A STUDY ON RADIATION PROTECTION AMONG PATIENTS AND STAFF IN THE IMAGING DEPARTMENT AT KENYATTA NATIONAL HOSPITAL.

RESEARCH DONE BY: DENIS NOVENA MUNG’AHU COLLEGE NUMBER: D/MIS/10007/191

RESEARCH PROPOSAL SUBMITTED TO THE DEPARTMENT OF MEDICAL IMAGING SCIENCES-NYERI CAMPUS IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE STUDY.

JANUARY 2013

KENYA MEDICAL TRAINING COLLEGE
P.O BOX 466
NYERI.

Contents
DECLARATION 1
DEDICATION 3
List of abbreviation 4
Operational definition 5
Chapter 1 6
1.0 Introduction 6
1.1 Broad objective 6
1.2 Specific Objectives 6
1.3 Problem Statement 6
1.4 Research Question 7
1.6 Study Justification 8
Chapter 2 9
Literature review 9
2.0: Introduction 9
2.1: Practice of radiation protection principles by the radiographers 10
2.1.1: Beam collimation by the radiographer 10
2.2.2: Beam Limiting Devices 11
2.2.2: Technique Selection 12
2.2.3: Patient identification 12
2.2: The practice of the radiation protection principles 13
The principle of limiting time 13
2.2.2 The principle of distance 14
2.2.3 The principle of applying shielding 15
2.3 To determine patients' level of knowledge 15
2.4 Conclusion 16
Chapter 3 16
Methodology 16
3.0 Background information 16
3.1 Position and size 16
3.2 Topography, climate and temperature 17
3.3 Population 17
3.5 Design 18
3.6 Study area 18
3.7 Sampling size determination 18
3.8 Ethical consideration 19
CHAPTER 4 19
APPENDIX I 19
Introduction 19
QUESTIONNAIRE 20
Observational checklist 23
Appendix 2 24
BUDGET 24
Appendix.3 25
Time schedule 25
References 26

DECLARATION
This proposal is an outcome of an independent study. Any input by others in the making of the project a success is fully acknowledged.
I hereby declare that this proposal has not been submitted either in same or different form to this or in any other institution for academic qualification.
Student Signature____________________ Date________________ D/MIS/10007/167

Internal supervisor External supervisor
Name……………………………… Name………………………………
Signature………………………… Signature…………………………
Date………………………………… Date…………………………………

DEDICATION
This dissertation is dedicated to my loving two aunts Sarah and Scholastica together with my mum MaryGorret, for their continuous love and support throughout my life and the far I have made it to. For the many sleepless nights and sacrifices that they have had to endure for my success; may GOD abundantly bless you all and I cherish you.

List of abbreviation

RPA- Radiation Protection Act
WHO- World Health Organization
CT- Computed Tomography
MRI- Magnetic Resonance Imaging
KNH- Kenyatta National Hospital
NQF- National Quality Forum
SID- Source Image Distance
KMTC-Kenya Medical Training College
ICRP-International Commission on Radiation Protection
UON-University of Nairobi
KVp-Kilo voltage Peak mAs-Milliampere per second

Operational definition

Radiographer-
Beam limiting devices-
Kilo voltage peak-
Milliampere per second-
Fluoroscopy-
Radiation protection-

Chapter 1
1.0 Introduction
The purpose of this chapter is to introduce all the research details. It contains a clear statement of the problem and the objectives of the researcher are also laid here.
1.1 Broad objective
To assess the level------ of radiation protection among patients and staff in the imaging department at the Kenyatta National Hospital.
1.2 Specific Objectives
1. To determine the practices of radiation protection by the radiographers in the imaging department at the KNH.
2. To determine the principles of radiation protection employed in the imaging department at the KNH.
3. To determine the level of knowledge on radiation protection among patients undergoing examinations in the imaging department at the KNH.
1.3 Problem Statement
According to the Radiation Protection Act(RPA)-Chapter 2,Section 1(Art.8&9)- Art 8 is about justification of radiation exposure which states: An activity that involves the exposure of people or the environment to ionizing radiation may only be carried out if it can be justified in terms of the associated benefits or risks..
There has been an initiative in determining the level of radiation protection in the imaging department in order to have a basis on to which protection from the harmful radiation is offered to both the patients and the staff.
In conjunction to radiation protection there’re various principles that provide effective radiation protection.
However, x-rays have very long term effects to the people (in this case are the patients) and the environment. At the Kenyatta National Hospital, I have identified that there remedial measures put in place in respect to radiation protection but they are no longer adhered to by respective radiographers. Many patients feel insecure thus unsafe from radiation and they are afraid to be associated with radiations. The issue of neglecting these remedial measures inhibits patients from getting better health care and due to this, there result in the death of cells in their bodies which would also undergo genetic mutation.
Therefore, in response to this problem, I propose to investigate several options for revisiting remedial measures to have maximum safety for patients. I plan to investigate for options such as ensuring no leakage on x-ray tubes; alert the individual radiographer of the penalties they may face on assuming these remedial measures put in place and to even take a step in educating patients on the remedial measures concerned with radiation protection.
1.4 Research Question
Are radiation protection principles to the safety of patients in the imaging department at Kenyatta National Hospital being practiced by radiographers?
1.5 Significance
Study on radiation protection remedial is very important to the society as it prevents patients, radiologic technologists and any other member within the imaging department from adverse effects of radiation which include; deoxyribonucleic acid breakage, chromosomal aberrations and gene mutations. It also provides evidence base for evolving technologies to help improvements in practice and for radiation protection practices.

1.6 Study Justification
The study is very important because of its significance to the community at large. The community according to the proved science, continuous exposure to radiation will effect in the death of cell and lead to genetic mutation of the individual being.
Therefore, the study aims at protecting the future and the current lives of the patients who are still the community thus enhancing normal being preventing the disabilities that could be caused in the community.

Chapter 2
Literature review
2.0: Introduction
In the imaging department, there are various ways aimed at a successful strategy for providing and improving essential radiation protection to patients without considering the age, financial status, physical stability, racial minority, tribe etc.
In respect to the study objectives, there is enough literature review that supports them. The objectives include; practice of radiation protection, radiation protection principles and patients’ knowledge on radiation protection.

2.1: Practice of radiation protection principles by the radiographers
The radiation protection practices in the imaging department by the radiographer runs across so many factors. These include beam collimation, beam centering, proper patient identification, processing, proper positioning, immobilization, correct anatomical marking etc. all these if considered will enhance patients’ safety in the radiological department. Radiation protection devices by the radiographers range from a strict adherence to safety practices to complacency to unsafe procedures. This would advance the practice of radiologic sciences by determining the degree of compliance with radiation safety.
2.1.1: Beam collimation by the radiographer
Basing on http:/www.icro.org/docs/2005_recsCONSULTATION_draft1a.pdf, radiology technologists take x-rays and administer nonradioactive materials into patients' bloodstreams for diagnostic purposes. Some specialize in diagnostic imaging technologies, such as CT and MRI. Radiologic technologists and technicians, also referred to as radiographers, produce x-ray films (radiographs) of parts of the human body for use in diagnosing medical problems.
They prepare patients for radiology exams by explaining the procedure, removing articles through which x-rays cannot pass and positioning patients so that the parts of the body can be appropriately radiographed. To prevent unnecessary radiation exposure, these workers surround the exposed area with radiation protection devices, such as lead shields, or limit the size of the x-ray beam with collimation.
Radiology technologists position radiographic equipment at the correct angle and height over the appropriate area of a patient's body. Using instruments similar to a measuring tape; they may measure the thickness of the section to be radiographed and set controls on the x-ray machine to produce radiographs of the appropriate density, detail, and contrast. They place the x ray film under the part of the patient's body to be examined and make the exposure. They then remove the film and develop it.
2.2.2: Beam Limiting Devices
Beam limiting devices attach directly to the x-ray tube and confine the useful beam before it enters the body, which in turn limits the area irradiated to only the necessary area of interest. Limiting the beam to focus on the correct anatomy reduces scatter and will reduce patient dose.The different Types of Beam Limiting Devices are so many and they include:2.2.2.1: Aperture Diaphragm Is the simplest type of beam restricting device. It consists of a sheet of lead with a hole in the center that determines the size and shape of the beam and attaches directly to the x-ray tube.2.2.2.2: Cones Circular metal tubes that attach to the attach to the x-ray tube, limiting the x-ray beam to a predetermined size and shape. Cones can be either a flared cone with the upper portion be smaller than the lower or a straight cone which is the same size all the way through.2.2.2.3: Extension Cylinders Used with spot or very small field radiography, they are long usually about 10 to 20inch cylindrical metal tubes that are attached to the regular cone to increase the length of the cone. This extension piece further limits the useful beam for precise imaging.|
2.2.2: Technique Selection
Selecting the appropriate technical factors for the exam will allow the radiographer to obtain diagnostic images while keep the radiation dose to of the patient as minimal as possible. The use of high kVp and low mAs techniques will reduce the dose to the patient. Higher kVp results in more free transmission, therefore the patient is absorbing less of the dose. Increasing the kVp by 15 percent will double the density in the radiograph and reduce patient dose in comparison to doubling the mAs. So next time you go to "bump up the mAs" instead try the 15% KVp rule which will still provide a diagnostic image and your patient will thank you! However while kVp increases and mAs decreases radiographic contrast decreases which can lead to poor image quality so you technique adjustments must be within reason for the exam you are performing.|
2.2.3: Patient identification
WHO Collaborating Centre for Patient Safety Solutions Aide Memoire Statement of problem and impact: Throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families.
Basing on the NQF, the major areas where patient misidentification can occur include drug administration, x-ray examinations, phlebotomy, blood transfusions, and surgical interventions. The trend towards limiting working hours for clinical team members leads to an increased number of team members caring for each patient, thereby increasing the likelihood of hand-over and other communication problems. Because patient misidentification is identified as a root cause of many errors, the Joint Commission, in the United States of America, listed improving patient identification accuracy as the first of its National Patient Safety Goals introduced in 2003, and this continues to be an accreditation requirement. While in some countries wristbands are traditionally used for identifying hospitalized patients, missing bands or incorrect information limit the efficacy of this system. Color coding of wristbands facilitates rapid visual recognition of specific issues, but the lack of a standardized coding system has led to errors by staff that provide care at multiple facilities.
2.2: The practice of the radiation protection principles
The radiation protection principles are commonly practiced to minimize on the Radiation Protection Dose (RAD). The 3 principles are called cardinal rules of radiation protection: i.e. time, distance and shielding.
2.2.1 The principle of limiting time
Nicholas and Jeffrey (2006) stand to reason that the longer a person is exposed to a field of radiation the greater that exposure is and its consequences may be. From a diagnostic imaging point of view occupation exposure risk can be minimized by limiting unnecessary patient dose which is beneficial to the patient and the radiographer. Imaging professional must practice diligent exposure principles during fluoroscopy and all x-ray procedures like e.g. there are 4 dynamic ways of reducing time of exposure in fluoroscopy: intermittent beam on-off imaging’s, use of last image hold technique, avoiding long static fluoroscopic imaging and keeping occupational dose below the regulated equivalency limits.
2.2.2 The principle of distance
In spite of the advances in radiation protection, such as collimation, cones, and positive beam limiting devices, distance is still the best tool for radiation protection and it’s the most common method of protecting personnel, visitors and adjacent patients from ionizing radiation use. Few person in the health care environment understand why distance effectively protects them and therefore they continuously question, “At what distance am I considered safe?” the answer lies in the understanding the relationship of one’s distance from a source of exposure intensity. A safe distance can be accurately estimated from the vector of radiation exposure and its initial intensity using the inverse square law. One should note that this law only applies to a point source of radiation such as primary radiation (x-rays and gamma rays), and does not apply to particulate ionizing radiation , or scatter radiation which is the major type of occupational radiation exposure personnel should encounter.
A basic characteristic of radiation emitted from a small point source such as an x-ray tube, is that the beam diverges from that source to cover an increasingly larger area. The inverse square law states that the intensity of x-ray photons or gamma radiations decreases inversely as the area the beam covers increases. Using this law we see that if the distance from the point source is doubled, then the intensity of radiation in the same unit area would be reduced to one-fourth the original concentration and that the total radiation would be spread out over an area that is the square of the distance. The SID is also a factor to be looked at when considering patient safety in radiation protection.
2.2.3 The principle of applying shielding
Shielding is a required practical method of radiation protection. Commonly used materials for shielding are lead, concrete or bricks to prevent or reduce transmission of radiation. Alpha particles are the most damaging radiations but can be stopped with a sheet of ordinary paper. Beta particles can be stopped completely with ¼ inch of plastic but gamma and x-rays are never completely stopped by shielding materials used in walls or found in apparel.
In the case of highly penetrating radiation, the shielding formula is used to complete the reduction in radiation intensity using half-value-layer and 10th value layering schemes. In shielding we look at the linear attenuation coefficient which is defined as the fraction of the number of photons removed from the radiation field per cm of absorber through which it passes. It is expressed as a percentage e.g. 10% with a function like the decay constant. LAC can be adjusted to whatever percentage desired.
2.3 To determine patients' level of knowledge
The medical journal of Kocatepe (2009) puts it clear when students carried out a survey of 224 patients in a University Hospital. A questionnaire that tested patients' information about ionizing radiation, harmful effects and protection from this effect was given out to them. The journal concludes that, although many participants had radiological examinations previously, they had insufficient knowledge about radiation protection. Since the level of education for most patients was primary school, it would be appropriate to include lessons about radiation protection and side effects of ionizing radiation in primary school, in waiting rooms, informative brochures about radiation protection could be useful for patients.
2.4 Conclusion
Basing on the literature above, it conclusively informs the entire citizens of the Kenya and the world as a whole the importance of carrying out research on the remedial measures of radiation protection.

Chapter 3
Methodology
3.0 Background information
3.1 Position and size
Kenyatta national hospital is located in Nairobi upper hill-Nairobi city Kenya. It is located off Mbagathi road. It was founded in 1901 as the native civil hospital. It is currently the largest referral and teaching hospital in the country. KNH has a capacity of 1800 beds and has over 6000 staff members. It covers an area of 45.7ha. The UON medical school, KMTC Nairobi and several government agencies are located at it.
3.2 Topography, climate and temperature
Nairobi city is situated at an elevation of about 1660m in the highlands of southern part of the country. Topography is straight forward central Nairobi, sky scrapers and all, rises mirage-like from the flat edge of Embakasi and Athi plains.
Situated at high altitudes, Nairobi has a moderate climate. The summer months are sunny and warm without blistering temperatures, while winters are mild to cool, with very chilly evening. Rainfall is also moderate, the wettest part of the year being late summer to autumn, when cloudy, drizzly days are common. Temperatures of Nairobi are quite cool and dry with minimum and maximum of 120C and 250C respectively with midday relative humidity of only 46%.
3.3 Population
Nairobi’s population on Jan 1st 2010 is approximately 2,074,433(Extrapolated from a population census of 3,138,258 on august 3rd 2009 and a population of 3,138,553 on October 9th 2010.

3.4 Communication
Most roads in Nairobi are tarmacked and hence easy communication network in terms of transport and accessibility to KNH.
3.5 Design
The study is a descriptive in which questionnaires, interviews and observation are used. This enables the researcher to save on time and have his/her research effective.
3.6 Study area
The study will be carried at KNH found within Nairobi County or rather city.
3.7 Sampling size determination
The study will employ a random sampling. The general population of this study will be patients and radiographers. Therefore the formula to be used is modified Fisher’s et al (1998) for population of