Exposure of radiology staff to patients with tuberculosis during x-ray procedures. Exposure may also occur after radiology procedures are completed, from treatment rooms not properly ventilated after being occupied with a patient who has TB.

The hospital's safety and health plan should address safe handling of TB patients in the radiology area, (CPL 2.106 OSHA Directive, Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis) including:

Facilities in which TB patients are frequently treated should have an area in the radiology department that is ventilated separately for TB patients.

• If this is not possible, TB patients should wear surgical masks and should stay in the radiology suite the minimum amount of time possible, then be returned promptly to their isolation rooms.
  
  
• Healthcare facilities serving populations that have a high prevalence of TB may need to supplement the general ventilation or use additional engineering approaches in general-use areas where TB patients are likely to go (e.g., waiting-room areas, emergency departments, and radiology suites). Engineering approaches include:
  
  
• A single-pass, non-recirculating system that exhausts air directly to the outside.
  
  
• A re-circulation system that passes air through HEPA (High Efficiency Particulate Air) filters before re-circulating it to the general ventilation system.
  
  
• Upper Air Ultraviolet Germicidal Irradiation (UGVI) may be used in such areas.

Signs and Tags:

• Employees should receive adequate information about the hazards of TB through the use of labels and signs, as indicated in 1910.145 Accident Prevention Signs and Tags. The CDC and OSHA recommend that signs should be posted at the entrance to:
  
  
  • Isolation rooms or areas, such as radiology examination rooms where procedures or services are being performed on an individual with suspected or confirmed infectious TB. The signs could bear a "STOP" sign and the legend "No admittance without wearing a type N95 or more protective respirator."
    
    
  • Employers should use biological hazard tags on air transport components (e.g., fans, ducts, filters), that may reasonably contain air infected with tuberculosis to warn employees, temporary employees, or contractors of possible hazards of contamination.
    
    
  • Contaminated air ducts leading from this area should have a warning label posted on them. The warning labels on these air systems could be labeled with, "Contaminated Air-Respiratory Protection Required."
  
  
• After the area is vacated by an individual with suspected or confirmed infectious TB, the sign shall remain posted at the entrance, until the room or area has been ventilated according to CDC recommendations for removal efficiency of 99.9%. (CPL 02.106, Appendix A, See Appendix A, pg. 35 and Table S3-1, page 72).
  
  
• The CDC in CPL 02.106, Appendix A, document page 72,  table S3-1 has published guidelines regarding the length of time for such sanitation of the room air based upon the air exchanges per hour. Requiring that the sign remain posted until the room or area is adequately ventilated will assure that unprotected employees do not inadvertently enter while an infection risk is still present.

For additional information, see HealthCare Wide Hazards - Tuberculosis.

Exposure of radiology staff to possible work-related musculoskeletal disorders (MSDs) (e.g., strain and sprain injuries to back and shoulder areas) from constant lifting and reaching for patients during x-ray procedures and/or transfers.

Employers should assess the radiology area for ergonomic stressors and identify and address ways to decrease stressors such as:

• Train employees in proper lifting techniques:
  
  
  • Lift items close to the body.
    
    
  • Avoid awkward postures, such as twisting while lifting.
    
    
  • Avoid lifting/reaching or working above shoulder height.
  
  
• Use mechanical aids to reduce the need to lift.
  
  
• Provide sufficient staff to handle lifts.
  
  
• Instruct the patient in ways to help facilitate the lift and procedure.

For additional information, see HealthCare Wide Hazards - Ergonomics.

Staff exposure to radiation from portable and fixed X-ray machines as they are used for diagnostic procedures. Potential health effects of radiation exposure are somatic (body) and/or genetic (offspring) in nature:

• Acute: Erythema and dermatitis. Large whole-body exposures cause nausea, vomiting, diarrhea, weakness, and death.
  
  
• Chronic: Skin cancer and bone marrow suppression. Genetic effects may lead to congenital defects in the employee's offspring.

Radiation exposure occurs when unprotected employees are near a machine in operation. The degree of exposure depends on the amount of radiation, the duration of exposure, the distance form the source and the type of shielding in place.

• OSHA Technical Manual Hospital Investigation Health Hazards. Section VI chapter 1. In regards to x-ray machines, recommends:

	Film badges or their equivalent should be used for long-term monitoring. Examples include: Film Badge: Passive dosimeter for personal exposure monitoring should be worn whenever working with x-ray equipment, radioactive patients or radioactive materials. Depending on the work situation, body badges may be worn at collar level, chest level or waist level. Double-Badging: Personnel who work in high-dose fluoroscopy settings may be asked to wear two badges for additional monitoring. Ring badges: (used for measuring beta and gamma doses to the hand) should be worn on the hand which is closest to the radiation source.
	Other controls include:
	X-ray rooms that are equipped with a barrier wall with a lead platted glass window so technician can step behind barrier wall to take the x-ray, and avoid radiation exposure.
	Lead plated glass is also used as a barrier to protect against radiation exposure when procedures must be done close to the patient.
	Lead strips provide some protection from radiation exposure for employee running fluoroscopy procedures.
	Lead aprons and lead gloves offer some protection for employees and patients and should be worn in the direct x-ray field. Opaque goggles are to be worn in the direct x-ray field. OSHA Tech Manual Section VI, Chapter 1-Health Hazards.
	Some procedures like those that use remote fluoroscopy can be run from controls in an adjacent room, free from radiation exposure.
	A specific person should have the responsibility for assuring proper maintenance of the portable x-ray machines. Preventive and corrective maintenance programs for x-ray machines are detailed in 21 CFR 1000, Radiological Health.
	Kits containing radioactive isotopes or specimens and excreta of humans and animals who have received radio nucleotides may pose a hazard. Exposure may also result from handling of radioactive spills (29 CFR 1910.1096), Ionizing Radiation Standard.
	There should be a separate storage area for radioactive sources. This area should be adequately shielded.
	Document and retain inventories of radioactive materials. Only authorized personnel should have access to storage areas.
	For information about exposure limits see: 1910.1096 Ionizing Radiation Standard. The standard also requires:
	Every employer shall supply appropriate personnel monitoring equipment, such as film badges, pocket chambers, pocket dosimeters, or film rings, and shall require the use of such equipment 1910.1096(d)(2). Employers shall maintain records of the radiation exposure of all employees for whom personnel monitoring is required under paragraph (d) of this section and advise each employee of his individual exposure at least yearly.
	At the request of a former employee an employer shall furnish to the employee a report of the employee's exposure to radiation records 1910.1096(o)(1).
	Such report shall be furnished within 30 days from the time the request is made.
	The report shall also include the results of any calculations and analysis of radioactive material deposited in the body of the employee.
	The report shall be in writing and contain the following statement: "You should preserve this report for future reference."
	Each radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution symbol, with the wording "Caution Radiation Area". 1910.1096(e)(2)
	Hazard Information Bulletin Radioactive Contamination of Lead Shielding.(1997, June 24). Some shielding products used for radiation protection contain lead contaminated with small amounts of naturally occurring radio nuclides. The products identified to date include medical devices used for radiation protection such as lead aprons, gonad shields, and thyroid shields manufactured after October 1, 1996.

There is a potential for slips and falls in the radiology area, and when using portable X-ray machines if employees slip on fluids spilled on the floor such as blood, vomit, or excreta, or trip over x-ray power cords.

• [1910.22(a)(2)] requires floors be kept clean and dry.
  
  
• Aisles and passageways shall be kept clear and in good repairs, with no obstruction across or in aisles that could create a hazard [1910.22(b)(1)]. Provide floor plugs for equipment, so power cords need not run across pathways.
  
  
• Good work practice recommends:
  
  
  • Spills reported and cleaned up immediately.
    
    
  • The use of no skid waxes and surfaces coated with grit or waterproof footgear to help decrease slip/fall hazards.

For additional information, see HealthCare Wide Hazards - Slips/Falls.

Exposure of staff to blood and Other Potentially Infectious Materials, (OPIM) (e.g., excreta, vomit, sputum), during the x-ray process. Definition for OPIM is found in 1910.1030(b).

Implement Universal Precautions according to the Bloodborne Pathogens Standard [1910.1030(d)(1)].

• Treat all blood and OPIM with appropriate precautions such as:
  
  
  • Use gloves, masks, and gowns if blood or OPIM exposure is anticipated.
    
    
  • Use engineering and work practice controls to limit exposure.

Provide appropriate Personal Protective Equipment (PPE) such as gloves or gowns as required by the Bloodborne Pathogens Standard 1910.1030(d)(3)(i), if there is occupational exposure to blood or OPIM.

• Gloves must be worn when hand contact with blood, mucous membranes, OPIM, or non-intact skin is anticipated, and when performing vascular access procedures, or when handling contaminated items or surfaces [1910.1030(d)(3)(ix)].

For additional information, see HealthCare Wide Hazards - Bloodborne Pathogens and Universal Precautions.

Exposure of employee to potential violence from uncooperative, disoriented, or combative patients. Many radiology patients come from the emergency area and may be confused and violent.

• Have a plan in place to deal with difficult patients.
  
  
• Provide training to staff to identify, recognize, and diffuse potentially violent situations and patients.
  
  
• Be alert for potential violence and suspicious behavior and report it.
  
  
• Provide adequate staffing levels, with experienced clinicians on each shift.
  
  
• Use appropriate engineering controls to provide security such as:
  
  
  • Install concealed panic buttons-in the x-ray area, that can be pushed for emergency help.
    
    
  • Improve lighting and video surveillance.
    
    
  • Use an escort or buddy system, when taking a possibly violent person to radiology.

For additional information, see HealthCare Wide Hazards - Workplace Violence Module and the Emergency Room Module.

Tasks that use a computer (e.g., remote radiology computer workstation, data entry clerk, secretary) intensively for 4 hours or more per day, can lead to musculoskeletal disorders of the hand/arm, shoulder, neck and back.

For additional information, see HealthCare Wide Hazards - Administration Module - Computer Workstations.