“We Have to Do Better”: Infection Prevention Experts Warn Lead Aprons May Be an Overlooked Source of Pathogen Transmission

In a new Infection Control Today (ICT) roundtable, produced in collaboration with Diagnostic Imaging® (DI®), perioperative and infection prevention experts discussed contamination concerns, adenosine triphosphate (ATP) testing, inconsistent cleaning standards, and why reusable lead garments may represent a major blind spot in health care hygiene.

"We have to do better," panelists warned as they called for standardized protocols, interdisciplinary collaboration, and stronger environmental hygiene practices.

In operating rooms, catheterization laboratories, interventional radiology suites, and emergency departments across the country, lead aprons and thyroid collars are considered routine personal protective equipment (PPE). They shield health care professionals from radiation exposure during fluoroscopy-guided procedures and are worn daily by surgeons, nurses, technologists, and physicians.

But according to a panel of infection prevention and perioperative experts convened by Infection Control Today and sister publication Diagnostic Imaging, these garments may represent a major blind spot in health care hygiene and infection prevention.

During the recent roundtable discussion, panelists explored why reusable lead garments have largely escaped standardized cleaning protocols, how contamination may contribute to health care-associated infections (HAIs), and what hospitals should do to address what several participants called an "infection prevention gray zone."

"We have to do better," said Peter Graves, BSN, RN, CNOR, CEO of Clinical Solution, LLC, and former Association of periOperative Registered Nurses board director. "Everything's supposed to be clean. And if it's not, we have to do better."

A Hidden Risk in Procedural Areas

The discussion began with concerns about how frequently lead garments move through clinical environments without consistent disinfection practices.

"Lead aprons and thyroid collars are used daily in ORs and other procedural areas yet often fall outside formal cleaning standards," moderator and Infection Control Today Lead Editor Tori Whitacre Martonicz said. "That raises an important question for infection preventionists. Are reusable lead garments truly low risk, or have they simply been overlooked?"

Graves argued the issue stems partly from the assumption that lead garments do not directly enter the sterile field.

"I would argue they do on every single case," Graves said. "The only thing is that we sequester them behind a sterile gown."

That distinction matters, the experts said, because pathogens may still transfer from contaminated surfaces, particularly when garments come into contact with providers' clothing, arms, necks, or procedural equipment.

"We don't go back and culture the lead ever," Graves noted. "When we think about radiation-attenuating devices, lead actually functions much like PPE, no differently from our gloves or gowns."

"The Gross Factor Is Real"

Among the strongest warnings came from Justin McKay, cofounder of RadCare Services, who has spent more than a decade focused exclusively on lead garment management and decontamination.

"After acquiring ringworm from wearing shared thyroid collars, I started consulting with infection prevention professionals," McKay said. "That helped me develop a process to really have a best-practice solution for hospitals."

According to McKay, contamination is far more common than many clinicians realize.

"When 25 x-ray garments were cultured in Michigan by an interventional radiology provider, 21 of the 25 had Staphylococcus species, 3 of which were later confirmed to be methicillin-resistant Staphylococcus aureus (MRSA), and 21 of the 25 had ringworm," he said.

McKay also described conditions observed during lead garment servicing.

"The gross factor is real," he said. "Some of our technicians who physically work on these garments jokingly keep a dry-heave counter on their whiteboard because of what they see and smell coming off the garments."

In some cases, McKay said contamination begins before garments even arrive at health care facilities.

"X-ray garments are manufactured in open-air environments," he explained. "Ten people may have touched them before they're placed into a cardboard box and shipped into a sterile environment where they're assumed to be clean."

Lack of Standardization Creates Confusion

One recurring theme throughout the discussion was the absence of clear, universal cleaning standards.

Jill Holdsworth, MS, CIC, FAPIC, AL-CIP, CRCST, CHL, NREMT, medical affairs manager and infection preventionist at CS Medical, said many organizations still lack consistent protocols.

"The only thing The Joint Commission used to look at was whether lead aprons were hanging correctly," Holdsworth said. "They weren't asking about cleaning."

Although some surveyors have recently begun asking about cleaning schedules, Holdsworth said documentation often lacks substance.

"We had a paper log that somebody wrote something down on," she said. "But how were they cleaned? Did somebody casually wipe it, or did they just mark it down because their manager said so?"

Holdsworth questioned why lead garments have escaped the same scrutiny as other reusable equipment.

"We shouldn't even have to make a statement about a singular item," she said. "We already know that if something comes out of a patient room, it needs to be disinfected."

Ownership Problems and Operational Barriers

Brenna Doran, PhD, MA, ACC, CIC, AL-CIP, consultant and coach for Innovative Partners Institute, LLC, said ownership disputes frequently complicate compliance efforts.

"Some of these pieces of lead belong to an individual person," Doran explained. "They're embroidered. They belong to someone. Do they belong to the provider or the hospital? That becomes a barrier."

She also highlighted uncertainty surrounding cleaning chemistry and material compatibility.

"What do you clean them with?" she asked. "Does using a disinfectant wipe damage the material? What do you do when there's a tear or rip?"

McKay agreed that conflicting manufacturer guidance has contributed to confusion.

"Don't fold them, don't crease them, no UV light, no alcohol, no bleach," he said. "Someone managing 1,500 garments is left saying, 'What do I do here?'"

ATP Testing Drives Buy-In

Several panelists emphasized that ATP testing and environmental culturing may help secure leadership support.

"Data drive your program," Graves said. "Go into your interventional radiology department, your cath lab, your OR, your emergency department, and take a look at your lead."

McKay described using ATP testing to compare lead garments with common high-touch surfaces.

"I ATP-tested a gas pump handle because I thought it was gross," McKay recalled. "Then we tested lead in the OR, and it was nine times dirtier than the gas pump handle."

That type of evidence can fundamentally change conversations, panelists said.

"When infection prevention sees the data, they say, 'We cannot ignore this,'" McKay said.

Doran added that ATP testing may also help influence clinicians who are resistant to change.

"Testing the lead aprons of top providers may very well be a recipe for how infection preventionists can get the buy-in needed to move this initiative forward," she said.

Could Lead Garments Contribute to Surgical Site Infections?

Although definitive epidemiologic evidence remains limited, several panelists expressed concern that contaminated lead garments may contribute to HAIs and surgical site infections (SSIs).

"When we have an SSI, we look for the smoking gun," Doran said. "I can't imagine there have not been surgical site infections seeded from a dirty apron."

Graves agreed that more research is needed.

"If you have a cluster of dermal infections in total joints, go back and culture the lead," he said. "See if you can trace the organism."

He added that hospitals often fail to investigate lead garments because they are stored outside procedural environments.

"Out of sight, out of mind," Graves said. "Therefore, it's not a problem. But we need to do a full 360 on this."

Building a Playbook for Hospitals

The panel ultimately agreed that infection preventionists, perioperative leaders, radiology departments, and environmental hygiene teams must work collaboratively to establish standardized protocols.

"I would love there to be a playbook that IPs can go to and say, 'OK, this is what we need to consider,'" Doran said. "It's so much easier to do something someone else has done successfully than to create the wheel on our own."

Graves stressed that any successful strategy must involve multidisciplinary collaboration.

"You need to partner with your OR people, your interventional radiology people, radiology, the ER," he said. "It needs to be multifocal."

McKay echoed the importance of collaboration and relationship building.

"I'm not going to tell hospitals, 'This is how you're going to do it,'" he said. "I want to help build the program together."

"This Is an Us Problem"

Despite the operational challenges, panelists repeatedly returned to a shared message: infection prevention surrounding lead garments is everyone's responsibility.

"This isn't just a circulator problem or a provider problem," Graves said. "It's a team problem. It's an 'us' problem."

For infection prevention professionals listening to the discussion, McKay hopes the conversation itself becomes a catalyst for change.

"I'm excited that infection prevention leaders throughout the US will say, 'I haven't thought about this before, and I'm not going to go it alone,'" he said. "That's how meaningful change begins."