ALARA
As Low As Reasonably Achievable

• The National Council on Radiation Protection has established maximal permissible doses for persons who receive occupational exposure.
• The Nuclear Regulatory Commission has suggested that occupational exposure should be as low as reasonably achievable.
• Three principles of radiation protection:
  1. Increase distance from source.
  2. Reduce exposure time.
  3. Use These Radiation Protective Products:

Radiation Protective Eyewear

• With the newly designed frames and ultralight lenses, protective leaded eyewear is now used by approximately 95% of the physicians and staff in Cardiac Cath and EP labs, and increasingly for urological procedures, interventional radiology, pain management and orthopedic surgery.
• Today, with the increased selection of styles and the ability to customize the eyewear with prescriptions, there is radiation protective eyewear to meet the needs of any physician, nurse, or diagnostic technician.

How Radiation Affects the Eye

• Relatively high doses of radiation can damage the conjunctiva, iris, sclera, and blood vessels of the retina.
• The lens, however, is the critical site, for it may sustain irreversible damage from a relatively low dose of radiation.
• The lens, or focusing part of the eye, is where cataracts are formed.
• Radiation-induced cataracts are distinct from naturally occurring cataracts in that they form in the posterior (back) pole of the lens.

Radiation Induced Cataracts

• The sensitivity of the lens to radiation is felt to be due to the failure of normal cell replacement.
• The cell damage from low dose radiation consists of cell death and abnormal cell reproduction which produces mutated cells.
• The normal metabolism of the eye cannot remove these mutated radiation damaged cells.
• This results in a premature clouding of the crystalline lens causing reduced vision which can be corrected only when the cataract matures (over time) and is removed.

Radiobiology

• Cardiac Cath with Angiography and Electro-physiology can deliver the greatest dose of x-ray radiation of any of the diagnostic medical procedures.
• Physicians and techs in these specialties receive low  levels of scattered radiation over a period of months to decades. The physicians performing these procedures should be familiar with potential genetic and somatic effects of radiation and products provided to reduce or eliminate x-ray exposure.
• The use of x-rays in the Cath and EP Lab is only deemed acceptable due to the patient benefits derived from these procedures which are considered to outweigh the risks to the physician.
• Personnel exposures result from the primary x-ray beam being scattered by the patients skeletal structure. The chest, thyroid and eyes of the doctors and nurses receive most of the scattered radiation.

AORN
Standards, Recommended Practices, and Guidelines

Occupational exposure to radiation should be minimized in the practice setting.


1. During radiation exposure, all personnel should stand at least 6 ft (ie, 2m) from the x-ray tube and behind leaded shielding. Distance from the radiation beam and attenuation by leaded shielding and wall materials will decrease radiation exposure.
   
   
2. Leaded shielding should be provided to personnel who cannot leave the room or cannot stand approximately 6 ft (ie, 2m) away from the x-ray tube and the patient. Leaded screens and / or leaded aprons and thyroid shields minimize exposure to scattered radiation.
   
   
3. Personnel should be positioned out of the direct line of the primary projection beam. Personnel, even when protected by leaded aprons, leaded shields, and thyroid shields, should position themselves behind or to the side of and as far away as possible from the radiation beam. Leaded aprons do not attenuate 100% of the radiation beam.
   
   
4. Personnel wearing leaded aprons should face the unit that is emitting radiation. To provide protection, the leaded aprons must be between the source of radiation and the body.
   
   
5. Slings, traction devices, and sandbags should be used to maintain patient position during radiation exposure. Cassette holders should be used to position films. Personnel should not hold the patient unless absolutely necessary and should avoid exposure to the direct beam. Protective gloves and leaded aprons should be worn if the patient must be held. Holding devices allow personnel to reduce their exposure by distancing themselves from direct and scatter radiation.
   
   
6. During fluoroscopy, personnel should wear
   
   • leaded aprons,
     
   • thyroid shields if they are in proximity to the patient,
     
   • eye protection (eg, lead-glass lenses, face masks with lead-acrylic windows) if they are next to the patient during frequent or long periods of fluoroscopy, and
     
   • radioprotective gloves if their hands are exposed to the direct beam.
   
   The potential for exposure to radiation is greater during fluoroscopy than during conventional radiographic studies due to increased radiation scatter and exposure time. The areas at greatest risk of radiation exposure for personnel within a 6-ft (ie, 2-m) range of the radiation source are the head, neck, and hands. In practice, perioperative personnel may receive the same exposure to their unprotected thyroid as the surgeon. Moving and holding the C-arm unit during fluoroscopy exposes the surgeon’s fingers to high dosages of radiation. Radiation-attenuation surgical gloves block 50% of the dosage. The lens structure of the eye is sensitive to radiation. lead glass lenses and face masks with lead-acrylic windows afford a high degree of protection. There is a significant degree of lens and brain dose reduction afforded by the use of glass or photochromic lenses.
   
   
7. During lateral / oblique radiation, including fluoroscopy, personnel remaining in the OR should wear leaded aprons and thyroid shields and stand at least 6 ft away from the projected beam. Levels of scattered radiation can increase up to four times when the radiation is directed at an oblique angle. This results in greater exposure to the head and neck areas of personnel in proximity.
   
   
8. Guidelines for radiation safety are based on the principles of time, distance, and shielding. When exposed to radiation at a constant rate, the total dose equivalent received depends on the length of time exposed. If the distance from the point source of radiation is doubled, the exposure is quartered. Radiation that scatters as the x- ray beam passes through the patient also can be a source of radiation exposure. Passage through materials reduces the amount of radiation. Government regulations stipulate the dose limits for occupational exposure and are described in the glossary. At the time of the publishing of this document, there was no industry consensus regarding the management of the patient undergoing sentinel node biopsy.
   
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October 18, 1994

MEMORANDUM FOR:  OSHA Regional Administrators Heads of Directorates

FROM:  James W. Stanley Deputy Assistant Secretary

SUBJECT: Employers Obligation to Pay for Personal Protective Equipment

It is important that a uniform approach be taken by all OSHA offices with respect to the question of employer responsibility for payment of the cost of personal protective equipment question of employer responsibility for payment of the cost of personal protective equipment (PPE).Under certain circumstances, employers may be obliged to pay for personal protective equipment, as they would pay for other engineering and administrative controls. Please advise your staff to apply the following guidance when dealing with this issue.

The personal protective equipment standards at 29CFR 1910.132 through .138 establish the employer's obligation to provide personal protective equipment to employees.

"Protective equipment, including personal protective equipment for eyes, face, head and extremities, protective clothing, respiratory devices and protective shields and barriers, shall be provided, used and maintained in a sanitary and reliable condition wherever it is necessary by reasons of hazards of processes or environment,chemical hazards, radiological hazards or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation or physical contact." (29CFR 1910.132(a))

In order to accommodate work situations in which it is customary, as an exception, for workers in a particular trade to provide their own PPE,the standard acknowledges that employees may provide their own equipment, but does not specify that practice as the norm: instead, the standard underscores the employer's obligation to assure that such equipment is adequate and that it is properly maintained.

The "worker-provided" clause on the PPE standard (1910.132(b)),now also codified for the construction industry at 1926.95(b),has raised questions as to when employers are required to pay for PPE. this memorandum is intended to clarify the situation.

OSHA has interpreted its general PPE standard, as well as specific standards,to require employers to provide and to pay for personal protective equipment required by the company for the worker to do his or her job safely and in compliance with OSHA standards. Where equipment is very personal in nature and is usable by workers off the job, the matter of payment may be left to labor-management negotiations. Examples of PPE that would not normally be used away from the work site included, but are not limited to: welding personal protective equipment, wire mesh gloves, respirators, hard hats, specialty glasses and goggles (e.g. designed for laser or ultraviolet radiation protection),specialty for protection (such as metatarsal shoes and linemen's shoes with built in gaffs),face shields and rubber gloves, blankets, cover-ups and hot sticks and other live-line tools used by power generation workers. Examples of PPE that is personal in nature and often used away from the work site include non-specialty safety glasses, safety shoes, and cold-weather outer wear of the type worn by construction workers. However,shoes or outer wear subject to contamination by carcinogens or other toxic or hazardous substances which cannot be safely worn off-site must be paid for by the employer. Failure of the employer to pay for PPE that is not personal and not used away from the job is a violation and shall be cited.

Compliance officers shall be informed of this policy and advised to evaluate carefully assertions by employers that particular items of personal protective equipment should be paid for by employees.

Please provide a copy of this memorandum to State designee's.

Questions of this policy may be direct to Russelle R. McCollough in the Office of General Industry Compliance Assistance.

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