# Radiation Protection Compliance in Fluoroscopy-Assisted Procedures: A Prospective Audit in Operating Theatres

## TL;DR

This study found that while most operating theatre staff follow radiation protection rules during fluoroscopy procedures, some roles like trauma surgeons and scrub nurses show significant non-compliance, suggesting a need for better training and monitoring.

## Contribution

The study identifies specific compliance gaps in radiation protection among clinical roles in fluoroscopy-assisted procedures and proposes targeted interventions to improve safety.

## Key findings

- 78% of staff fully complied with radiation protection protocols, but 22% were non-compliant with thyroid shielding.
- Trauma surgeons and scrub nurses showed the highest rates of non-compliance with radiation protection measures.
- Statistical analysis revealed significant differences in compliance rates across clinical roles.

## Abstract

Background: Fluoroscopy-assisted procedures expose operating theatre staff to ionising radiation, with the thyroid, eyes, and hands being particularly vulnerable. Despite established protection protocols, compliance remains inconsistent across clinical roles.

Objective: This study aims to evaluate adherence to radiation protection protocols, particularly thyroid shielding, among theatre staff during fluoroscopy-assisted procedures, identify compliance gaps, and propose targeted interventions.

Materials and methods: A prospective audit was conducted over 10 weeks (May to August 2025) in the operating theatres of a level 1 major trauma centre (MTC) in the United Kingdom. Observational data were collected on thyroid protection use, supplemented by dosimetry and adherence to personal protective equipment (PPE) checklists. A total of 712 (100%) staff members were observed during 91 fluoroscopy-guided procedures. Notably, the audit was conducted in a blinded manner; no theatre staff were aware that radiation protection behaviour was being monitored, apart from the radiographers. This approach ensured that the data reflected authentic staff conduct without being influenced by observational bias. Chi-square tests were used to assess differences in compliance across roles and specialities, with statistical significance set at p < 0.05.

Results: Among the 712 (100%) staff members assessed during 91 operations, 555 (78.0%) demonstrated full compliance with lead gown and thyroid protection protocols. However, 157 (22.0%) were non-compliant with thyroid protection. Of these, roughly 150 (21%) wore a lead gown without a thyroid shield, and seven (1.0%) wore neither a gown nor a thyroid shield.

When examining the distribution of non-compliant cases across operation types, 79.1% (n = 72) occurred during trauma and orthopaedic surgeries, 17.6% (n = 16) during spine surgeries, and 3.3% (n = 3) during other procedures. Chi-square analysis revealed no statistically significant association between operation type and PPE non-compliance (p = 0.0995, df = 2), exceeding the conventional threshold of 0.05.

When analysed by role, non-compliance was observed in 38.7% (n = 58) of surgical team members, 26.0% (n = 39) of scrub nurses, 20.7% (n = 31) of anaesthetic staff, and 14.7% (n = 22) of individuals in other roles. (χ² = 14.87, p < 0.001), with odds of non-compliance 2.31 times greater (OR = 2.31, 95% CI: 1.52-3.52). Scrub nurses also demonstrated elevated non-compliance (χ² = 7.43, p = 0.006, OR = 1.74, 95% CI: 1.18-2.89), as did anaesthetic staff (χ² = 5.12, p = 0.024, OR = 1.58, 95% CI: 1.06-2.52) and individuals from other roles (χ² = 3.87, p = 0.049, OR = 1.42, 95% CI: 1.01-2.21).

Conclusions: Although overall adherence to thyroid protection protocols was high, notable and statistically significant gaps were identified, particularly among trauma surgeons, scrub nurses, and anaesthetic staff. These findings underscore the need for targeted educational initiatives, routine equipment audits, and ongoing compliance monitoring to strengthen radiation safety practices across all clinical roles.