Fluoroscopy Re-CredentialingFluoroscopy Re-Credentialing

William Robeson, Radiation Safety OfficerWilliam Robeson, Radiation Safety OfficerNorth Shore University HospitalNorth Shore University HospitalRadiology/Radiation Safety OfficeRadiology/Radiation Safety Office(516) 562- 3895(516) 562- 3895

Presentation created by: Miyuki Yoshida-HayPresentation created by: Miyuki Yoshida-Hay

ObjectivesObjectivesThe Joint Commission accreditation requires The Joint Commission accreditation requires physicians who use or operate fluoroscopic x-ray physicians who use or operate fluoroscopic x-ray systems be properly credentialed. This training shall systems be properly credentialed. This training shall include radiation safety, management of fluoroscopic include radiation safety, management of fluoroscopic radiation and operation of fluoroscopic x-ray system(s) radiation and operation of fluoroscopic x-ray system(s) used by the physician. Training in radiation safety and used by the physician. Training in radiation safety and fluoroscopic radiation management is in addition to fluoroscopic radiation management is in addition to any clinical training or qualifications required to any clinical training or qualifications required to perform the specific clinical diagnostic or therapeutic perform the specific clinical diagnostic or therapeutic procedures for which the fluoroscopic systems are procedures for which the fluoroscopic systems are used. The re-credentialing process is required in used. The re-credentialing process is required in order to familiarize practitioners with the latest order to familiarize practitioners with the latest developments in technology and radiation safety.developments in technology and radiation safety.

Re-Credentialing RequirementsRe-Credentialing RequirementsThe hospital requires documentation of appropriate training The hospital requires documentation of appropriate training before granting fluoroscopic privileges Practitioners are before granting fluoroscopic privileges Practitioners are required to be re-credentialed every two years.required to be re-credentialed every two years.In order to become re-credentialed, a physician must do the In order to become re-credentialed, a physician must do the following:following:– View this powerpoint presentationView this powerpoint presentation– Complete the self-assessment quizComplete the self-assessment quiz– Upon completing the training, each physician will need to Upon completing the training, each physician will need to

complete an attestation. The attestation certificate is complete an attestation. The attestation certificate is available for printing.available for printing.

– Present this certificate to the department chairperson for Present this certificate to the department chairperson for recording the successful completion of the fluoroscopy recording the successful completion of the fluoroscopy safety requirement.safety requirement.

It is up to the each department to establish other training and It is up to the each department to establish other training and education requirements needed to obtain fluoroscopy education requirements needed to obtain fluoroscopy privileges.privileges.

TOPICSTOPICSMobile C-armsMobile C-armsFactors Influencing Fluoroscopy Exposure RateFactors Influencing Fluoroscopy Exposure RateSources of Radiation ExposureSources of Radiation ExposureRadiation ProtectionRadiation ProtectionPersonnel MonitoringPersonnel MonitoringExample of a Skin Injury from FluoroscopyExample of a Skin Injury from FluoroscopyRadiation and PregnancyRadiation and PregnancySummarySummary

Mobile C-armsMobile C-armsMoved around ORs to visualize anatomy during Moved around ORs to visualize anatomy during surgerysurgeryMetallic c-arm contains x-ray tube at one end and Metallic c-arm contains x-ray tube at one end and image receptor at the otherimage receptor at the otherAn associated unit contains the displayAn associated unit contains the display

Modern fluoroscopy units produce images with an Modern fluoroscopy units produce images with an iimage mage iintensifier (ntensifier (IIII) which brightens the image level sufficiently ) which brightens the image level sufficiently so that the image may be displayed on a TV screen. so that the image may be displayed on a TV screen. Fluoroscopy units are usually operated in an automatic Fluoroscopy units are usually operated in an automatic brightness control (ABC) mode.brightness control (ABC) mode.

These units will automatically adjust the brightness by These units will automatically adjust the brightness by first increasing the kVp to increase x-ray penetration and first increasing the kVp to increase x-ray penetration and then adjusts the mA to increase intensity.then adjusts the mA to increase intensity.

Note: Exposure to a thick patient will be greater than to a thin Note: Exposure to a thick patient will be greater than to a thin patient and also abdominal fluoro will require a greater exposure patient and also abdominal fluoro will require a greater exposure than a chest fluoro due to increased thickness and tissue density in than a chest fluoro due to increased thickness and tissue density in the abdomen.the abdomen.

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure RateExposure Rate

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure RateExposure Rate (cont.)(cont.)

Recommendation # 1: The image intensifier input should Recommendation # 1: The image intensifier input should be positioned as close to the patient as practicable. be positioned as close to the patient as practicable. This results in a lower patient dose and sharper image.This results in a lower patient dose and sharper image.

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 2: Use the exposure pedal as Recommendation # 2: Use the exposure pedal as sparingly as possible.sparingly as possible.

Radiation exposure during fluoroscopy is also directly proportional to Radiation exposure during fluoroscopy is also directly proportional to the length of time the unit is activated by the foot pedal. Depression of the length of time the unit is activated by the foot pedal. Depression of the foot pedal determines the length of exposure. The fluoroscopy time the foot pedal determines the length of exposure. The fluoroscopy time is an important determinant of patient and staff radiation dose. is an important determinant of patient and staff radiation dose. Fluoroscopy units are equipped with a timer and an alarm which sounds Fluoroscopy units are equipped with a timer and an alarm which sounds at the end of 5 minutes. The alarm serves as a reminder of the elapsed at the end of 5 minutes. The alarm serves as a reminder of the elapsed time. time.

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 3: Use “last-image” hold and Recommendation # 3: Use “last-image” hold and pulsed fluoro whenever possible.pulsed fluoro whenever possible.

Most modern fluoro units are equipped with “last-image” hold, which Most modern fluoro units are equipped with “last-image” hold, which stores the last fluoro image and allows viewing without having to expose stores the last fluoro image and allows viewing without having to expose the patient again. Many fluoro units also offer a “pulsed fluoro mode”, in the patient again. Many fluoro units also offer a “pulsed fluoro mode”, in which the x-ray beam is pulsed rapidly on and off and results in a lower which the x-ray beam is pulsed rapidly on and off and results in a lower radiation dose without significantly degrading the appearance of the radiation dose without significantly degrading the appearance of the image on the display. image on the display.

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Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 4: Use the smallest field of view Recommendation # 4: Use the smallest field of view practicable.practicable.Radiation exposure also depends on x-ray field size and keeping the x-ray field Radiation exposure also depends on x-ray field size and keeping the x-ray field as small as possible (by using collimators) which will as small as possible (by using collimators) which will decreasedecrease the dose to the dose to BOTHBOTH the patient and staff in the fluoroscopy suite. Restricting the field size not the patient and staff in the fluoroscopy suite. Restricting the field size not only decreases radiation dose but will also produce a better image. The only decreases radiation dose but will also produce a better image. The contrast in the image between various tissue types will be greater for the contrast in the image between various tissue types will be greater for the smallest field of view that encompasses the desired anatomy.smallest field of view that encompasses the desired anatomy.

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 5: High dose or detail modes Recommendation # 5: High dose or detail modes should be used only sparingly.should be used only sparingly.Many fluoro units will have various dose modes, such as low dose, Many fluoro units will have various dose modes, such as low dose, medium dose and high dose mode. medium dose and high dose mode.

It is important to recognize that fluoroscopic image quality can be It is important to recognize that fluoroscopic image quality can be adversely affected by too few x-rays in the image; the image is noisy for adversely affected by too few x-rays in the image; the image is noisy for low dose. More tissue contrast is produced by the “high dose” mode low dose. More tissue contrast is produced by the “high dose” mode which will improve the image quality at the expense however of which will improve the image quality at the expense however of increased patient dose.increased patient dose.

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 6: Magnification should be used Recommendation # 6: Magnification should be used only when necessary.only when necessary.

Fluoroscopy units are capable of using different magnification modes. Fluoroscopy units are capable of using different magnification modes. Image resolution is improved with magnification but field size is reduced Image resolution is improved with magnification but field size is reduced and patient radiation dose is increased. Patient dose is minimized by and patient radiation dose is increased. Patient dose is minimized by using the lowest magnification (largest field size) appropriate for the using the lowest magnification (largest field size) appropriate for the image procedure being performed.image procedure being performed.

Under Normal mode, there is little magnification with the whole beam used to generate a bright image. Under Mag 1 mode, a smaller beam area is projected to the same II output.  The resulting object size is larger, but the image is dimmer due to the less beam input. The ABC system senses the brightness loss and either boosts machine X-ray output, increases tube voltage, or a combination of both.

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6 inch mag FOV increases dose by a factor of 4 over non-mag image

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

Recommendation # 7: For C-arm type fluoroscopy Recommendation # 7: For C-arm type fluoroscopy units the patient should be positioned as far from the units the patient should be positioned as far from the x-ray tube as practicable to minimize patient entrance x-ray tube as practicable to minimize patient entrance dose. To reduce personnel exposure the x-ray tube dose. To reduce personnel exposure the x-ray tube should be positioned beneath the patient.should be positioned beneath the patient.

In the case of portable C-Arm systems, eliminating the air gap In the case of portable C-Arm systems, eliminating the air gap between the between the I-II-I and the patient ensures that the table top is as far and the patient ensures that the table top is as far away as possible from the X-ray tube, minimizing radiation away as possible from the X-ray tube, minimizing radiation exposure to the patient’s skin. exposure to the patient’s skin.

Note: The separator cone Note: The separator cone should alwaysshould always be utilized before be utilized before commencing fluoroscopy on portable C-arm systems, as depicted commencing fluoroscopy on portable C-arm systems, as depicted below on the image at right.below on the image at right.

   

Factors Influencing Fluoroscopy Factors Influencing Fluoroscopy Exposure Rate Exposure Rate (cont.)(cont.)

In conventional under-table x-ray tube fluoroscopic units, the x-ray tube In conventional under-table x-ray tube fluoroscopic units, the x-ray tube is located at a fixed distance from the patient’s skin. is located at a fixed distance from the patient’s skin.

In C-arm fluoroscopy, where the distance between the x-ray tube and In C-arm fluoroscopy, where the distance between the x-ray tube and image intensifier is fixed, the patient can be positioned in close image intensifier is fixed, the patient can be positioned in close proximity to the x-ray tube which increases the entrance skin dose and proximity to the x-ray tube which increases the entrance skin dose and reduces image sharpness.reduces image sharpness.

It is preferable to locate the C-arm x-ray tube underneath the patient. It is preferable to locate the C-arm x-ray tube underneath the patient. Since the radiation transmitted through the patient is typically only 5 – Since the radiation transmitted through the patient is typically only 5 – 10 % of the entrance dose, inadvertent exposure to the operator hand 10 % of the entrance dose, inadvertent exposure to the operator hand on the exit side of the patient will result in a smaller dose compared to on the exit side of the patient will result in a smaller dose compared to the dose to the hand on the entrance side of the patient. Also the the dose to the hand on the entrance side of the patient. Also the amount of scatter radiation the operator is exposed to on the beam exit amount of scatter radiation the operator is exposed to on the beam exit side of the patient is significantly less than on the beam entrance side.side of the patient is significantly less than on the beam entrance side.

Note: The benefit is exaggerated - some operator dose occurs on the image intensifier (I-I) side.

Sorenson, 2000.

X-ray tube

X-ray tube

Sources of Radiation ExposureSources of Radiation Exposure

DIRECT EXPOSUREDIRECT EXPOSURE– Entrance Skin Exposure (ESE) rates (where the x-rays enter the Entrance Skin Exposure (ESE) rates (where the x-rays enter the

patient) are limited to less than 10 R/minutepatient) are limited to less than 10 R/minute(NOTE: At ESE rates of 10 R/min, 30 minutes of fluoroscopy can (NOTE: At ESE rates of 10 R/min, 30 minutes of fluoroscopy can deliver 300 R in skin dose.) deliver 300 R in skin dose.)

– ESE rates for typical fluoroscopy procedures are usually less than ESE rates for typical fluoroscopy procedures are usually less than 5 R/min.5 R/min.

– On some machines an operator can deliberately choose a setting On some machines an operator can deliberately choose a setting that will increase the output. The use of higher radiation rates or that will increase the output. The use of higher radiation rates or "boost" modes are useful in situations requiring high video image "boost" modes are useful in situations requiring high video image resolution. ESE of up to 20 R/min is permitted for short duration. resolution. ESE of up to 20 R/min is permitted for short duration. Special operator reminders, such as audible alarms, are activated Special operator reminders, such as audible alarms, are activated during "boost" modes.during "boost" modes.

Sources of Radiation ExposureSources of Radiation ExposureSCATTER EXPOSURE TO SCATTER EXPOSURE TO PERSONNELPERSONNEL– Most of the radiation exposure Most of the radiation exposure

received by the operator or other received by the operator or other personnel in the fluoroscopy suite personnel in the fluoroscopy suite is due to scatter radiation from the is due to scatter radiation from the patient.patient.

– The operator will be exposed to a The operator will be exposed to a dose rate of approximately one dose rate of approximately one one-thousandth (1/1000) of the one-thousandth (1/1000) of the ESE rate at a distance of 1 meter ESE rate at a distance of 1 meter from the center of the fluoroscopy from the center of the fluoroscopy field.field. Sorenson, 2000.

Sources of Radiation ExposureSources of Radiation ExposureFactors which increase the dose from scatter Factors which increase the dose from scatter radiation: radiation: – Large patients which will cause the automatic brightness Large patients which will cause the automatic brightness

control (ABC) to adjust the kVp and mA to higher values control (ABC) to adjust the kVp and mA to higher values causing greater amounts of scatter radiation.causing greater amounts of scatter radiation.

– A large x-ray field, a result of not restricting field size will A large x-ray field, a result of not restricting field size will increase scatter radiationincrease scatter radiation

– The length of time the fluoroscopy unit is on. Complex The length of time the fluoroscopy unit is on. Complex interventional cases will require greater procedure time, interventional cases will require greater procedure time, increasing dose to both the patient and operatorincreasing dose to both the patient and operator

Other sources of exposure to the operator Other sources of exposure to the operator may be associated with the following:may be associated with the following:– A small percentage of exposure to the operator may A small percentage of exposure to the operator may

be due to leakage radiation through the x-ray tube be due to leakage radiation through the x-ray tube housing.housing.

– C-arm operators should be aware that the shielding C-arm operators should be aware that the shielding built in to “fixed” fluoroscopy systems is not available built in to “fixed” fluoroscopy systems is not available for protection against backscatter. This may be of for protection against backscatter. This may be of greater concern if the C-arm is rotated out of the greater concern if the C-arm is rotated out of the normal vertical plane.normal vertical plane.

Sources of Radiation ExposureSources of Radiation Exposure

Radiation ProtectionRadiation ProtectionThe The threethree most productive means of reducing radiation most productive means of reducing radiation dose is:dose is:

TimeTime: : MinimizeMinimize time spent in the radiation field. time spent in the radiation field. Use of “last-image-hold” and pulse fluoro features Use of “last-image-hold” and pulse fluoro features

are technical advantages in reducing the total time are technical advantages in reducing the total time x-rays are produced x-rays are produced

Distance:Distance: Radiation dose rates Radiation dose rates increaseincrease or or decreasedecrease according to the according to the inverse square lawinverse square law

Ex: Double your distance from the source and Ex: Double your distance from the source and decrease your exposure by a factor of 4 decrease your exposure by a factor of 4

– Shielding:Shielding: Use of lead garments, lead gloves, thyroid Use of lead garments, lead gloves, thyroid shields, leaded eyeglasses, lead drapes and shields, leaded eyeglasses, lead drapes and clear leaded glass barriers between the patient clear leaded glass barriers between the patient and operator and operator

PPE and Radiation MonitoringPPE and Radiation Monitoring

Personnel MonitoringPersonnel MonitoringEven when radiation protection techniques and Even when radiation protection techniques and engineering controls are in place to reduce personnel engineering controls are in place to reduce personnel exposure, individual dose monitoring is required.exposure, individual dose monitoring is required.

Various types of dosimeters are available (i.e., film Various types of dosimeters are available (i.e., film badges, thermo-luminescent (TLD) and optically-badges, thermo-luminescent (TLD) and optically-stimulated luminescent (OSL) badges).stimulated luminescent (OSL) badges).

Badges are assigned to an individual and must never be Badges are assigned to an individual and must never be shared.shared.

A badge designed to measure the whole body (torso A badge designed to measure the whole body (torso including head) should be worn at the collar – including head) should be worn at the collar – OUTSIDEOUTSIDE the lead apron.the lead apron.

Note that the time to expression of symptoms is long enough that the patient Note that the time to expression of symptoms is long enough that the patient may no longer be in the hospital when symptoms appear. The physician may no longer be in the hospital when symptoms appear. The physician performing the fluoroscopy cannot discern the damage by observing the patient performing the fluoroscopy cannot discern the damage by observing the patient immediately following the procedure.immediately following the procedure.

FDA Specification of Radiation-Induced Skin InjuriesFDA Specification of Radiation-Induced Skin Injuries

Threshold DoseThreshold Dose Typical Fluoro-On Time in MinutesTypical Fluoro-On Time in Minutes

Skin EffectSkin Effect remrem SvSv Normal mode @ Normal mode @ 10 R/min10 R/min

High Dose mode @ High Dose mode @ 20 R/min20 R/min

Time to Time to OnsetOnset

Early Transient Early Transient ErythemaErythema 200200 22 20 minutes20 minutes 10 minutes10 minutes HoursHours

Temporary Temporary EpilationEpilation 300300 33 30 minutes30 minutes 15 minutes15 minutes 20 days20 days

Basal Cell Basal Cell ErythemaErythema 600600 66 60 minutes60 minutes 30 minutes30 minutes 10 days10 days

Permanent Permanent EpilationEpilation 700700 77 70 minutes70 minutes 35 minutes35 minutes 20 days20 days

Dry Dry DesquamationDesquamation 10001000 1010 100 minutes100 minutes 50 minutes50 minutes 30 days30 days

Example of a Skin Injury from Example of a Skin Injury from FluoroscopyFluoroscopy

This case, patient A is that of a 40-This case, patient A is that of a 40-year-old male who underwent year-old male who underwent coronary angiography, coronary coronary angiography, coronary angioplasty and a second angioplasty and a second angiography procedure due to angiography procedure due to complications, followed by a complications, followed by a coronary artery by-pass graft, all on coronary artery by-pass graft, all on March 29, 1990. The area of injury March 29, 1990. The area of injury six to eight weeks following the six to eight weeks following the procedures. The injury was procedures. The injury was described as "turning red about one described as "turning red about one month after the procedure and month after the procedure and peeling a week later."peeling a week later."

In mid-May 1990, it In mid-May 1990, it had the appearance of had the appearance of a second-degree burn. a second-degree burn. The condition in late The condition in late summer 1990, exact summer 1990, exact date unknown, with date unknown, with the appearance of a the appearance of a healed burn, except healed burn, except for a small ulcerated for a small ulcerated area present near the area present near the center. center.

Example of a Skin Injury from Example of a Skin Injury from Fluoroscopy Fluoroscopy (cont.)(cont.)

Skin Skin breakdown breakdown continued continued over the over the following following months with months with progressive progressive necrosis. necrosis.

Example of a Skin Injury from Example of a Skin Injury from Fluoroscopy Fluoroscopy (cont.)(cont.)

The injury eventually The injury eventually required a skin graft. required a skin graft. The magnitude of the The magnitude of the skin dose received by skin dose received by this patient is not known. this patient is not known. However, from the However, from the nature of the injury, it is nature of the injury, it is probable that the dose probable that the dose exceeded 20 Gy. exceeded 20 Gy.

Example of a Skin Injury from Example of a Skin Injury from Fluoroscopy Fluoroscopy (cont.)(cont.)

Wagner LK, Eifel PJ, Geise RA. Potential Biological Effects Following High X-ray Dose Interventional Procedures. JVIR 1994; 5:71-8

Pregnancy and RadiationPregnancy and RadiationThe decision to perform a radiological procedure on a The decision to perform a radiological procedure on a patient who may be pregnant is a medical decision and patient who may be pregnant is a medical decision and shall be made by a physician in consultation with the shall be made by a physician in consultation with the patient. If the procedure is to be performed, the physician patient. If the procedure is to be performed, the physician must explain the risks to the patient, provide informed must explain the risks to the patient, provide informed consent and the appropriate consent form shall be signed.consent and the appropriate consent form shall be signed.Shielding shall be used to shield the abdomen from Shielding shall be used to shield the abdomen from radiation provided it does not interfere with the procedure.radiation provided it does not interfere with the procedure.Every attempt must be made to minimize direct exposure Every attempt must be made to minimize direct exposure to the fetus according to the principles described in this to the fetus according to the principles described in this presentation.presentation.Medical emergency radiological procedures however take Medical emergency radiological procedures however take precedence over pregnancy status.precedence over pregnancy status.

PAUSE to properly plan and prepare for study Activate dose saving features of equipment No exposures unless necessary Depress last image hold and last image grab instead PULSE at lowest possible rate

Principles for Fluoroscopy

QuizQuiz1.1. Which parameter effects the penetration of an x-ray beam through a Which parameter effects the penetration of an x-ray beam through a

patient?patient?a)a) kVpkVpb)b) mAmAc)c) BothBoth

2.2. Automatic brightness control (ABC) _______ the quantity of Automatic brightness control (ABC) _______ the quantity of radiation for large patientsradiation for large patientsa)a) IncreasesIncreasesb)b) DecreasesDecreasesc)c) Has no effectHas no effect

3.3. Correct fluoroscopy technique requires which of the following to be Correct fluoroscopy technique requires which of the following to be close to the patient:close to the patient:a)a) X-ray tubeX-ray tubeb)b) Image intensifierImage intensifierc)c) Does not matterDoes not matter

QuizQuiz

4.4. Which of the following reduces patient dose?Which of the following reduces patient dose?a)a) Last image holdLast image holdb)b) Pulsed fluoroscopyPulsed fluoroscopyc)c) Both of the aboveBoth of the above

5.5. Which of the following is better technique to reduce patient Which of the following is better technique to reduce patient dose?dose?a)a) Use of collimationUse of collimationb)b) Use of magnification modeUse of magnification modec)c) Neither has an effect on doseNeither has an effect on dose

6.6. For c-arm fluoroscopy, which is better?For c-arm fluoroscopy, which is better?a)a) Position x-ray tube under tablePosition x-ray tube under tableb)b) Position x-ray tube over tablePosition x-ray tube over tablec)c) It does not matterIt does not matter

QuizQuiz

7.7. When wearing a single radiation badge during a fluoroscopy When wearing a single radiation badge during a fluoroscopy procedure, it must be worn:procedure, it must be worn:a)a) Attached to the thyroid collarAttached to the thyroid collarb)b) Underneath the lead apron at the waistUnderneath the lead apron at the waistc)c) There is no need for radiation badges in fluoroscopyThere is no need for radiation badges in fluoroscopy

8.8. The biggest concern for patients receiving high dose fluoroscopy is:The biggest concern for patients receiving high dose fluoroscopy is:a)a) Skin damageSkin damageb)b) Cancer inductionCancer inductionc)c) Both concerns are equalBoth concerns are equal

9.9. Fluoroscopy procedures should Fluoroscopy procedures should nevernever be performed on a pregnant be performed on a pregnant woman.woman.a)a) TrueTrueb)b) FalseFalse

QuizQuiz10.10. The most productive means of reducing radiation exposure during The most productive means of reducing radiation exposure during

fluoroscopy is:fluoroscopy is:a)a) Wearing lead garmentsWearing lead garmentsb)b) Reducing fluoroscopy timeReducing fluoroscopy timec)c) Both of the aboveBoth of the above

Answers1 a 6 a2 a 7 a3 b 8 a4 c 9 b5 a 10 c

I have read the material on radiation safety and fluoroscopy and understand the operation and radiation safety features of the fluoroscopic units that I will use.

Print Name ___________________________

Department ____________________________

The information presented in this training document is designed to give a practitioner a basic knowledge of radiation safety principles as they apply to the use of fluoroscopy. In addition, the practitioner must have knowledge and experience in the use of the specific radiographic systems which they will utilizing.This attestation must be submitted and filed with the department chairman who privileges physicians to perform specific fluoroscopic procedures. The responsibility for delineation of clinical privileges ultimately lies with the department chairman.

Signature _______________________________________ Date ___________

PHYSICIAN ATTESTATIONFLUOROSCOPY RE-CREDENTIALING