Imagine you’re standing at the table during a fluoroscopy-guided procedure. You notice the attending physician hasn’t stepped back; neither has the scrub tech. The C-arm is about to fire. There are three main ways to limit their exposure to scatter radiation, and consistently applying them is the best way to reduce your staff’s cumulative dose over their career.
These three ways are interconnected, and together they make up the three rules of ALARA: time, distance, and shielding.
What Does ALARA Stand for, and Why Do Healthcare Workers Need To Know?
The ALARA, or As Low As Reasonably Achievable, standard provides regulatory guidance for reducing occupational radiation exposure. As elements of a broader safety program, ALARA and radiation safety are deeply related to each other.
As ALARA is the governing principle of occupational radiation protection in healthcare, it’s important for healthcare workers to understand what it means and the impact of managing time, distance, and shielding for radiation exposure. When paired with radiation dose monitoring for healthcare workers, the ALARA standard improves staff safety as well as regulatory compliance.
ALARA’s meaning is based on the fact that “there is no compelling evidence to indicate a dose threshold below which the risk of tumor induction is zero,” as a National Research Council study found. That means even relatively low doses carry theoretical risk, especially over workers’ careers, making it especially important to apply the ALARA principle consistently, across every procedure.
How Do the Three Rules of ALARA Reduce Radiation Exposure?
As two of the three key components of ALARA fluoroscopy guidance, time and distance work together to reduce radiation exposure best when used in tandem by minimizing exposure duration and increasing the physical distance between staff and radiation-producing equipment. Applying the third ALARA component by using well-maintained shielding reduces exposure risk even further.
Here is a closer look at how each of the ALARA principles can reduce radiation exposure:
- Time: It’s understood that scatter radiation doses accumulate with increased exposure duration. A few effective ways to reduce this duration include using pulsed fluoroscopy modes rather than continuous, minimizing active imaging to what’s clinically required, and stepping away from active imaging equipment when your presence isn’t required.
- Distance: Radiation intensity drops off sharply as the distance between the radiation source and the personnel involved in the procedure increases. The science behind this is known as the inverse square law, which states that when the distance is doubled, the dose is reduced by a factor of four.
- Shielding: There are two key forms of shielding that can reduce exposure: engineering controls (like lead-lined walls, doors, and barriers) and radiation protection equipment (including lead aprons, thyroid shields, protective eyewear, and gloves).
Why Can’t Interventional Clinicians Always Use Time or Distance?
For interventional cardiologists, vascular surgeons, and pain management physicians, it’s not always possible to apply both time and distance (which is partially why ALARA compliance for a hospital only requires what is “reasonably achievable”).
That’s because procedures like ablations and endovascular repair can’t be rushed and require staff to remain in the room for their duration. In these cases, the third component of ALARA, shielding, takes on greater importance.
What Does the Shielding Rule of ALARA Actually Require?
The ALARA shielding principle requires an appropriate physical barrier between clinicians and ionizing radiation sources. In practice, the minimum standard includes the use of lead aprons, thyroid shields, eyewear, and gloves. When worn consistently and correctly, these measures provide substantial scatter radiation attenuation.
The effectiveness of radiation protection equipment also depends on its condition and maintenance, making regular radiation protective equipment inspection a must.
How Do You Know if a Lead Apron Is Actually Protecting You?
A lead apron can appear to be perfectly intact but still fail to provide the necessary protection against scatter radiation exposure, as damage like internal cracks and degradation of shielding material are imperceptible to the naked eye.
Tactile inspections are similarly insufficient, as one study found that only 6% of study participants using these inspection methods were able to correctly identify all defects.
The only reliable method for confirming shielding integrity is radiographic X-ray scans, which the Joint Commission requires to be performed on at least an annual basis, with all findings properly documented.
It’s also important to address the potential for lead apron contamination. When worn close to sterile fields, like during X-rays and fluoroscopy procedures, lead aprons function as high-touch objects capable of accumulating pathogens over time. In one study (Gilat et al., 2020), 87.8% of protective lead garments tested positive for bacterial contamination. In another study, 84% (Jaber et al., 2014) of garments tested positive for Staphylococcus aureus and Tinea species (ringworm).
Lead aprons with tears in their outer layer, cracks in the internal lead material, frayed bindings, and worn-out closures are more difficult to thoroughly clean and disinfect. This can lead to contamination, which can be mitigated through proper lead apron storage (hanging on heavy-duty hangers, never folded or creased), routine inspections, and proper deep cleaning and disinfection procedures.
How Can Healthcare Facilities Actually Build a Reliable ALARA Shielding Program?
While two of the three ALARA rules, minimizing exposure time and maximizing distance from a radiation source, are behavior-related and dependent on training, shielding – the third ALARA rule – often requires a broader institutional program.
A comprehensive and compliant ALARA shielding program includes components like:
- Deep cleaning and disinfection of protective garments
- Annual radiographic integrity scanning
- Documented inventory management
- Defined workflows for repair and/or disposal
When these program elements are fragmented across radiology, the OR, and the supply chain without clear documentation, shielding becomes a weak link in ALARA’s three-rule framework.
Instead, clear ownership of the garment lifecycle management process, along with complementary best practices like radiation dose monitoring for healthcare workers, is required. RadCare Services (RCS) closes this gap for hospitals by offering a comprehensive program that includes deep cleaning and disinfection following CDC-aligned protocols, annual X-ray scanning for integrity verification, and inventory tracking through the proprietary RadComply® platform.
Contact the team today to learn how a managed garment program through RCS can support your facility’s ALARA compliance.
