Radiology Department Hazards: The Cost of Doing Business

Jeff Killion, PhD, RT(R)(QM), and James Johnston, PhD, RT(R)(CV)

   ^*Asssistant Professor, Department of Radiologic Science, Midwestern State University, Wichita Falls, Texas.
   ^†Asssistant Professor, Department of Radiologic Science, Midwestern State University, Wichita Falls, Texas. 
   Address correspondence to: Jeff Killion, PhD, RT(R)(QM), Assistant Professor, Department of Radiologic Science, Midwestern State University, 3410 Taft Boulevard, Wichita Falls, TX 76308. E-mail: jeff.killion@mwsu.edu.

ABSTRACT

Darkroom disease, multiple chemical sensitivity, and latex allergies can cost healthcare facilities thousands of dollars and potentially more. One approach to creating an informed workforce and implementing changes to address these health hazards is the use of the Stages of Change Model developed by James Prochaska, PhD. It is believed that the steps described in this model can facilitate change within radiology departments to modify their standards and practices, which will help them avoid risking the health of employees, in addition to avoiding the overall cost associated with healthcare problems within the workforce. Although implementing such changes within a department has its own costs, with today’s shortages, the loss of productivity from just 1 radiologic technologist may well pay for such a program.

Introduction

This article will discuss 3 areas of concern for radiology departments: darkroom disease, multiple chemical sensitivity (MCS), and latex allergies. An overview of each condition is presented and similarities are identified. The costs and legal aspects concerning a health facility will also be reviewed. Finally, an education and prevention model will be introduced to address the safety of radiologic technologists (RTs).

Darkroom Disease

In the 1980s, the term darkroom disease was coined by Marjorie Gordon, a former RT, to describe the condition caused by exposure to chemicals found in the developer and fixer of film processors.¹ One of the first people to be affected by the disease, Ms Gordon was exposed to chemical vapors from a processor and her immune system was compromised to such a degree that she had to leave the field of radiology.

Symptoms such as tinnitus, a painful sore throat, and a heart arrhythmia led Ms Gordon to begin researching the cause of her condition.¹ She discovered that the chemical glutaraldehyde, which has been used in automatic processing machines since 1967 but was added at a greatly increased amount in the 1980s, was the source of not only her own health problems, but that other RTs were becoming ill with similar symptoms.¹

RTs are exposed to high levels of acetic acid, formaldehyde, glutaraldehyde, and sulphur dioxide.² Glutaraldehyde is listed as a main agent in triggering an allergic response.³ It is also used as a sterilant and is known as a skin sensitizer.⁴ To add to this chemical mix, dry laser printers use chemicals that are listed as irritants.³

Most chemical injuries come from solvents, according to William J. Rea, MD, founder and director of the Environmental Health Center in Dallas, Tex.⁵ In his work, Dr Rea has described patients who, because of their MCS allergies, cannot go to hospitals because of the chemicals used there.⁵ Some studies classify darkroom disease as a type of MCS and the similarities of symptoms support this assertion.^5,6 Symptoms that are common between MCS and darkroom disease include headache, runny nose, itchy eyes, nausea, asthma, and fatigue.

Latex Allergies

The number of individuals affected by latex allergies has steadily increased since the introduction of universal precautions in the 1980s.⁷ Following the standard precautions of radiology, gloves are required for the majority of procedures. RTs must often wear gloves because they are in contact with blood and bodily fluids, specifically when performing barium enemas, intravascular ultrasounds, all angiography/interventional cases, biopsies, trauma, and room cleanup.

During the manufacturing of latex gloves, more than 200 chemicals are involved, in addition to cornstarch, which is used in the production to aid the donning of gloves. When the gloves are used, latex proteins attach to the cornstarch and it creates an aerosolized irritant. Powder-free gloves can be purchased but chlorine is used in the manufacturing of these, which also can trigger an allergic reaction.⁸ RTs and patients are at risk for developing allergic reactions to latex proteins. Allergic reactions can occur through skin, respiratory, or mucomembranous absorption. The most common allergic response to latex is generally linked to 1 of the 200 chemicals added during the manufacturing process of latex.⁸ In 1998, the US Food and Drug Administration mandated that manufacturers place label warnings on products containing latex.⁹

Multiple Chemical Sensitivity

MCS does not have a standard definition for diagnostic purposes. Generally, it is acknowledged as a condition experienced by individuals when they are exposed to low levels of chemicals found in everyday substances.¹⁰ These individuals have an adverse allergic reaction when exposed to a variety of chemicals. MCS, a multisymptom disease, is not recognized by mainstream medicine.^10-13 There are ongoing debates about whether MCS is a physical or psychological classification; some suggest that this dispute may be politically motivated.¹⁴ It is important to chemical companies that it be labeled as a psychological condition. Lawsuits filed against employers for Americans With Disabilities Act (ADA) accommodations may be settled out of court with the stipulation that settlements are sealed, as not to encourage new lawsuits. Currently, MCS lawsuits under the ADA are in their infancy and in favor of employers. Should MCS gain stronger acceptance in the medical community, this situation will change quickly.¹³ The American Medical Association has reported that it does not want MCS to be considered and the World Health Organization has called for continued research because it does not believe validity has been established.⁹

The process of MCS occurs in 2 stages: initiation and triggering.^10,15 Initiation (causation) is the first stage, in which there is 1 massive exposure or multiple low-level exposures to an agent. The second stage, triggering, is a consequence of the first stage. Once a person is sensitized, a variety of substances will cause an allergic reaction. Common triggering agents include: cleaning agents, chlorine, lead, and formaldehyde. MCS follows the same pattern as drug addiction: acquisition, maintenance, withdrawal, and relapse.¹⁶ Drug abusers and those affected by MCS report the same stimulatory and withdrawal symptoms. Both groups adopt strategies to avoid the withdrawal symptoms. However, the difference between the 2 groups is that the addict searches for another fix and the individual with MCS tries to avoid further exposure.¹⁵  

Similarities

Darkroom disease and type IV latex allergy have similarities to MCS, and may even fall under the common umbrella of MCS.^5,6 The common symptoms of MCS, darkroom disease, and latex allergy (in general) are asthma,^{2,5-7,10,17,18} eye problems (eg, itchy and/or sore),^{3,4,6,7,10,17,18} and nasal problems (eg, runny nose and/or nasal discharge).^3,7,17-19

The common thread for darkroom disease and latex allergy to be considered forms of MCS is a chemical cause. To use the umbrella term MCS for all 3 conditions, the following 3 premises must be accepted: (1) Darkroom disease is a form of MCS^5,6; (2) The most common latex allergy is type IV and attributable to 1 of the 200 chemicals used in the manufacture of latex^8,20; and (3) There is a common set of symptoms presented. With all 3 premises accepted, the evidence would allow 1 umbrella term, MCS, to include darkroom disease and latex allergy, all of which could be addressed in 1 prevention program.

A Case for Intervention

Prevalence rates of darkroom disease, indicating the number of cases at one given time, have been rarely reported in published literature. Of those found, the range was 1.2% to 6.44%.^2,3 MCS prevalence rates ranged from 6.3% to 23%.^10,12,16 The rates for latex allergies were 5% to 30%, with most reports falling in the range of 8% to 17%.^7,18,20-23

Despite these prevalence rates, 1 large survey of RTs indicates a lack of concern. In a recent study, 2880 RTs ranked communicable diseases and radiation safety “high” in concern but chemical and latex allergies “average” in concern, even below ergonomics.²⁴ These perceptions, particularly about workplace, play an important role in employee adoption of safe work practices.²⁵

A look at the financial and legal impact of these conditions completes the picture. There is a lack of literature to provide information about the cost of darkroom disease and MCS. Therefore, the cost and impact of latex allergy alone is used as an example. Conclusions from the evidence suggest that latex allergy alone can be quite costly and worth consideration. Cost resulting from latex allergies encompasses a variety of areas: administrative management, salary, litigation, medical evaluation, relocation to a nonclinical job, absenteeism, retraining, and temporary or permanent disability.⁷ These various components can add up to a substantial amount of money for a healthcare facility.

In the Ranta study, 3 healthcare facilities of varying size analyzed what the cost would be to switch to a latex-free glove environment.^7,27 Each indicated that a latex-free glove environment is more expensive than the use of latex gloves. However, each of the hospitals reported that if 1% or fewer of those at risk for the development of latex allergy become fully disabled, or 2% become partially disabled, the use of latex gloves would exceed the cost of a latex-free glove facility. The Ranta study concluded that, regardless of the size of the healthcare facility, switching to a latex-free environment would provide financial benefits.^7,27

In the late 1990s, The Johns Hopkins Medical Institutions switched to the use of nitrile examination gloves. Because of the increasing number of lawsuits involving latex allergy, it implemented a patient and employee latex safety program. Johns Hopkins also created a task force to address the issue and form a safer environment for patients and employees. The switch to nitrile gloves was successful overall, but the cost of switching to nonlatex surgical gloves was prohibitive.²⁸

Administrators in the studies by Schwingerdorf, Lenehan, and Zaglaniczy reported that cost would be astronomical to switch a hospital to a latex-free glove environment and implement preventive measures.^28-30 However, they also reported that it would be cheaper to implement latex-free measures than to pay the cost of 1 lawsuit. In 2002, 1/3 of hospitals had an increase of 100% or more in liability insurance premiums. More than 25% of hospitals reported a reduction or discontinuance of services as result of growing liability premiums.³⁰ In disability claims, awards are substantial to compensate for the loss of livelihood.²⁹ Also, there are indirect costs of morbidity to a person, such as loss of career, professional identity, social contacts, and financial security.⁷

In the United States, there are 2 sources of legal support for disabilities related to latex allergy, MCS, and darkroom disease, including the ADA and the Workers Compensation Act.^29,31 Under the ADA, it matters little whether MCS is psychological or toxicogenic, as proven by the legal cases that have been brought against glove manufacturers and hospitals.^{4,5,27,29,31,32} In 2001, Karen Zaglaniczny, PhD, CRNA, FAAN, reported in the American Association of Nurse Anesthetists Journal that approximately 250 cases have gone to federal court.³⁰ Thirteen states reported latex allergy cases on the books. Of the 30 cases discussed, 21 were awarded compensation.²⁹ Review of the literature found compensation awards for latex-related problems in the United States, Australia, and the United Kingdom, ranging from $2759 to $215 000.^4,5,7,27,32

Using Models to Implement Change

The use of an established health education/disease prevention model to modify the attitudes of RTs toward chemical threats to health and move them toward safer practice is necessary. The anticipated payoff is a healthier, more productive workforce, in addition to reduced financial drain resulting from these conditions.

Although education and prevention programs are considered important in the field, and management often supports this key to success, no programs were found in use.^8,25,33-35 However, program development and prevention were discussed as important goals in the available literature.^7,8,22,34,36 The only complete model found in this search discussed the organizational development change model, which was used to implement the change to a latex-safe environment in Milton Hospital, Milton, Mass. This program was proven to be useful and effective in guiding change at Milton Hospital.³⁴ The constructs of the organizational change model include:

• Initiation: Beginning the change process in an informed manner.
• Clarification: Defining what needs to be changed and what resources will be needed.
• Specification/agreement: The agenda is set with goals and objectives. The administration commits resources to the project.
• Diagnosis: A narrowing of the focus to the problem at hand.
• Goal setting: Based on the diagnosis, an action plan is developed with a time frame.
• System intervention: The action plan is set in motion, work begins.
• Evaluation: A comprehensive assessment of the change plan and success of efforts.
• Alterations: Adjustments are made in light of evaluation.
• Continuation: Minor adjustments and maintenance of the change.
• Termination: The dissolution of the implementation group once the change has become institutionalized. ³⁴

The Stages of Change Model

The Stages of Change (Transtheoretical Model) developed by James Prochaska, PhD, is one model that can be used to address chemical safety in the radiology department.³⁷ This model can be utilized to evaluate the department’s readiness to change. It can also guide the design of educational curricula to motivate individuals within the department toward safe practice. Such efforts will reduce financial risk to the facility.

The Stages of Change Model involves the following 6 stages³⁷:

• Precontemplation stage: A person who has no plans to change with regards to a health issue within the next 6 months.
• Contemplation stage: Someone who does have plans to change with regards to a health issue.
• Preparation stage: Someone who is getting ready to take action with regards to a health issue.
• Action stage: Someone who is currently in the process of changing with regards to a health issue.
• Maintenance stage: Someone who has completed the change process with regards to a health issue but does have a risk of relapse.
• Termination stage: Someone who has changed with regards to the health issue such that it is no longer a problem and does not enter the conscious mind.

To determine which stage each individual is in, a survey should be used with questions similar to the Planning Guide for Staging and Intervention flow chart, as shown in the Figure (Adobe Acrobat required to view figure). Based on responses to the survey, individuals could be grouped by stage and the appropriate portion of the education curriculum delivered. As an example, the constructs are listed below with a suggested educational intervention.

• Precontemplation: Provide these individuals with brochures and other reading materials to raise awareness about the health issue. The messages should be simple and direct.
• Contemplation: Provide these individuals with more in-depth information that will further their understanding of the health issue and create a desire to change. These educational messages should focus on key points of the health issue and identify benefits of change.
• Preparation: Provide these individuals with the “how to change” information and help them prepare to take action. These individuals have made a decision to change and now need the tools to make that change.
• Action: These individuals are following through on the decision to change; therefore, they need encouragement and the tools to succeed. Remove any barriers that would hinder progress.
• Maintenance: These individuals have successfully made the change but they are in danger of relapsing into old habits. Regular checks on their status using surveys is warranted. Reminder messages will also help reduce the likelihood of relapse.
• Termination: This is the target stage. Here, the change has become so ingrained that no thought or effort is needed to maintain it. In the case of the radiology department, this stage would reflect the corporate culture’s view regarding the health issue.

Conclusions

The dangers of MCS, darkroom disease, and latex allergies are real for RTs. These threats are largely unrecognized; therefore, continuing to ignore them may prove costly in the long term. Problems associated with darkroom disease, MCS, and latex allergies for radiology departments are 2-fold. First, they threaten the health and safety of employees. Second, they are potentially costly in terms of litigation and lost productivity. Administrators report that implementing a safety program to address these 3 ailments would considerably increase a department or hospital budget. However, administrators also report that the cost of litigation, loss of productivity, and compensation outweighs the cost of a safety program. To help avoid these costs, the Stages of Change Model is suggested to help create a program to protect and inform RTs. The ultimate goal is to reduce lost production caused by missed work, lower litigation and compensation costs, and keep employees safe. With today’s shortages and legal costs, an effective safety program will benefit a healthcare facility financially and protect it legally.

References

1. McLoughlin D. Crying in the dark: Marjorie Gordon's x-ray vision. NCchem Website. Available at: http://www.ncchem.com/snftaas/crying_in_the_dark.htm. Accessed August 21, 2006.

2. Liss GM, Kerr M, McCaskell L, et al. Evaluation of work-related symptoms, asthma, sensitization, and exposures among x-ray technologists. Ontario Workplace Safety and Insurance Board Web site. Available at: http://www.wsib.on.ca/wsib/wsibsite.nsf/Public/ResearchProjectsFunded2000. Accessed January 12, 2007.

3. Dimich-Ward H, Wymer M, Kennedy S, et al. Excess of symptoms among radiographers. Am J Ind Med. 2003;43:132-141.

4. Gupta K, Horne R. The influence of health beliefs on the presentation and consultation outcome in patients with chemical sensitivities. J Psychosom Res. 2001;50:131-137.

5. Sanchez T. When it hurts to breathe: chemicals and RTs. ASRT Scanner. 1999;31:7-8.

6. Dowd SB. Darkroom disease: does it no longer matter? Cont Ed Rad Tech. 2003;1:25-29.

7. Caress SM, Steinemann AC, Waddick C. Symptomatology and etiology of multiple chemical sensitivities in the southeastern United States. Arch Environ Health. 2002;57:429-437.

8. Woolf A. A 4-year-old girl with manifestations of multiple chemical sensitivities. Environ Health Perspect. 2000;108:1219-1223.

9. Black DW, Okiishi C, Schlosser S. A nine-year follow-up of people diagnosed with multiple chemical sensitivities. Psychosom. 2000;41:253-261.

10. Kutsogiannis DJ, Davidoff AL. A multiple center study of multiple chemical sensitivity syndrome. Arch Environ Health. 2001;56:196-208.

11. Hu H, Stern A, Rotnitzky A. Development of a brief questionnaire for screening for multiple chemical sensitivity syndrome. Toxicol Ind Health. 1999;15:582-589.

12. Spurgeon A. Models of unexplained symptoms associated with occupational and environmental exposures. Environ Health Perspect Suppl. 2002;110(suppl 4):601-606.

13. Horowitz S. Indoor environmental health threats: prevention and detoxification. Alt Complement Ther. 2002;8:363-369.

14. Miller CS. Toxicant-induced loss of tolerance. Addict. 2001;96:115-138.

15. Miller KK. Research based prevention strategies: management of latex allergy in the workplace. Am Assoc Occup Health Nurs. 2000;48:278-290.

16. Becker HS. An analysis of the epidemiology of latex allergy: implications for primary prevention. Medsurg Nurs. 2000;9:135-144.

17. Roy DR. Latex glove allergy: dilemma for health care workers. Am Assoc Occup Health Nurs. 2000;48:267-277.

18. Schwingerdorf W. FDA proposed latex standards better late then never. ASRT Scanner. 1999;31:6-8.

19. Muller BA. Minimizing latex exposure and allergy. Postgrad Med. 2003;113:91-98.

20. Karvonen CA. Latex allergy in health care workers: what are the risks? Am Assoc Occup Health Nurs. 1999;47:519-525.

21. Baur X, Chen Z. Summary of appropriate measures to prevent natural rubber latex allergy. Allergy Int. 1999;48:31-37.

22. Altman GB, Keller KM. Practice powder-free and latex safe. Nurse Pract. 2003;28:55-57.

23. Yip E, Roman M. Latex protein allergy and your choice of gloves: a balanced consideration. Medsurg Nurs. 2003;12:20-26.

24. American Society of Radiologic Technologists. Workplace safety issues survey: February 2001. Available at: http://www.asrt.org/. Accessed August 21, 2006.

25. Gucer PW, Oliver M, McDiarmid M. Workplace threats to health and job turnover among women workers. J Occup Eviron Med. 2003;45:683-690.

26. Lenehan G. Separating fact from fiction. Nurs. 2002;32:58-64.

27. Gershon RRM, Karkashian CD, Grosch JW, et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control. 2000;28:211-221.

28. Ranta PM, Ownby DR. A review of natural-rubber latex allergy in health care workers. Clin Infect Dis. 2004;38:252-256.

29. Brown RH, Hamilton RG, McAllister MA. How health care organizations can establish and conduct a program for a latex safe environment. Jt Comm J Qual Saf. 2003;29:113-123.

30. Zaglaniczny K. Latex allergy: are you at risk. AANA J. 2001;69:413-424.

31. FDCH Regulatory Intelligence Database [online]. New HHS report shows problems in health care system are worsening as medical litigation crisis deepens. Washington, DC: Department of Health and Human Services; 2003. Updated March 3, 2003.

32. Decker JT, Aarestad D, Elliott W, Lowe C. Chemical sensitivity in the workplace. J Soc Work Disability Rehabil. 2002;1:45-61.

33. Horwitz IB, Kammeyer-Mueller JD. Natural rubber latex allergy workers' compensation claims: Washington state healthcare workers, 1992-1999. Appl Occup Eviron Hyg. 2002;17:267-275.

34. Manuel S, Donahue J. Implementing a latex safe environment in a hospital setting. Am Assoc Occup Health Nurs. 1999;47:207-212.

35. Haight JM, Thomas RE. Intervention effectiveness research: a review of the literature on leading indicators. Chem Health Safety. 2003;10:21-25.

36. Bowyer RV. The implications of latex allergy in healthcare settings. J Clin Nurs. 1999;8:139-144.

37. Janz NK, Champion VL, Strecher VJ. The health belief model. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education. 3rd ed. San Francisco, Calif: Jossey-Bass; 2002: 45-66.