aspects of safe work practice and standards are being strictly adhered to all applicable radiation safety standards, especially in DR and RT departments, is recommended. Rules and regulations as well as regular environmental monitoring using survey meters should be enforced. All HCWs should receive appropriate pre-employment and periodic refreshing training programs related to safety measures. All needed personal protective clothes and equipment should be provided to all HCWs occupationally exposed to ionizing radiation and regular recording of the radiation level readings.
The authors thank the Head of Public Health and Community Medicine, Faculty of Medicine, Tanta University, for his generous support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]