ALARA - "As Low As Reasonably Achievable"

ALARA is a general principle relative to keeping radiation dose exposure to patients as low as reasonable for each procedure, given clinical need and patient factors.


Ways to achieve ALARA

    Proper Radiological Positioning

    • Maximize distance between x-ray tube and patient
    • Minimize distance between patient and detector
    • Inverse square law – make use of it!
    • Keep hands out of the beam

    Reduce Dose

    • Reduce field size (collimate)
    • Minimize field overlap
    • Avoid unnecessary exposures
    • Limit acquisition to what is essential for diagnostic and documentation purposes
    • Remember:
      • Pediatric patient more radiation sensitive 
      • Pediatric longevity
      • Use US where possible 
    • Optimize operating parameters for x-ray machines

    • Regularly inspect and maintain equipment

    • Machine Selection and Maintenance

    Personal Protection - Identify and provide the best personal protective gear to staff

    • Mobile Devices

    • Radioprotective non-lead patient drapes

    • Well fitted lead apron (knees)

    • Leaded glasses (with sides)

    • Thyroid shield

    • Lead gloves – anesthetist and operator

    • Front or Back lead

    Establish Facility Quality Improvement Program

    • Develop QA and QC Dosimetry Programs

    • Appropriate x-ray equipment QA program

    • Overseen by a medical physicist

    • Equipment evaluation/inspection

    • Adequately train staff on equipment capabilities re: image quality and dose

    • Include Medical Physicist in decisions

    • Incorporate Dose-Reduction Technologies and Dose-Measurement Devices in equipment

    Education and Training

    • Comprehensive Training of Operators
      • Radiation Biology, Physics, and Safety
    • Attend high-quality courses or complete a self-training course given by appropriate professional societies
    • Comply with applicable state requirements

    Dosimetry Records

    • Measure and Record Patient Radiation Dose

    • Record Fluoroscopy Time

    • Record Available Measures

      • DAP (Dose Area Product)

      • Cumulative Dose
      • Skin Dose
    • Inform patients who have received high doses to examine x-ray beam entrance site for skin erythema

    Dosimetry Follow-up

    • Develop Methods to Quantify Late Effects
      • Design medical records to clearly document the number and types of interventional procedures received by the patient
      • Maintain a database of all patients with procedures and dose information
      • Review dose information to identify patients with high doses (>3Gy) for follow-up
      • Establish procedures for follow-up; including skin examination at 30 days

    Physician-Patient Interaction pre-procedure

    • Ask patient about prior history of interventional fluoroscopy
    • Communicate details of the procedure, patient dose, and immediate and long-term health effects to patients and their primary care providers
    • Counsel patients on radiation-related risks, as appropriate, along with the other risks and benefits associated with the procedure

    Physician-Patient Interaction post-procedure

    • Schedule a 30 day Follow-Up Visit if:
      • Radiation Skin Dose =/> 2 Gy, or
      • Cumulative Dose =/> 3 Gy
    • Send interventional fluoroscopy procedure description, operative notes, doses and information about the possible short-term and long term effects to the patient’s primary care provider
    • The patient and primary care physician should be specifically requested to notify the operator if observable skin effects occur

    Monitor and Improve Operator Performance

    • Audit outcomes of procedures (including patient radiation dose for each operator)
    • Share information learned in audits with operators and provide additional training as needed
    • Provide annual radiation safety education for all operators.
    • Collaborate in clinical trials to identify best practices for optimizing doses to patients and minimizing dose to health care providers

    Awareness of Technology Advances

    • 3D Rotational Angiography
    • Flat Detector Systems
    • Cone Beam CT (“CT-Like Imaging”)

    Marketing and Business Improvement

    • Inform patients and the community of the efforts taken by your facility to achieve ALARA
      • Posters in patient areas
      • Notes on documents and deliverables
      • Website, Email