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Society guidance

ALARA+:
As low and as light as reasonably achievable

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More than
42,000 full-time positions
for cath lab staff are currently open nationally. Physical injury accelerates attrition.19
ALARA+
12 working days
An ERPD unit pays for itself19*
*Based solely on cath lab operating costs. The ROI calculation does not require optimistic assumptions and only requires that one physician remains in the lab.
Pain from aprons
66%
of interventional cardiologists in the 2023 SCAI survey report musculoskeletal pain from aprons or lab work8
Cath lab nurses
77%
of cath lab nurses experience work-related musculoskeletal disease annually19

What is ALARA+?

ALARA+ stands for as low and as light as reasonably achievable. It extends ALARA, the radiation safety principle of keeping exposure as low as reasonably achievable, to cover the orthopedic injuries that come from wearing heavy lead-equivalent aprons. The term comes from a multidisciplinary Think Tank summit held at the 2025 Society for Cardiovascular Angiography & Interventions (SCAI) Scientific Sessions in Washington, DC, whose proceedings were published in JSCAI in March 2026.8

Eleven organizations were represented at the summit and co-planned it: SCAI, ACC, ACVP, ASE, HRS, ORSIF, SIR, SNIS, SPR, SVS and SVIN. The proceedings conclude that reaching the next generation of ALARA means advocating for widespread implementation of enhanced radiation protection devices (ERPDs) and imaging systems, like EggNest®.8

Member of ORSIF, the Organization for Occupational Radiation Safety in Interventional Fluoroscopy.

Key messages from the summit

The four groups of the proceedings' Figure 1, in its own words.8

  1. Risks to operators

    • Orthopedic
    • Cataracts
    • Malignancy
    • Skin disease
    • Cardiovascular risks

  2. Hiring and keeping staff

    • Women underrepresented in catheterization labs
    • Widespread shortages in the nursing workforce
    • Staff burnout
    • Operators lost to injury, early death or disability from orthopedic injury or cancer

  3. Financial and administrative challenges

    • Capital constraints
    • Regulations vary between jurisdictions
    • Scattered advocacy delays updated regulations

  4. Call to action: ALARA+

    • Spread best practice with technology already available
    • Broader use and customization of ERPDs
    • Innovation that protects every catheterization lab clinician
    • Real-time dosimetry
    • Advocacy at federal and state levels

Salavitabar A, Vora AN, Altschul D, et al. JSCAI 2026;5(4):104166, Figure 1.8

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What are aprons costing your department?

The ALARA+ proceedings name cost as a clear barrier to ERPDs and set it against the cost of the hazard. Put your own institution's numbers beside theirs.8

An advanced radiation protection system
can be paid for in 12 working days
in the cath lab based on operating cost alone19
Each case of musculoskeletal disorder
$12,000 to $45,000
ORSIF's estimate, as the proceedings report it8
Each case of cancer
$200,000 nonfatal, $9 million fatal
ORSIF's estimate, as the proceedings report it8
Replacing a physician
$500,000 to $1 million
estimated for nonspecialty physicians, likely higher for interventional8
"Hospital economics are not a justifiable excuse to delay or forgo these safety protections."
Multi-society consensus statement, 20263

Cost calculator

Calculating potential costs at your institution

Estimate the health-related costs of radiation exposure and heavy lead aprons for the staff in your fluoroscopy labs. The starting figures are an example lab of 6 physicians and 20 other staff. Change any number to match your institution; totals update as you type.

Cancer

1 in 25 high-volume operators; care costs of ~$50K to $200K.3,6 Starting figure: 1 in 25 of $125,000, or $5,000 per physician.

Potential cost $30,000

Early onset cataracts

Staff with cumulative dose >100 mSv; 50% of exposed physicians; care costs of $7,000 per eye.7,8 Starting figure: both eyes, $14,000.

Potential cost $42,000

Orthopedic injury

60% of staff may experience pain, with at least one severe injury; treatment costs of ~$10K and surgery costs of ~$50K.9,10,11 Starting figures: 16 of 26 staff treated; one surgery under Other costs.

Potential cost $160,000

Lost revenue from physician absence

Two months' loss of revenue, $570,000, due to one physician orthopedic injury.14,15 Absence can run six months or more. Starting figure: two physicians, or one physician out four months.

Potential cost $1,140,000

Other costs

Anything specific to your institution: workers' compensation, replacement staffing, lead apron inventory and disposal.

Total estimate

Potential health-related costs to your institution from radiation exposure and heavy lead aprons.

$1,422,000

For illustrative purposes only. Estimates reflect potential risks and costs due to radiation exposure and the use of heavy lead aprons. Base the number of staff at risk on your institution's staff numbers and radiation exposure.

References for risk and cost estimates
  1. Rizik DG, Sutton NR, Lansky AJ, Alasnag M, et al. SCAI/ASE/HRS/SIR/SVS expert consensus statement on enhanced radiation protection: time for mandatory and urgent action. J Soc Cardiovasc Angiogr Interv. 2026;5(8):105455.
  2. Odanovic N, Gonzalez PE, Vora AN. Is Egg ready to leave the nest? J Soc Cardiovasc Angiogr Interv. 2025;4:103863.
  3. National Research Council. Health risks from low-level ionizing radiation: BEIR VII phase 2. National Academies Press; 2006:115.
  4. Andreassi MG, Piccaluga E, Guagliumi G, et al. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;9:e003273.
  5. ORSIF. Economic impacts of radiation in interventional fluoroscopy. Occupational Radiation Safety and Innovation Foundation; 2018.
  6. Mariotto AB, Yabroff KR, Shao Y, et al. Cost of cancer care in the US: 2010–2020. J Natl Cancer Inst. 2011;103:117–128.
  7. Vano E, Kleiman NJ, Duran A, et al. Radiation-associated lens opacities in cath personnel. J Vasc Interv Radiol. 2013;24:197–204.
  8. MyVision.org. The cost of cataract surgery with or without insurance. 2 Mar 2022.
  9. Abudayyeh I, Dupont AG, Hermiller JB, et al. Occupational health hazards in the cardiac catheterization laboratory: results of the 2023 SCAI survey. J Soc Cardiovasc Angiogr Interv. 2025;4(4):102493.
  10. Spears CA, et al. Health care resource utilization and management of chronic, refractory low back pain in the United States. Spine. 2020;45(20):E1333–E1341.
  11. Chang D, et al. Comparative review of the socioeconomic burden of lower back pain in the United States and globally. Neurospine. 2024;21(2):487–501.
  12. Riley RF, Kidd S, Power J, et al. Comparative effectiveness of 2 next-generation scatter radiation shielding systems. J Soc Cardiovasc Angiogr Interv. 2025;4:103786.
  13. Wilson R, Gainor J, Valeti U, Montague J, Wilson B. TCT-248: A new device to markedly reduce cardiac cath lab radiation levels. J Am Coll Cardiol. 2018;72(13 Suppl):B103.
  14. Ellison A. 5 specialties that drive the most revenue to hospitals. Becker's Hospital Review. 19 Jul 2022.

© 2026 Egg Medical. All rights reserved. EggNest is a trademark of Egg Medical, Inc. 0426.4044

The consensus statement

What does the multi-society consensus statement say?

It says enhanced radiation protection in the fluoroscopy lab is no longer optional. The "SCAI/ASE/HRS/SIR/SVS Expert Consensus Statement on Enhanced Radiation Protection: Time for Mandatory and Urgent Action" was written by 25 authors led by David G. Rizik and published in JSCAI (2026;5(8):105455, online 14 July 2026), and jointly in the Journal of Vascular and Interventional Radiology and JACC: Cardiovascular Interventions. Six societies endorsed it as official society guidance in May 2026: SCAI, the American College of Cardiology (ACC), the American Society of Echocardiography (ASE), the Heart Rhythm Society (HRS), the Society of Interventional Radiology (SIR) and the Society for Vascular Surgery (SVS).3

Its argument runs through existing regulation. ALARA, as federal regulation defines it (10 CFR 20.1003), takes account of the state of technology. Because ERPDs have redefined what exposure is achievable, the statement concludes that relying only on aprons and small operator-positioned shields is no longer consistent with ALARA, and it calls for mandatory implementation of ERPDs. It gives hospitals the proximate responsibility and x-ray equipment manufacturers the ultimate responsibility, and it says cost is not a reason to delay.3

The statement names EggNest as a commercially available ERPD system.3

Its five recommendations

Paraphrased from the statement's closing recommendations.3

  1. Implement ERPDs now. Federal regulation requires ALARA, ALARA accounts for the state of technology, and ERPDs should be implemented immediately.3
  2. Standardize barrier rules across states, and build safety features in at the manufacturing level, as with car safety features.3
  3. Certify lab personnel nationally, with uniform training requirements and competency assessment.3
  4. Standardize radiation monitoring and reporting on one platform that satisfies every relevant regulator.3
  5. Set up a national occupational dose registry that includes procedural radiation data such as fluoroscopy time.3

For your lab

The guidance moving forward

  • Enhanced protection in every labThe consensus statement calls ERPD implementation mandatory.3 In his 2024 SCAI Presidential Address, quoted in the ALARA+ proceedings, Dr James B. Hermiller called for advanced radiation protection in all new cath labs, retrofitted into existing ones.8

    EggNest is designed to work in a variety of case types across different specialties.

  • Real-time dosimetryStrongly advised with every ERPD, above all while it is being introduced.3 ALARA+ wants it used to find practice patterns that can change.8

    Real-time dosimetry comes included with EggNest Complete.

  • Protection for the whole teamStaff near the head of the table often face similar or greater exposure than the operator.3,8

    EggNest lowered scatter against standard shielding at every staff position measured, the head of the table included without adding additional trip hazards or clutter.14

  • Training for everyoneStructured radiation and orthopedic safety training for all who operate fluoroscopic equipment,8 and a national certification program for lab personnel.3

    Egg Medical team will train staff for one to two weeks post installation and provide educational resources for recurring training.

  • Apron decisions with conditionsReduced or no aprons only with real-time monitoring, a defined zone of protection and state compliance,3 and state rules on barrier protection vary.9

    Lead Free, Responsibly

  • ERPD inclusion in budgetALARA+ asks that advanced protection be included in the operating budget.8 The consensus statement says hospital economics are not a justifiable reason to delay.3

    See all of our payment options

See how EggNest fits each of the statement’s criteria

Evaluating an ERPD

Evaluating the EggNest

The consensus statement sets out what an Enhanced Radiation Protection Device should be measured against: clinical evidence, regulatory clearance, measurable quality standards, protection at each position in the room, and six tests of how it works in a case. The tables below follow its own section on the validation and evaluation of ERPDs.3

1. Evidence, clearance and quality standardsClinical evidence · Regulatory clearance · Quality standards
1. Evidence, clearance and quality standards
Criterion What the statement asks3 How EggNest exceeds the standard
Clinical evidence High-quality clinical evidence of safety and effectiveness, standard protocols for use, rigorous monitoring of radiation exposure, and continuing research Four peer-reviewed, published EggNest studies available for review. Six studies in progress across various specialties. See every study.
Regulatory clearance All ERPDs must meet FDA quality system and labeling rules FDA Class I clearance. See user manuals for guidance per country.
Quality standards Measurable standards for attenuation, mechanical integrity, ergonomics, compatibility with the fluoroscopy equipment, and cleaning and maintenance, tested to standards such as ASTM F2547 and IEC 60601-2-43 Shields of 0.5 mm lead equivalence in the Protect 2.0 base and the Complete Flex (manual 4511rC, pp7 to 16; manual 4344rC, p7). Cleaning instructions in the manual (manual 4511rC, pp35 to 36). The test standard behind the lead equivalence: data on file.
2. Radiation protection, position by positionHow to measure · Tableside operators · Head of the table · Nurses and technologists
2. Radiation protection, position by position
Position What the statement asks3 How EggNest exceeds the standard
How to measure Total-body protection at each position, by real-time dosimetry at the waist and thyroid, as the median dose per case, set against mean fluoroscopy time and case radiation exposure Measured this way in 135 real-world coronary cases: real-time dosimeters at the hip and shoulder, over and under the apron, reported as the median dose per case, with procedural characteristics for each group.20
Tableside operators Every operator position, including procedures with an operator on the left side of the table EggNest provides 360 degree protection around the table for operators and staff working on either the patient left or patient right. Studies have shown up to >99% radiation reductions for the operator.1
Head of the table Anesthesia staff, the primary nurse and echocardiographers at the patient's head Phantom study, against standard shielding: 96% lower at the echo or EP implanter position and 85% lower at the anesthesia position.14 A hanging head shield keeps the shielding continuous around the head of the table, and head flip shields raise to protect staff there (manual 4511rC, pp11 and 15).
Nurses and technologists The rest of the fluoroscopy team Assistant and circulating nurse, 0.03 mrem collar dose per case each with EggNest Complete in real-world procedures.20
3. How it works in a caseVascular access · C-arm angles · Tripping and tipping · Setup and emergency access · Durability · Turnover
3. How it works in a case
Test What the statement asks3 How EggNest exceeds the standard
Vascular access Full protection while gaining access: femoral on both sides, radial, internal jugular and brachial An arm positioning system holds the right arm for radial, ulnar, brachial or axillary access, and the upper shielding can be moved under the drape to suit the access site (manual 4511rC, pp13 and 27). Switching from a femoral to a radial setup takes 10 to 15 seconds, as Dr. Santiago Garcia describes it (SOLACI 2026, 3:49). The ScatterPro™ disposable shielding drape adds further protection at any access site.
C-arm angles Full protection at every C-arm angulation Phantom study: lower scatter than standard shielding at every position and height in all five angulations measured.14 For steep angles, lateral imaging or rotational angiography, the hanging side shields can be retracted out of the gantry's way (manual 4511rC, pp9 to 10).
Tripping and tipping No tripping or tipping hazards Every part mounts to the procedure table, its rail, or for Complete the existing ceiling boom. Nothing stands on the floor (manual 4511rC, pp8 to 17; manual 4344rC, p8).
Setup and emergency access Quick setup, and quick removal for emergency access to the patient, resuscitation included The statement itself describes EggNest's shields as folding away easily for patient loading and access.3
Durability Resistance to cracks or tears that could let radiation through Flexible shielding checked every six months or on visible damage, and taken out of use if fluoroscopy shows cracks or holes. One-year warranty from installation, with repair or replacement within 30 days of notice of a covered problem (manual 4511rC, pp36 to 37).
Turnover Time to set up and take down between cases In 133 STEMI patients, median door-to-balloon time was 48.0 minutes in the EggNest Complete lab against 52.0 with standard shielding, with no significant difference.16
4. Monitoring, training and apronsReal-time dosimetry · Training · Aprons
4. Monitoring, training and aprons
Topic What the statement asks3 How EggNest exceeds the standard
Real-time dosimetry Strongly advised with every ERPD, above all while it is being introduced, alongside the monthly badges the radiation safety officer oversees The EggNest Complete System includes a real-time dosimetry system with 4 badges. See the EggNest in use with real-time dosimetry in live cases (SCAI 2026 live case, 4:18; SOLACI 2026, 4:53).
Training Staff education and training so the device is used consistently and well Egg Medical staff will be on-site for training and education for 1 to 2 weeks following installation, with routine check-ins after that.
Aprons Reduced-weight or no aprons only where the ERPD has demonstrably brought exposure within regulatory limits, with rigorous real-time institutional monitoring, a clearly defined zone of protection and compliance with state rules The EggNest System makes the choice available: whole-room protection above and below the table, real-time dosimetry so every case is measured, and ultralight 0.125 mm aprons for anyone who chooses to wear one. If your lab chooses to go apron-free, we will work with you to provide data to support a variance request per state regulations if your state does not already have a variance.7,9

Paraphrased from the consensus statement's sections on real-time dosimetry, standards for validation and evaluation, and training and dosimetry monitoring, and from its third consensus point.3 Manuals are Egg Medical's current user manuals.

Questions

Questions about ALARA+ and the consensus statement.

Does the consensus statement name EggNest?

Yes. The SCAI/ASE/HRS/SIR/SVS expert consensus statement describes EggNest, from Egg Medical, as a modular radiation protection system of table- and ceiling-mounted shields giving 360° of protection, one of six commercially available ERPDs in its Table 1.3

Is ALARA+ a law or a regulation?

No. ALARA+ is the name the 2025 SCAI Think Tank summit gave to extending ALARA to orthopedic risk, and its proceedings call for advocacy toward state and federal legislation.8 The consensus statement argues that federal ALARA regulation, which takes account of the state of technology, already makes ERPDs an obligation, and six societies endorse it as official guidance.3 Neither paper is itself a law, and state rules on barrier protection and aprons still vary.9

References
  1. Riley RF, Kidd S, Power J, Stegman B, Dahle TG. Comparative effectiveness of 2 next-generation scatter radiation shielding systems. J Soc Cardiovasc Angiogr Interv. 2025;4(8):103786. doi:10.1016/j.jscai.2025.103786.
  2. Rizik DG, Sutton NR, Lansky AJ, Alasnag M, et al. SCAI/ASE/HRS/SIR/SVS expert consensus statement on enhanced radiation protection: time for mandatory and urgent action. J Soc Cardiovasc Angiogr Interv. 2026;5(8):105455. doi:10.1016/j.jscai.2026.105455. Endorsed by SCAI, ACC, ASE, HRS, SIR and SVS.
  3. Frizzell J, Gurevich S, Emani S, Guddeti R, Haddox K, Riley R, Henry T, Kereiakes D, Rudick S, Tribble S, Harper R, Bias A, Garcia S. TCT-1061: Comparative effectiveness of a novel scatter radiation shielding system versus standard shielding. J Am Coll Cardiol. 2025;86:B453. doi:10.1016/j.jacc.2025.09.1260.
  4. Salavitabar A, Vora AN, Altschul D, et al. ALARA+: summit on radiation and orthopedic risks in fluoroscopic laboratories. J Soc Cardiovasc Angiogr Interv. 2026;5(4):104166. doi:10.1016/j.jscai.2025.104166.
  5. Vora AN, Hermiller JB, Gupta R, et al. Variability in state-level regulations regarding occupational radiation exposure. J Soc Cardiovasc Angiogr Interv. 2025;4(6):103597. doi:10.1016/j.jscai.2025.103597.
  6. Riley RF, Kamen J, Tao A, Gomez-Cardona D. Comparative effectiveness of the EggNest Complete shielding system to standard shielding in the cath lab. Am Heart J Plus. 2025;54:100543. doi:10.1016/j.ahjo.2025.100543.
  7. Hutchings J, Mai E, Blay SP, Ballinger C, Riley RF. Incorporating an enhanced radiation protection device into the treatment of ST elevation myocardial infarctions: a single center retrospective analysis. Am Heart J Plus. 2026;68:100816. doi:10.1016/j.ahjo.2026.100816.
  8. ALARA+ Coalition. Resources and toolkits. ALARA+. alara-plus.org/resources. Accessed 6 October 2026.
  9. Guddeti RR, Schmidt CW, Riley RF, Kamen J, et al. Evaluating standard shielding versus novel enhanced radiation protection devices in the cardiac catheterization laboratory. J Am Heart Assoc. Published online 10 October 2026. doi:10.1161/JAHA.126.050577.

Put the consensus statement to work in your lab.

Tell us about your room and your case mix, and we will walk your team through what the consensus statement and ALARA+ ask of it.

Talk to our team See every study