Abstract
Background
The demands and hazards of working in the cardiac catheterization laboratory (CCL) are well-represented in the literature and include radiation exposure, orthopedic injuries, and physical and psychological stress. This analysis aimed to compare occupational hazards in the CCL between 2014 and 2023, focusing on orthopedic injuries, cancer diagnoses, and pregnancy-related issues.
Methods
Society for Cardiovascular Angiography & Interventions members were invited to complete an online survey regarding occupational hazards in the CCL from May to August 2023. This survey included questions about demographics, caseload, self-reported injuries, malignancies, radiation and orthopedic protection, and pregnancy.
Results
The 2023 survey had an 8% response rate and included 296 respondents (91% interventional cardiologists, 7% fellows-in-training, and 2% interventional echocardiographers or invasive noninterventional cardiologists). The majority of respondents were men (83%), 30 to 50 years old (61%), and in practice for 5 to 15 years (39%). The 2023 survey reported orthopedic injuries and lifetime cancer in 59.8% and 6.1% of respondents, respectively, vs 49.4% and 4.5% reported in the 2014 survey. Among women respondents, 28% reported being discouraged from working in the CCL due to pregnancy or considering pregnancy, and 71% wanted the option to step away from the CCL during pregnancy.
Conclusions
A high prevalence of orthopedic injuries and cancer diagnoses was reported in a 2023 survey of Society for Cardiovascular Angiography & Interventions members working in the CCL. It is imperative to promote the widespread use of radiation protective gear to decrease radiation exposure and encourage utilization of newer radiation protection systems that can minimize the use of lead aprons, a major contributor to orthopedic injuries. Attention to effective measures for the safety of CCL personnel is a critically important goal in interventional cardiology.
Keywords: cancer, cardiac catheterization laboratory, occupational injury, orthopedic injury, pregnancy, radiation safety
Introduction
Transcatheter cardiac interventions have expanded in number and complexity over the last 4 decades. This reflects clinical evidence supporting the use of new devices and techniques coupled with training, which has expanded the breadth of procedures to improve the outcomes of patients with coronary, peripheral, and structural heart disease.1 Advances in fluoroscopic imaging, such as improved imaging quality, enhanced safety features, and the emergence of better shielding technology, have contributed to the expanded utilization of radiation mitigation tools in most aspects of cardiac interventions.2 Though these technological advances have permitted patients to receive percutaneous procedures only dreamed of decades ago, the resulting increase in the number of procedures and their length and complexity has adversely impacted the health of operators working in the cardiac catheterization laboratory (CCL).3 These include radiation injury, physical injuries, and pain due to wearing protective radiation aprons, as well as the physical and psychological demands of the work involved.4 All of these hazards are cumulative over a career of 30+ years for the average operator. Although there is considerable literature on the effects of ionizing radiation on the body and methods to mitigate it, specific effects on the well-being of interventional staff, including interventional cardiologists, in the CCL are an evolving field of study. Additionally, although previous studies have detailed individual hazards, this study uniquely captures the evolving nature of these risks and compares trends over time.
Occupational hazards can contribute to career-ending events such as cancer, chronic pain, orthopedic injuries, and psychosocial stressors.5,6 In turn, the impact of these events on the mental health of operators is understudied and potentially minimized. The 2023 Society for Cardiovascular Angiography & Interventions (SCAI) survey aimed to investigate these occupational hazards as self-reported by participants and compare the findings with the prior survey conducted a decade earlier, in 2014.7
Methods
An online, 29-item, multiple-selection survey (see Supplemental Document A for the full survey) was developed by SCAI’s Professional Wellbeing Taskforce. Questions focused on demographics, procedure volumes, and types, radiation exposure awareness, injuries sustained to self or colleagues, use of protective equipment, barriers to using such technologies, and anticipated practice change due to those injuries and exposure. To allow for longitudinal comparison, survey question wording and response options replicated those in the 2014 SCAI occupational health hazards survey as much as possible.7 In contrast to the 2014 SCAI survey, the current survey included questions focused on the impact of pregnancy on operators in the CCL. Further, SCAI’s expanded membership, which now comprises noninterventional cardiologists, and congenital, and international operators, was reflected in the current survey’s respondents. The survey questions were designed so that the majority were answered by electronically checking a box, except when specific numbers were needed, such as for procedure volumes or in write-in fields.
The survey was created in Alchemer, an online survey application, and emailed to 3406 SCAI US and international members, including CCL personnel. Participation was encouraged by 2 reminder emails and 3 SCAI community board postings. The survey was also promoted at SCAI’s annual scientific meeting using QR codes that directed potential participants to the online survey. Survey respondents were given the option to submit their contact information for a draw to receive free registration to SCAI’s annual scientific meeting. In total, the survey was open from May 17, 2023, to August 5, 2023. Duplicate respondents were identified behind an administrative firewall based on voluntarily submitted email addresses. After removing duplicate responses (n = 13), responses that only included demographic data (n = 26), nonphysician respondents (n = 2 nurses, 2 radiologic technologists, and 6 “other”), and respondents with extreme outliers in their annual caseload (n = 6), the analytic data set consisted of 296 responses. The data were stored so that the responses could be queried using different parameters and directly compared with the results of the 2014 survey. The survey response rate was 8% as compared to the 11% response rate in the 2014 survey. This survey-based research did not include protected health information; therefore, prior institutional review board review and approval was not required. A statistical consultant team supported the analysis using a deidentified data set.
Statistical analysis
All variables were examined using descriptive statistics. As continuous variables were found not to be normally distributed, these were analyzed by median and IQR. The total annual caseload (computed as the sum of all reported diagnostic procedures and all reported interventional procedures) was categorized by statistical quintiles into lowest quintile (≤350), second quintile (351-500), third quintile (501-720), fourth quintile (721-975), and highest quintile (>975) for further analyses. “Any orthopedic injury” was defined as any of the reported “cervical spine,” “lumbar spine,” “hip/knee/ankle injuries,” or “wrist/elbow/shoulder injuries.”
Bivariate analyses were used to assess the relationships between total annual caseload quintiles and types of orthopedic injuries and between age and various factors using χ2 or Fisher exact tests. Spearman correlation was used to test the association between the total number of orthopedic injuries and the number of preventative activities employed to mitigate such injuries. The nonparametric Mann-Whitney U and χ2 tests were used to test for differences in total annual caseloads and injuries reported between 2014 and 2023.
Multiple logistic regression was used to assess the association between total annual caseload and any orthopedic injury, adjusting for age and gender. In addition, we used multiple logistic regression to test for changes in the number of injuries from 2014 to 2023, adjusting for the total annual caseload. Data were presented as adjusted odds ratio (AOR) and 95% CI. A P value of <.05 was considered statistically significant.
All analyses were performed with SAS version 9.4 (SAS Institute).
Results
Demographics
A total of 296 participants completed the survey, 94% of whom were SCAI members (8% survey response rate among SCAI members) and 97% of whom were currently working in a CCL. Respondents’ characteristics are outlined in Table 1. Most respondents were men (83%), and 61% were between the ages of 30 and 50 years. Most respondents were from the United States (77%). An additional 16% of respondents were from Asia, with just over half of international respondents from India. The majority of respondents (91.3%) were interventional cardiologists, 7% were fellows-in-training, and 1.7% were interventional echocardiographers or invasive noninterventional cardiologists. Most (90%) reported treating adult patients, and 9% reported treating adult and pediatric patients. The median annual caseload was 602 cases (IQR, 478). Coronary procedures were the most common, with a median coronary caseload of 500 (IQR, 410).
Table 1.
Characteristics of survey respondents.
| Characteristics | N | % | Mean ± SD | Median (Q1, Q3) |
|---|---|---|---|---|
| Age, y | ||||
| 30-40 | 89 | 30.2 | – | – |
| 41-50 | 90 | 30.5 | – | – |
| 51-60 | 56 | 19.0 | – | – |
| 61-70 | 47 | 15.9 | – | – |
| >70 | 13 | 4.4 | – | – |
| Gender | ||||
| Men | 246 | 83.4 | – | – |
| Women | 49 | 16.6 | – | – |
| Years in practice | ||||
| <5 | 59 | 19.9 | – | – |
| 5-15 | 115 | 38.9 | – | – |
| 16-25 | 58 | 19.6 | – | – |
| >25 | 64 | 21.6 | – | – |
| Annual diagnostic procedures | ||||
| Coronary | 272 | – | 400 ± 282 | 350 (200, 500) |
| Peripheral | 188 | – | 43 ± 64 | 20 (0, 50) |
| Structural | 171 | – | 44 ± 73 | 10 (0, 60) |
| Adult congenital | 151 | – | 12 ± 28 | 5 (0, 20) |
| Pediatric congenital | 134 | – | 19 ± 90 | 0 (0, 0) |
| Annual interventional procedures | ||||
| Coronary | 272 | – | 193 ± 159 | 150 (100, 250) |
| Peripheral | 181 | – | 32 ± 50 | 20 (0, 40) |
| Structural | 196 | – | 63 ± 85 | 40 (0, 80) |
| Adult congenital | 155 | – | 20 ± 23 | 0 (0, 20) |
| Pediatric congenital | 133 | – | 13 ± 66 | 0 (0, 0) |
Impact of radiation and occupational hazards
A high percentage of survey respondents reported injuries or illnesses experienced either by themselves or their CCL staff and colleagues (Figure 1). About two-thirds of the respondents (66%) reported having experienced musculoskeletal pain related to wearing lead or working in the CCL, and 60% reported having at least 1 orthopedic injury. Approximately 20% reported hip/knee/ankle injuries or wrist/elbow/shoulder injuries, 25% reported cervical spine injuries, and 34% reported lumbar spine injuries. Only 18% reported no injuries from working in the CCL. Approximately 6% contracted cancer, whereas 5% reported having cataracts or skin injury. It is possible that survivorship bias limited self-reporting of some injuries such as brain tumors. Respondents reported even higher rates of injuries and illnesses among staff and colleagues. Of note, 25% reported cataracts among staff or colleagues, 11% reported knowledge of a colleague with a brain tumor, and 15% reported knowledge of a colleague with another type of cancer. It is possible that these rates could be overrepresentative if the same injury in a colleague is reported by multiple respondents.
Figure 1.
Injuries and illnesses experienced by survey respondents or colleagues/staff. MSK, musculoskeletal.
Radiation exposure and orthopedic injuries negatively impacted respondents’ ability to work in the CCL. Approximately 17% of respondents reported that a personal decision or institutional requirement led them to limit their hours in the CCL to reduce their radiation exposure. Nearly 1 in 5 respondents had limited or reduced procedures in the CCL due to orthopedic problems, and 21% had taken a leave of absence due to a physical or mental occupational hazard or injury. Eighty-two percent of respondents indicated they would plan to work longer in the CCL (retire later) if injuries were better prevented or managed, with 20% indicating they believed they would extend their careers by 10 years or more.
Annual caseload, age, and orthopedic injuries
Annual caseload quintiles were significantly associated with wrist/elbow/shoulder injuries (P = .035) and with having any orthopedic injury (P = .047). However, it was not significantly associated with hip/knee/ankle, cervical spine, or lumbar spine injuries (P = .117, P = .431, P = .446, respectively). Having musculoskeletal pain was also significantly associated with having each type of orthopedic injury (hip/knee/ankle: P = .036; wrist/elbow/shoulder: P = .024; cervical spine: P < .0001; lumbar spine: P < .0001) and with having any orthopedic injury (P < .0001). The survey did not separate groups of respondents by types of procedures performed (eg, structural, peripheral, CTO) or by the average length of procedure performed. Older age was associated with having any orthopedic injury (P = .009), and with having cancer (P < .001) (Table 2).
Table 2.
Association between age and reported orthopedic injury or cancer.
| 30-40 y | 41-50 y | 51-60 y | 61-70 y | >70 y | P value | |
|---|---|---|---|---|---|---|
| Ever experienced any orthopedic injury | 42/89 (47%) | 52/90 (58%) | 36/56 (64%) | 36/47 (77%) | 10/13 (77%) | .0085 |
| Ever had cancer | 0 | 5/90 (6%) | 3/56 (5%) | 9/47 (19%) | 1/13 (8%) | .0003 |
Age was significantly associated with having any orthopedic injury after adjusting for annual caseload in quintiles and gender. Compared with those aged 30 to 40 years, those aged 51 to 70 years had higher odds of an orthopedic injury (51-60 years: AOR, 2.28 [1.09-4.80]; P = .029; 61-70 years: AOR, 3.93 [1.67-9.27]; P = .002). The trend continued for those over the age of 70 years but did not reach statistical significance for that group (AOR, 3.85 [0.92-16.12]; P = .065). There was no significant association between gender and the odds of orthopedic injury (P = .609).
Therapeutic interventions and orthopedic injury in the CCL
More than three-quarters of respondents reported engaging in activities to prevent or manage injuries (Figure 2), including strength training (47%), stretching or yoga (42%), some other type of exercise (48%), massage (21%), or improving CCL ergonomics (14%). The number of injuries reported was significantly correlated with engagement in preventative or injury management activities (P = .003).
Figure 2.
Survey respondents’ participation in activities to protect against or manage injuries.
We examined the percentage of reported spine and total orthopedic injuries in respondents who exercised or participated in some type of therapy. A higher percentage of participants with the 3 most common orthopedic injuries reported using physical therapy (hip/knee/ankle, 40%; P < .001; cervical spine, 32%; P = .029; lumbar spine, 37%; P < .0001) compared to those without injury (18%, 20%, and 16%, respectively). In addition, a higher percentage of those with multiple injuries (37%) reported using physical therapy compared to those with 1 injury (27%) (P < .001). Stretching or yoga was more common in those with cervical spine injuries (53%, P = .027) and lumbar spine injuries (57%, P < .001) than those without injury (39% and 35%, respectively), as well as in those with multiple reported orthopedic injuries (58%) compared to those with 1 (41%) (P < .001). The percentage reporting strength training and massage therapy increased with a higher number of overall orthopedic injuries (P = .026 and P = .043, respectively). Although acupuncture use was not reported at all among individuals without injuries, 3 individuals with multiple orthopedic injuries reported using this therapy. Chiropractic care and other types of exercises were not associated with orthopedic complaint rates.
2023 survey results vs 2014 survey
Compared with the prior 2014 SCAI survey, the median number of coronary and structural procedures performed by the survey respondents increased. Median coronary procedures increased from 400 (IQR, 300) in 2014 to 500 (IQR, 410) in 2023 (P = .002), whereas the median number of structural procedures increased from 20 (IQR, 94) in 2014 to 50 (IQR, 150) in 2023 (P = .023). Peripheral procedures decreased from a median of 60 (IQR, 110) in 2014 to 37.5 (IQR, 90) in 2023 (P = .003). A bivariate analysis found no significant changes in the reporting of any types of orthopedic injuries between 2014 and 2023 (Figure 3). The changes occurring during the period may also be due, in part, to the change in respondent sample.
Figure 3.
Reported orthopedic injuries among survey respondents in 2014 vs 2023. There was no significant difference in reported injury rates for any type of reported injury.
Pregnancy in the CCL
Respondents reported reservations about working in the CCL while pregnant. Among female respondents, 28% reported being discouraged from working in the CCL while pregnant, and 71% reported that they would want to step away from the CCL during pregnancy. Overall, 43% of respondents had reservations about pregnant people working in the CCL.
Radiation exposure tracking and prevention strategies
Although 83% of respondents reported wearing their radiation badge regularly, 17% reported incidents when they had not worn their badge to avoid crossing exposure thresholds. Eighty-one percent of respondents reported that their CCL tracks staff radiation dose. There was no significant association between age and routine badge wearing (P = .194).
Only 70% of respondents reported that their workplace has formal radiation safety education requirements. Respondents reported adopting a variety of protective technologies for radiation protection, including low-dose imaging systems (46%), RADPAD (WorldWide Innovations and Technology Inc) or similar shielding (45%), hanging or tableside shielding (67%), shielded scrub caps (30%), and leaded eye protection (67%) (Figure 4). Less than 15% reported adopting “lead-free” or “reduced lead” technologies aimed at providing radiation protection while reducing orthopedic injuries including Zero-Gravity (Biotronik), RAMPART IC (RAMPART IC, LLC), Protego (Image Diagnostics Inc), and Corindus CorPath 200 vascular robotics (Koninklijke Philips N.V.), shielded gloves, or live radiation monitoring devices. However, 96% reported considering adopting 1 or more of the above-listed new technologies to reduce the risk of radiation exposure. The largest barriers to adopting new technologies were cost (83%) and administrative buy-in (71%) (Figure 5).
Figure 4.
Current use of radiation protection technologies by survey respondents.
Figure 5.
Anticipated barriers to enhancing cardiac catheterization laboratory safety among survey respondents.
Discussion
Although innovations in equipment and procedures have led to the treatment of more complex diseases and have improved outcomes for patients undergoing coronary, peripheral, and structural procedures, advances in occupational safety have lagged and are impairing the well-being of the interventional cardiology workforce. The use of radiation for imaging, lead aprons to mitigate exposure, and challenges in ergonomics continue to contribute to diseases including ocular diseases, malignancies, and musculoskeletal injuries.
The first and second SCAI surveys on occupational health in 20048 and 20147 highlighted major occupational hazards, including ocular injury, musculoskeletal injury, and malignancies. Unfortunately, the 2023 SCAI survey continues to demonstrate persistent issues impacting our workforce and has brought new insights into the issues faced by pregnant interventional cardiologists. The 2023 survey also assessed the reported use of protective equipment that might mitigate the adverse effects of working in the CCL and found low rates of adoption.
Although survey results do not demonstrate cause and effect between injury and therapeutic strategies, they do suggest that musculoskeletal injuries related to working in the CCL remain extremely common and that operators look for ways to mitigate these impacts. Respondents with musculoskeletal injuries were more likely to utilize physical therapy, strength training, massage, and yoga/stretching to manage their injuries or prevent further injury than those who did not experience injuries. The survey did not allow for insights into whether tailored exercise, ergonomic assessments, and medical therapies, including physical therapy, massage therapy, and chiropractic therapy, prevent injuries or whether they allow operators to return to work sooner after injuries. In addition, we were not able to ascertain whether individuals who suffered musculoskeletal injuries and who participated in physical therapy, massage therapy, or chiropractic therapy were less prone to recurrent injuries. However, results from a recent study showed that a routine stretching program may reduce upper-body musculoskeletal disability in CCL staff.9
Another concerning result of the survey was the preponderance of cancers and other types of radiation injury, such as cataracts. The percentage experienced by the respondents was 3-fold higher than what is observed in the general population.10 This is in line with other studies that demonstrate a significantly higher lifetime attributable risk for all cancers and particularly for head and neck, and thyroid cancers in similar professions such as interventional radiology.11 The incidence of malignancy, in general, and brain tumors in particular, does not appear to have been mitigated by the evolving fluoroscopic technology.12 There was no relationship between reported operator volume and radiation injury, but there is a statistically significant association between operator age and these injuries. Some respondents also reported stepping away from working in the CCL due to these complaints and potentially shortening their careers. In the current survey, 17% of respondents reported limiting their time in the catheterization laboratory due to radiation exposure, which is more than double the 6.9% who reported this in the 2014 survey. This finding may be attributable to the higher complexity of procedures being performed in recent years and may also be due to the change in the respondent population sampled.
In addition to the hazards mentioned above, women in interventional cardiology contend with the concerns about radiation exposure to the fetus coupled with the potential for maternal musculoskeletal injuries associated with wearing lead aprons while pregnant.13,14 Studies have suggested that with attention to radiation safety and appropriate shielding, the potential exposure to a fetus is relatively low. However, this is based primarily on measured radiation exposure during pregnancy and may not reflect long-term effects or the phase of pregnancy.15,16 Our findings demonstrate that these concerns may impact the willingness of women to work in the CCL while pregnant. Our survey did not have the statistical power to determine whether there was a differential impact of working in the CCL on women vs men with regard to musculoskeletal injuries, nor whether pregnant operators were prone to injuries. Our results reveal a concerning percentage of pregnant women who are discouraged by their peers from remaining active in the CCL. These findings demonstrate the need for further education and policies that empower female operators to protect their health during pregnancy and to ensure that their ability to perform procedures is not unduly curtailed.17
Several potential confounders may limit survey studies such as this.18 The potential for self-reporting bias, the relatively low response rate for survey completion, and the lack of verification of self-reported procedural numbers are potential limitations to our study. However, our survey questions were rigorously constructed to mimic the prior survey and add new information sources. Although a low response rate may limit the generalizability of the study findings, especially to noninterventional cardiology CCL operators, the survey response rate in this study was similar to that seen in the prior occupational survey7 adding credence to the conclusions. The information presented serves as an important representation of the state of the current interventional workforce.
The findings of the 2023 SCAI survey on occupational health hazards demonstrate unacceptable rates of injuries that impact health and the ability to continue to work as interventional cardiologists and a disturbing lack of progress since the last survey. The combination of orthopedic injuries, ocular injuries, malignancies, and the unique issues faced by women contemplating pregnancy or who are pregnant impact the majority of interventionalists and impede patient access. For some, these injuries will shorten careers; for others, they will shorten lives. Addressing these hazards is important for sustaining a healthy workforce, reducing career burnout, and ensuring continued access to high-quality patient care. As many of these injuries are directly related to radiation exposure, it is critical that interventional cardiologists no longer accept these occupational hazards. The path forward should first include aligned advocacy to challenge the current approaches to radiation safety and change the paradigm away from simply wearing heavy protection garments to directly reducing exposure by incorporating nonwearable radiation protection equipment (Central Illustration). Second, the contributions of poor ergonomics must be better understood, and the development of tailored programs for individuals must be implemented. Third, education and appropriate policies should be developed to enable female operators better to understand the radiation risks and musculoskeletal risks during pregnancy and to continue to have the opportunity to operate in the CCL safely. Fourth, employers should provide unique health benefits and disability benefits to address the health issues our workforce experiences while simultaneously incorporating new technologies to replace or supplement our current radiation protection equipment. The perceived barriers to adopting emerging technologies due to cost considerations or administrative buy-in, can be overcome by better appreciating the significant health benefits and cost advantages of reducing physician injury to the system. Formal radiation safety education should be a core requirement for working in the CCL.
Central Illustration.
Results and desired action from the Society for Cardiovascular Angiography & Interventions (SCAI) 2023 Occupational Health Hazards Survey.
Serious occupational hazards are possible deterrents from entry into the field of interventional cardiology and limit the longevity of many operators’ careers. New research should focus on improving CCL ergonomics, reducing radiation exposure without wearing heavy lead aprons, physical activities or treatments and their impact as we age, and providing insights on how injuries impact the workforce. Novel technologies such as Zero-Gravity, RAMPART IC, Protego, Egg Nest Complete system (Egg Medical), and Corindus CorPath 200 vascular robotics will hopefully replace or supplement current radiation protection equipment.19,20 There, is, however, heterogenicity in the data supporting the use of such technologies and levels of protection; hence, operators will need to carefully assess their needs, workflows, and published evidence in selecting such tools.21, 22, 23, 24, 25 In addition, future research will also need to address the unique impact of stressors that affect mental wellness and the associated impact on operators and their families. The survey results suggest that intentional actions are needed to address these important health and occupational hazards to chart a different future, change the status quo, and maintain health and safety for operators in this field.
Acknowledgments
The authors are grateful to Dr Magda Shaheen, Dr Katrina Schrode, and Deyu Pan at Charles R. Drew University for their support in performing the statistical analysis and review of the manuscript.
Declaration of competing interest
Islam Abudayyeh serves as a member of the California Department of Public Health’s Radiologic Technologist Certification Committee. The other authors have no relevant disclosures.
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
Ethics statement and patient consent
This survey-based research did not include identifiable protected health information; therefore, institutional review board review and approval were not required and informed consent was not obtained.
Footnotes
To access the supplementary material accompanying this article, visit the online version of the Journal of the Society for Cardiovascular Angiography & Interventions at 10.1016/j.jscai.2024.102493
Supplementary material
References
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