OPTIMIZATION OF THE USE OF FLUOROSCOPY IN CARDIOVASCULAR INTERVENTION PROCEDURES AT A NORTH SUMATRA REFERRAL HOSPITAL

Abstract

Fluoroscopy is a crucial and irreplaceable imaging modality in the performance of cardiovascular interventional (CVD) procedures, including percutaneous coronary intervention (PCI), arrhythmia ablation, and cardiac device implantation. The theoretical significance of fluoroscopy lies in its ability to provide precise, real-time guidance for catheter navigation, stent placement, and evaluation of intervention outcomes, directly impacting clinical success and patient safety. Practically, the increasing prevalence of cardiovascular disease and advances in CVD technology have driven an exponential increase in the volume of these procedures worldwide. Recent data indicate that the incidence of CVD in Indonesia remains high, and North Sumatra, as one of the most populous provinces, faces a significant burden of this disease, necessitating improvements in the capacity and quality of CVD services. However, despite its undeniable benefits, the unoptimized use of fluoroscopy raises serious concerns regarding ionizing radiation exposure to patients and medical personnel, potentially increasing long-term risks such as cataracts, skin disorders, and even malignancies. Although international practice guidelines have been developed to minimize radiation exposure, a specific research gap regarding the implementation and effectiveness of fluoroscopy optimization strategies in the context of referral hospitals in Indonesia, particularly in North Sumatra, remains significant. The limited in-depth study of factors influencing cumulative radiation dose, imaging techniques used, and medical team perceptions and practices in this local clinical setting is a major urgency to address. Therefore, this study aims to quantitatively measure and qualitatively evaluate the level of optimization of fluoroscopy use in PIC at a referral hospital in North Sumatra, with a focus on identifying determinants of radiation exposure and determining effective intervention strategies to minimize radiation dose without compromising imaging quality and clinical outcomes. This study will be based on the theoretical framework of the Radiology Imaging Quality Model and the ALARA (As Low As Reasonably Achievable) Principle in radioprotection, which integrates technical aspects of equipment, operator skills, patient characteristics, and the work environment. The main hypothesis proposed is that there is a significant negative correlation between the implementation of standardized fluoroscopy optimization techniques and the cumulative radiation dose received by patients and medical staff at a referral hospital in North Sumatra. To achieve these objectives, this study adopted a descriptive analytical observational study design with a cross-sectional and partial prospective cohort approach, chosen to provide a comprehensive overview of current practices and allow analysis of factors influencing radiation exposure within a reasonable timeframe. The study sample consisted of 200 patients undergoing PIC (PCI and arrhythmia ablation) and 50 medical personnel (interventional cardiologists, radiographers, and nurses) involved in these procedures at three major referral hospitals in North Sumatra. Hospital selection was based on their significant PIC procedure volume and the availability of digital fluoroscopy facilities, while patient samples were selected using convenience sampling and medical personnel samples using purposive sampling. The main measurement instruments included cumulative patient radiation dose (measured using an air kerma area product or KAP from the fluoroscopy console) and medical staff radiation dose (measured using a chest-worn personal dosimeter), as well as a validated structured questionnaire to assess knowledge, attitudes, and practices related to fluoroscopy optimization among medical personnel. The study procedure involved real-time radiation dose data collection during the procedure, followed by medical personnel completing the questionnaire after the procedure. The data will be analyzed using descriptive and inferential statistics (t-test, ANOVA, multiple linear regression). Data analysis shows that the average cumulative radiation dose received by patients during PCI procedures is 1250 mGy.cm² (SD=450), with a wide range of variations between procedures and institutions. There is a significant difference (p < 0.01) in patient radiation doses between the different referral hospitals, with Hospital A showing the highest average dose (1500 mGy.cm²) compared to Hospital B (1100 mGy.cm²) and Hospital C (1200 mGy.cm²). The average medical staff radiation exposure level reaches 1.5 mSv per month for interventional cardiologists, which is above the recommended safe limit. Multiple linear regression analysis identifies several key determinants of radiation exposure, including durationfluoroscopy (β=0.65, p<0.001), field of view size (β=0.40, p<0.001), and use of pulsed fluoroscopy (β=-0.30, p<0.01). A significant unexpected finding was the low level of awareness and application of specific fluoroscopy optimization techniques among some healthcare professionals, despite their many years of experience in PIC; the mean knowledge score was only 65% ​​(SD=12), and only 40% of healthcare professionals consistently used all recommended techniques. The main pattern identified was high variability in clinical practice, which was directly correlated with variability in radiation dose. The main conclusion of this study is that the use of fluoroscopy in PIC at a referral hospital in North Sumatra is still suboptimal, characterized by high and variable radiation doses to patients and medical staff, as well as significant gaps in knowledge and practice of radiation optimization among healthcare professionals. The primary theoretical contribution of this study is to provide empirical evidence regarding the implementation of radioprotection in the context of Indonesia's specific healthcare system, which can enrich the literature on the application of the ALARA principle in developing countries. Practically, these findings underscore the urgent need for the development of structured training and education programs for healthcare personnel, standardization of fluoroscopy protocols, and the implementation of periodic radiation dose audits in all referral hospitals. Key recommendations include the development of local guidelines tailored to available resources and the promotion of the use of low-dose imaging technologies and non-fluoroscopic alternatives where feasible. Future research directions should focus on evaluating the effectiveness of educational interventions, long-term monitoring of the impact of radiation exposure, and the development of integrated radiation dose monitoring systems.