Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

^IMathematician, Master's Degree in Medicine and Health, Professor at União Educacional do Norte (Uninorte)
^IIMD, Doctorate in Medicine (Clinical Radiology), Titular Professor at Universidade Federal da Bahia
^IIIMD, Private Docent at Faculdade de Medicina da Universidade Federal da Bahia

Mailing Address

INTRODUCTION

In Brazil, one can say that the necessity to establish morerigorous standards for the sectors of radiodiagnosis andradiotherapy is a relatively recent concern triggered by theincident occurred in Goiânia, GO, in September of 1987,when outsiders destructed with a hammer a powered cesium-137source obtained from an abandoned private medical facility. Thisepisode was widely divulged both in the national andinternational media, and several adjustments and new practicesstarted being implemented in thesector^(1,2).

For several reasons, the major concern with regards to thestandards severity has not led to the immediate publishing of thenew legislation; an example is the Portaria (Order) SVS/MS no.453 dated of June 1st, 1998⁽³⁾, published onlyten years after the incident in Goiânia. Most recently,this Order has been gradually improved by means of supplementaryresolutions: RDC Anvisa no. 50, of February 21, 2002, regulatingthe technical planning, scheduling, elaboration and analysis ofphysical projects of health care facilities⁽⁴⁾,and the RE Anvisa no. 64, of April 4, 2003, including the Guia deProcedimentos para Segurança e Qualidade de Imagem emRadiodiagnóstico Médico (Procedures Guidance forSafety and Imaging Quality in MedicalRadiodiagnosis)⁽⁵⁾.

In spite of these better regulations, new developments and amore rigorous inspection are necessary for the Brazilian safetyand quality standards to achieve minimum levels. In Brazil, somestudies demonstrate the extent and magnitude of the negligence ofthe workplaces managing ionizing radiation sources with safetyand quality standards. At Hospital UniversitárioClementino Fraga Filho of Universidade Federal do Rio de Janeiro,for example, only three of twenty services working with ionizingradiation kept individual dosimetric monitoring of theiremployees, but there was no control for cases where high doseswere found⁽⁶⁾. Another study carried out indental offices in the city of Bauru, SP, has reported that thepatients could receive lower radiation doses if simpleprecautions, like a better films positioning, wereadopted⁽⁷⁾. More serious situations have beenobserved in the radiology service of Hospital Central doExército do Rio de Janeiro, like inadequate supplies (forexample, films and films developing solutions) storage, wrongpositioning of the patient or of the film, use of equipment outof order, and in some cases partiallydamaged⁽⁸⁾. These and otherexamples^(9–12) reinforce the necessity thatlegal mechanisms, including educational programs, are employed bythe Brazilian sanitary authority to increase safety of theworkers in these services as well as of theiruser-population.

In the state of Acre, a process was initiated in 2001 forupdating the register of health care facilities with conventionaland dental radiodiagnosis services, In this process, 29conventional x-ray equipment and about 200 dental x-ray equipment(Pereira Filho T, Visa-Acre: personal communication). However,these services have not been evaluated under the criteriaestablished by the legislation in force. So the objective of thepresent study was to evaluate the services of conventionalradiodiagnosis of two hospital of the state public network in thecity of Rio Branco, in compliance with the Brazilianguidelines^(3–5).

MATERIALS AND METHODS

In the period between February 2 and 27 of 2004, the servicesof conventional radiodiagnosis in two institutions of the publicstate network in the city of Rio Branco, AC were evaluated. Forthe present study purposes, these institutions hereafter will benamed "institution 1" and "institution 2". Institution 1 providesspecialized attendance in 21 medical areas, and 159 hospitalbeds, distributed throughout four ambulatories and one intensivecare unit, all of them dedicated to the Sistema Único deSaúde – SUS (Brazilian Unified Health System). Theinstitution's staff includes 157 professionals with superioreducational level⁽¹³⁾; among them, fourphysicians specialized in radiology, and nine techniciansclassified in this same area. This hospital is also accredited bythe Ministry of Education as an ancillary teaching hospital,where residency programs are developed in the areas ofpediatrics, medical clinical practice, obstetrics and gynecology,general surgery, and communitarian general medicine. Recently,institution 1 was included in the Projeto Hospitais-sentinela(Sentinel-Hospitals Project) created byAnvisa⁽¹⁴⁾. In this institution, the meanmonthly number of hospital admissions is 650, and in 2002 about24,000 conventional x-ray studies wereperformed⁽¹⁵⁾.

Institution 2 is an emergency hospital with 200 hospital-bedsregistered at SUS. Of these hospital-beds, 39 are assigned togeneral surgery, 98 to medical clinical practice, two topsychiatry, 31 to pediatrics, and five to phthisiology. Theinstitution also counts on services considered as non-urgency inthe area of infectious and parasitary diseases, and its staffincludes 272 professionals⁽¹⁶⁾ of superioreducational level; among them one physician specialized inradiology, and nine technicians classified in this same area.Seven hundred hospital admissions, on average, occur per month,with a mean monthly hospital occupation rate of 75%. In 2002,67,952 x-ray studies were performed in the institution2⁽¹⁷⁾.

The following aspects were taken into consideration in theanalysis of the radiodiagnosis services of institutions 1 and 2:professional education, working-day, technicians and ancillarypersonnel routine and time of experience, documentation of theservices; physical structure as a whole, exam rooms, individualprotection equipment, conventional x-ray equipment, darkchambers, report rooms, procedures with patients, procedures withfilms and films development, and services protocols. Thisevaluation was performed in compliance with criteria establishedby the Brazilian legislation currently inforce^(3–5).

The characterization of technicians and ancillary personnel,and the evaluation of physical and operational facilities of themedical radiodiagnosis services were made by means of visits tothe facilities, interviews with the head of the service (or arepresentative indicated by the management of the unit),interviews with technicians and ancillary personnel, and directobservation, with quantitative and qualitative descriptions.Previously to the data collection, the proposed interviewsquestionnaires were applied to 10% of the target-public forvalidation. Once validated, visits were performed to bothinstitutions as necessary, until the two questionnaires werecompletely answered by both institutions. (Pacheco JG,unpublished data: Master's Dissertation, Universidade Federal daBahia). Additionally, whenever possible, photos were taken fromthe equipment and facilities.

In the qualitative analysis, comparisons were made betweenexpected situation (according to the referred legislation) andthe actual situation found during the visits to the health carefacilities included in the present study^(3–5).In the quantitative analysis, whenever possible, means andfrequency calculations were performed.

For practical reasons, all the professionals developingactivities at the level of technicians in radiology, in thisstudy were named "technicians". However, according to the Law no.7394, of October 29, 1985, regulating the practice of theprofession⁽¹⁸⁾, only those professionalsholding a diploma issued by a technical radiology school arelegally recognized as "technicians".

The research project was approved by the Committee for Ethicsin Research of Fundação Hospital Estadual do Acre(Report no. 049/2003). All the workers who proposed tocollaborate in this project were given all the necessaryexplanations before being asked to sign the Term of Free InformedConsent (Pacheco JG, unpublished data: Master's Dissertation,Universidade Federal da Bahia). Previously, the study had beenauthorized by the titular managers of both institutions, and alsoby the Secretary of Health for the State of Acre.

RESULTS

Evaluation of the services

The Table 1 includes the results of 15 items researched in each institution studied. In summary, in the institutions 1 and 2, 87% (15/2) and 80% (15/3) of the items, respectively, were in disagreement with the legislation in force. The Table 2 includes the conditions of hygiene and cleaning of the x-ray rooms, as well as the technical limitations observed in at least one of the fixed x-ray equipments and furniture observed in each institution. Both the institution 1 and institution 2 have two x-ray rooms. In the institution 1, the rooms are identified with number plates (1 or 2). In the institution 2, there is no identification plate for the rooms (for practical effects, the room at left side in the radiodiagnosis unit was named "A", while the room at right side was named "B"). Overall, the rooms evaluated in both institutions satisfied less than 7% of the requirements (Table 2), except for the room number 1 of the institution 1 that satisfied 5 of the 15 requirements (Table 2). Among the 15 interviewed professionals (six from the institution 1, and nine of the institution 2), only two of them had completed a 3-year technical course in radiology (one in each of the institutions). The other had attended the finished Programa de Reeducação e Avaliação Profissional (Program for Re-education and Professional Evaluation), and 86.6% of the interviewed technicians reported that they has learned to perform x-ray examinations by observing their more experienced colleagues. In the institution 1, the professional who had completed the technical course in radiology had less than one year of experience in this position, while the other had between 12 and 15 years of experience. None of the technicians had undergone any kind of training in radiological protection and quality assurance along their professional career. Additionally, none of the interviewed had received basic information from the institutions on the risks they were exposed to. Among the respondents, there was one technician who had completed post-graduation in a non-related area, one with superior course in physics, eleven technicians who has completed high school, one with complete elementary course, and other with incomplete elementary course. In 100% of cases, the contractual working-day (24 hours/week) was different from the actual working-day in both institutions: 30 weekly hours, on average, in Institution 1, and 65 weekly hours in Institution 2. In institution 1, four (66.6%) of the six technicians worked also for another institution. A similar situation was seen in Institution 2 (55.5% of cases, i.e., five of nine respondents). With the exception of one technician of institution 1, the other technicians in radiology of institution 1 and the technicians of institution 2 did not receive the 40%-additional pay for hazardous duty, although the majority of them (73.3%) had already such additional pay while employed by these institutions. Although they were entitled to have two 20-day vacation periods per year, in both institutions, it was frequent accumulation of vacation periods for more than 3 years. Apparently, this was the solution they found to avoid a decrease in the total value received at the end of each month formed by wage and additional pays resulting from overtime and shifts.

According the workers in both institutions, pre-admissionlaboratory tests (complete blood test and platelets counting)were not performed, and nor did the half-year blood testsrequired by the Order (Portaria) GM/SSSTb 24/1994.

The technicians of institution 1 reported that they alwaysworn the personal dosimeter attached to their trunk, and over thelead apron, as necessary. However, they were not given access todosimetric reports and did not know how to interpret them. Also,a worker in institution 1 was observed wearing the dosimeter ofanother worker who had been dismissed.

Neither institution 1, nor institution 2 had a protocol forradiographic technique. Consequently, each technician followedhis/her own parameter to perform examinations. During theinterviews, 26.6% of respondents informed not to be adequatelyprepared, and nor did they know how to accomplish their taskssafely.

Overall, 15 technicians and six ancillary workers in radiology, respectively, six technicians from institution 1, and nine technicians and six ancillary workers from institution 2 were interviewed. However, the three ancillary workers from institution 1 opted not to participate in this study. Table 3 shows the evaluation of the conditions of individual monitoring in both institutions, as well as their compliance with the law in terms of special vacation periods. As regards individual dosimetry in institution 2, it could not be evaluated, since it is not undertaken.

Procedures of the technicians in radiology with patients and their companions

During the visits to both institutions, the followingirregularities were observed: 1) bedside procedures wererestricted to immovable patients, but without using a mobileshielding and neglecting the duly minimum 2 m distance to be keptby companions and other patients from the x-ray equipment; 2) intwo occasions, the technicians performed the procedures with thex-ray room door open.; 3) the technicians did not offer the leadaprons to companions, although they were available in the room;4) the possibility of the patients' or companions' pregnancy wasnot checked in any of the cases observed (n = 45); 5) The mostsensitive organs of the patients (thyroid and gonads) were notprotected during the radiological examinations, since bothinstitutions did not had this type of individual protectionequipment available.

In institution 1, there were occasions where the technicianhad to operate the mobile x-ray equipment without wearing a leadapron because all the aprons available in the Institution werebeing used in other radiological procedures. In institution 2,there were situations where the technician could not delimitatethe precise site of x-ray beam incidence, because the collimatorlamp was broken. In such situations, the collimator remained withits maximum aperture, irradiating a larger area than thenecessary one for the examination; in this same institution, inmore than one occasion, a situation was observed where thestretcher handler supported the patients during the radiologicalprocedure without wearing any individual protection equipment.Therefore, the stretcher handler was exposed to several radiationdoses during a day. Once during a visit, we observed thesimultaneous presence of two patients and two stretchers handlersin the x-ray room during radiological procedures.

DISCUSSION

Comparatively, the problems diagnosed in institution 2 are thesame in institution 1. It is important to note, however, that itis expected that, in a very short time institution 1 will have amore efficient radiodiagnosis service, since it has been includedin the Projeto Hospitais-sentinela da Anvisa (AnvisaSentinel-Hospitals Project)⁽¹⁴⁾.

Both in institution 1 and institution 2 several items were indisagreement with the referredlegislation^(3–5). At least four measures mustbe adopted by both institutions aiming at achieving compliancewith the current legislation: 1) assignment or hiring of aradiological protection supervisor and a technical expert incharge; 2) constitution of a Committee for RadiologicalProtection, in compliance with provisions of Order (Portaria)SVS/MS 453/1998⁽³⁾; 3) periodical training andupdating courses; 4) implementation of a program for qualityassurance in the institutions, including a routine equipmentpreventive maintenance.

Experiences with other institutions demonstrate that hiringexperienced and skilled professionals, as well as investment intraining and updating courses, are effective measures,contributing significantly to improve the quality standards ofradiodiagnosis services. In 1999, the laboratories of hormonesand nuclear medicine of Hospital Universitário ClementinoFraga Filho at Universidade Federal do Rio de Janeiro presentedthe lowest indices in monthly personal dosimetersreadings⁽⁶⁾. According to the authors, this hasoccurred mainly as a result of training programs for thelaboratories staff, and the presence of a physicist, in the caseof nuclear medicine, continuously managing and guiding thepersonnel on the occupational risk of ionizingradiation⁽⁶⁾_. Also, in HospitalUniversitário do Rio de Janeiro, the implementation of aquality assurance pilot-program in the mammography unit, in 2002,included training for technicians, a more appropriate mammographmaintenance, and an increase in the mean daily number of patientsfrom 7 to 12, which has contributed to the stability of the filmsprocessor⁽⁹⁾. These changes have resulted in animprovement in the images quality, with absence of artifacts; asignificant decrease in costs and films rejection indices (from21% to 7.7%); and, consequently, a significant decrease inradiation doses for patients⁽⁹⁾.

A serious problem found, concerning radiodiagnosis procedures,was the examination of women or patients accompanied by women offertile age. In both institutions, the possibility of pregnancywas by no means investigated, and this is particularlyconcerning, as it is likely that there may be pregnant womenundergoing unnecessary radiation exposure, and a consequenthigher risk of mutations-related congenital abnormalities andinjury to the fetal central nervous system, besides delayedeffects for women^(19–21). Just affixing anotice board on the risks of radiation exposure for pregnantwomen, according to Order (Portaria) SVS/MS453/1998⁽³⁾, does not suffice; however there isa necessity for a reeducation program and guidance for patientsand companions in the occasion of the request, scheduling, andalso before the radiological procedure performance. However, alimitation to this kind of program is the high rate of functionalilliteracy in the Acre State - in 2001, it was30.2%⁽²²⁾. Another alternative, provided theclinical situation permits, is to establish a certain period forperforming radiological studies in women of fertile age, forexample, ten days after the last day of the menstrualperiod⁽²³⁾.

Another serious problem was stretchers handlers supportingpatients during radiological procedures without wearing any typeof individual radiation protection equipment. According to theOrder (Portaria) SVS/MS 453/1998⁽³⁾: 1), thepresence of a companion in the room during radiologicalprocedures should occur only on voluntary basis and out of thecontext of the companion professional activity; 2) a same personis forbidden to go about this activity on a regular basis; 3) itis mandatory for the companions wearing an individual radiationprotection equipment compatible with the radiologicalprocedure.

Most probably because the radiation originating from thex-rays is an invisible phenomenon, several other proceduresincompatible with the activity of workers in radiodiagnosisservices were observed. For reverting this situation, it isnecessary not only a significant investment in training, but alsothe development of systematic activities aiming at stimulatingand valorizing the workers in this sector, besides making themaware of the occupational radiation exposure risks.

Although the investigated institutions had two x-ray rooms aswell as infra-strutucture sufficient for two processors, bothhave been effectively operating with only one room and with asingle processor. Since a preventive maintenance does not exist,and both institutions operate 24 hours a day, the immediateconsequences are: frequent interruptions of the services as aresult of technical problems, and equipment overheating,affecting the images quality. Considering the relevance of theradiodiagnosis services for the population in the Acre State, thelack of a qualified maintenance and spare parts for immediatereplacement, the availability of additional x-ray equipment andprocessor is essential for both institutions.

Considering that these government agencies should not only toinspect and define penalties for infringements observed, but alsoguide and educate with basis on the Order (Portaria) SVS/MS453/1998⁽³⁾, as well as on federal, state andmunicipal regulations on this matter, the proximity of State andcity sanitary vigilance agencies may result in an improvement ofthe radiodiagnosis services.

Based on the results presented by this study, one may concludethat technical or operational infringements have occurredbasically because of unawareness of the legislation, the absenceof an equipment preventive maintenance program, and the lack ofinvestments in training and/or professional updating courses. So,the improvement of the radiodiagnosis services in the studiedinstitutions is highly dependent on urgent changes which, most oftimes, are simple and easy to be implemented, with immediateeffects on the quality of the services.

Acknowledgements

The authors thank to Marcos Vinícius Teixeira Navarro,Coordinator for Núcleo de Tecnologia em Saúde doCentro Federal de Educação Tecnológica daBahia; Tito Pereira Filho, Technician for Visa-Acre;Andréa F Giacomet, Technician for Anvisa; JoséAmsterdam de M. Sandres Sobrinho and Thor Oliveira Dantas,Director for Fundação Hospitalar do Acre andHospital de Urgência e Emergência de Rio Branco; andto all the people in the sector of medical radiodiagnosis whohave collaborated on the present study.

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Mailing Address:
José Geraldo Pacheco
Rua Plutão, 399, Bairro Morada do Sol
Rio Branco, AC, 69910-390 – Brazil
E-mail: jg.pacheco@uol.com.br

Received April 14, 2005.
Accepted after revision October 10, 2006.

* Study developed at Fundação Hospitalar do Acre and Hospital de Urgência e Emergência de Rio Branco, Rio Branco, AC, Brazil.