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How Two Radiology Faculty Pioneered Healthy Change Across Two Disciplines
By C.L. Stambush
Pandora’s Box
In late October 2016, Joy Cook ’95 ’03 M’09 EdD’22 and Heather Schmuck ’02 M'13 EdD'22 were in their campus offices catching up on class assignments and finishing up the week when an email from a colleague across town pinged their mailboxes. One of the University’s radiological community partners needed help assessing the dirtiness of the lead apparel worn by its radiologic technologist and radiologists.
The hospital hadprotocols and practices for cleaning its hundreds of weighty aprons, but when contacted by an outside service to clean the apparel for them—at a cost of a quarter of a million dollars—every six months—hospital administrators were prompted to ask: how germy is the protective apparel and how effective were cleaning protocols? “Our colleague knew we had been interested in doing some research on radiology lead identification markers and their use,” said Cook, Associate Professor of Radiologic and Imaging Sciences.
Every research project begins with a deep dive into literature reviews. Cook and Schmuck, Clinical Associate Professor of Radiologic and Imaging Sciences, dove into discovery mode to familiarize themselves with published research before evaluating the apparel. “One study came out that they were having a rash of ringworm show up on the radiology professionals,” Cook said. “It turns out it was being spread through the thyroid collars on the shields people were wearing, because that comes in direct contact with skin.”
Unlike food establishments that are inspected routinely by officials, and health code violations reported to the public in newspapers and online, medical institutions undergo no such rigorous oversight from an outside entity. The Center for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) provide guidelines for infection control only. The Joint Commission, a nonprofit organization that inspects and accredits U.S. hospitals, has rules regarding infection prevention but doesn’t measure institutional cleanliness. The hospital is only required, for accreditation purposes, to have a record of the apparel in use and an annual integrity inspection to ensure the apparel is not damaged and protecting the user.
To determine the level of bioburden on lead apparel, a handheld device called a bioluminescence meter calculates the molecular material in relative light units (RLU). There are no industry standards for acceptable levels of dirtiness, and each medical institution is expected to set its own. At this particular hospital, 50 RLUs was the threshold for lead apparel used in general patient care areas and 10 RLUs for surgery. The apparel was receiving quarterly cleaning using several methods—a spray cleaner with a brush and wipes—but bioburden wasn’t measured before, during or after cleanings.
Armed with one of USI’s bioluminescence meters, Cook and Schmuck randomly tested a percentage of the hospital’s wide variety of protective attire. The results were alarming: an average of 129.98 RLUs were detected. 
Exacerbating the issue was the fact that the protective equipment used in the many departments rarely stayed put, roaming the hospital from department to department, in and out of surgeries collecting a cocktail of bacterium. It wasn’t just lead apparel in use that teamed with germs, new products straight from manufactures were tested by Cook and Schmuck who discovered it arrived predisposed with an average of 51 RLUs.
The hospital’s sanitizing policy needed reassessing. Cook and Schmuck recommended upping the cleaning to monthly, even though it came with a cost. “Our community partner has 700 to 800 pieces of lead apparel,” Schmuck said. “When you’re talking about having to individually clean each one of those, it can get very labor intensive very quickly.”
Boxing in Germs
They returned a year later to evaluate the effectiveness of the change. “We sampled the aprons and found that we’d gotten it down to 58 RLUs,” Cook said. “That’s a huge difference from 129, but it still wasn’t where we wanted it to be.”
Since their initial research yielded little insight into best practices for cleaning lead apparel, figuring out best practices to remain under the hospital’s bioburden threshold led to a new phase of research. “We discovered no one has really figured out not only how often apparel should be cleaned,” Schmuck said, “but also what method is best, in terms of efficiency costs.”
The hospital purchases lead apparel from different manufacturers, each arriving in a box and wrapped in plastic along with slightly different user care information. They, like instructions in general, tended to get lost in the shuffle of busy hospital care, never reaching the intended users. Cook and Schmuck realized they needed to determine what method of cleaning eliminated the most biomatter in the most time-saving manner to recommend the hospital implement.
Students in Cook’s class helped her research the various lead apparel manufactures’ care instructions for commonalities and presented their findings to her, before she and Schmuck settled on three different methods to test at the hospital for effectiveness and efficiency:
With recommendations and a system for cleaning in place, two of the hospital’s radiologic technicians and USI alumna Angela Hollingsworthi ’95 ’17 and Christopher Prifogle ’21, radiologic and imaging, took on the arduous task of putting the three methods into practice while Schmuck swabbed the cleaned garments for germs and Cook recorded the new data.
Soap and water were not enough, and the two-step process using disinfectant worked well but the time involved was too costly. Employees had to wait for the garments to air dry between steps. The use of sanitizing wipes proved most effective in terms of eliminating germs and efficiency. “That ended up being our most effective method, not only in terms of reducing that bioburden, but also the time involved,” Schmuck said. “Now, you can literally grab the apron that you're planning to use for the day and wipe it down at the start of your shift and you're ready to go.”
The research sparked Schmuck to consider how germy the lead markers radiologist used over and over when imaging patients were. “With the switch to digital imaging, I’ve noticed some of my colleagues were starting to place those markers actually on the patient, which is a horrific idea,” she said. “I wanted to see how dirty they were, because they were placing them on the patient and then sticking them back onto their name tag.”
Schmuck surveyed her hospital colleagues and discovered different technologist used types of reusable adhesives to adhere the markers to the imagining plates. Some of the choices were worse than others.
Cook and Schmuck presented their lead apparel and marker findings at the Indiana Society of Radiologic Technologist 2018 conference, prompting their peers to think and ask questions, and have published their findings, along with co-authors Hollingsworth and Prifogle, in Radiologic Technology. The significance of shared findings benefits all. Regional and rural health care facilities won’t have the budget to undertake such research. “Someone from another local facility reached out to me because she needs the article as proof to take forward to her hospital administration,” Schmuck said.
Out of the Box
Cook was sitting with her daughter in the dentist office when an epiphany struck her. “I watched the dental hygienist unfold this apron where she had it stacked and put it on my child,” she said. “It had never occurred to me that radiology and dental, while two separate disciplines, have commonality—we both utilize X-rays.”
Germs weren’t the issue with the dentist’s office’s lead apparel, but rather its integrity. “Every time its folded, it creates a stress point that could crack and then it reduces its effectiveness,” Cook said. When she pointed this out to the dentist, he was rightly concerned and wanted to know if his apparel was compromised. Unlike hospitals with large X-ray machines, dental offices have no easy way of determining if cracks or stress lines have developed unless they partner with a local hospital or university, Schmuck said.
In the next few weeks, two of Cooks’ students examined and X-rayed the dentist’s six lead aprons. The students did all the analyzing of the apparel, determining if and where the weak spots and cracks were, and wrote a report for the dentist. The goal was to not only inform the dentist of his aprons’ integrity but to provide understanding and procedures to keep it free of defects and patients safe. “Our intention in doing this was to make sure that appropriate care gets maintained in practice,” she said. “We can show them that just because it looks okay on the outside it doesn’t mean that on the inside it is. Students at USI are taught how to store the aprons appropriately, but somewhere in practice, and not at all dental offices, that got lost.”
A chance conversation at the coffee pot resulted in a larger collaboration with Amanda Reddington, Clinical Assistant Professor of Dental Hygiene/Assisting, Cook said. “I was discussing some of the things that we were doing with our students on campus and how we had this ‘aha’ moment and realization concerning care of lead apparel in dentists’ offices, and Amanda was very interested in getting our two groups together.”
Schmuck, Cook and Reddington devised a unique interprofessional service-learning project for the divergent, healthcare career seekers to collaborate on in USI’s Dental Clinic and Radiology Lab that combined the two research projects—the dentist’s office and hospital bioburden RLUs. The trio applied for an internal grant to purchase equipment needed for the project and received $3,000. The students were divvied into four groups (the number of lead aprons in the dental clinic) to test the apparels’ cleanliness and integrity, as well as ancillary devices used in the departments.
“The student teams swabbed, cleaned and swabbed again, checking the dirtiness level of the pieces of lead apparel before coming up to the radiology lab. Once at the radiology lab, students conducted a visual and manual inspection where they looked at and felt the lead apparel to see if they could detect any holes by touch or sight. They then move the lead apparel into the energized lab to create an X-ray image of each quadrant of the lead apparel to determine if there were integrity issues,” Schmuck said.
“We thought it was important to get the two groups of students together—who don't realize that they really have a lot in common—to catch these pre-professionals and share the importance of making sure things are clean before used on ourselves and our patients,” Cook said.
The impact of Hollingsworth’s initial email in 2016, wondering if the hospital lead apparels’ germ levels were within an acceptable range, sparked research, collaboration, interprofessional projects and most importantly, change that has increased both patient and professional’s safety.