RADIOGRAPHY SCHOOL RADIATION SAFETY POLICY
I. IRRP & RSO CONTACTS
A. CONTACT PERSON: The UA’s Individual Responsible for Radiation Protection (IRRP) is the person whose name is posted on the current Ohio Certificate of Registration and is responsible for all institutional radiation safety related to radiation-generating equipment. The Radiation Safety Officer (RSO) is the person whose name is on the current Ohio Radioactive Materials License and is responsible for all institutional radiation safety related to radioactive materials. The IRRP & the RSO have a complete copy of the applicable portion of the Ohio Radiation Protection Rules. Any questions regarding radionuclide spills should be directed to the RSO. For other radiation safety issues, dosimetry, etc. if you are uncertain as to which person to notify, you may notify either one.
The UA Radiation Safety Officer (RSO) is Jason McNicholas who can be contacted at:
1. Office - (330) 972-5712
2. E-mail - firstname.lastname@example.org
The UA Assistant UA Radiation Safety Officer (RS0) is Alex Stakleff who can be contacted at:
1. Office - (330) 972-5372
2. E-mail - email@example.com
II. GENERAL RADIATION SAFETY
A. AUTHORIZED OPERATION
1. STAFF RADIOGRAPHER’S: Medical x-ray procedures shall be performed only by a qualified Radiographer minimally holding an appropriate current license from the Ohio Department of Health (ODH) and only when and as authorized by a licensed physician. Preferred qualifications include documented graduation from an AMA- approved school of Radiologic Technology and/or registration with the American Registry of Radiologic Technologists (ARRT).
2. STUDENT RADIOGRAPHERS: Students may operate equipment under the direct supervision of a staff Radiographer only when and as authorized by a licensed physician. Until competency has been meet Student Radiographers may operate radiographic equipment only under direct supervision. After demonstrating competency on a specific procedure or examination, Student Radiographers may operate radiologic equipment on those procedures or examinations under indirect supervision.
III. BEAM RESTRICTION & GONADAL SHIELDING
A. GENERAL: The beam shall be limited to the area of clinical interest during both radiographic and fluoroscopic examinations. At no time should exposures be made where the student could come in contact with the direct beam. This requires restricting the exposed field size to the actual area of interest and/or the image receptor, whichever is smaller.
B. GONADAL SHIELDING: Shielding of the gonads on all patients, regardless of age, shall be employed for all radiographic procedures if the gonads are in the primary beam and such shields do not interfere with the examination.
IV. CONTROL BOOTH STANDARDS
A. HAND CONTROLS: All hand exposure controls will be mounted in the control booth in such a way as to prevent the operator from making an exposure while in an unshielded position. This will be accomplished by permanent attachment of the hand control and/or by limiting the length of the exposure cord. No one shall make any alteration in attachment to the control or length of the cord without prior approval by the IRRP. If through wear or any other reason a hand control is found to be removable, the Radiology Supervisor shall be notified at once. The supervisors will determine whether the UA IRRP needs to be notified.
B. UNSHIELDED PERSONNEL: All unshielded students radiographers shall stand in such a position as to assure that their entire body is shielded by the control booth barrier or by a portable protective barrier during radiographic examinations involving stationary x-ray units.
A. WEARING RADIATION BADGES: The radiation monitoring badge shall be worn by all Student Radiographers at all times when operating any radiographic equipment (while doing a clinical assignment or while in the UA Radiography lab). At all times the whole body radiation badge shall be worn on the collar outside of a lead apron.
B. BADGE SUBMISSION: The radiation monitoring badge must be submitted for processing quarterly. Any student losing or destroying their radiation badge must contact the UA Radiation Safety Officer (RSO) or the Radiolography Program Director immediately. When a badge is reported lost, the radiation monitoring company will be contacted for a new radiation badge to be issued. Radiation monitoring devices will be submitted for quarterly, yearly, and cumulative dosage readings.
C. EXPOSURE REPORTING POLICY: Radiation badge reports are reviewed quarterly by the UA IRRP and the RSO. A summary of the review is presented to the Radiation Safety/Quality Assurance Committee and the Radiology Education Coordinator. The review is conducted to identify:
1. Radiation badge readings that exceed the allowable limit
2. Persistently high radiation readings that are within allow limits
3. Inconsistencies with radiation badge readings
Guidelines for the review are based upon the Ohio Department of Health (ODH) which requires that the annual occupational effective dose be limited to fifty (50) mSv (not including medical and natural background exposure), with equivalent dose annual limits to the lens of the eye @ 150 mSv and the skin, hands, and feet @ 500 mSv. However, these levels are considered excessive by UA standards and a strong promotion by the RSO and the IRRP of the principle of ALARA (as low as reasonably achievable) is accomplished through frequent monitoring and discussions with the staff on radiation management. The IRRP, RSO, and/or the Radiography School Program Director will discuss corrective action(s) with any individual whose badge report high or inconsistent readings. For student review of their radiation exposure, quarterly badge reports are posted in the Radiography School classroom. Any student wishing to review their radiation badge report may discuss it with the IRRP, RSO, or Radiography School Program Director. If the reading indicates that the dose to an individual is in excess of the Ohio MPD the IRRP or RSO shall conduct an investigation. The commercial radiation monitoring company may be contacted to aid in the investigation. If the IRRP or RSO determines that the individual has received a dose in excess of the limits, a report of overexposure shall be submitted to the Director, Ohio Department of Health as required.
D. STUDENT RADIOGRAPHERS: The Student Radiographers shall have their radiation records reviewed with them by the Program Director at the end of every semester. Based on the opinion of our radiation physicist, a radiation reading of 150+ mRem/quarter (50+ mRem/month or 60+ mRem/year) would be considered unusual. In support of the ALARA principles any Student Radiographer whose radiation badge report exceeds this criteria will be counseled by the Program Director on methods for reducing their radiation exposure.
E. OCCUPATIONAL EXPOSURE OF MINORS: For education and training purposes it may be necessary to accept students under the age of eighteen (18) years old. National Council on Radiation Protection and Measurement (NCRP) guidelines recommends that the annual occupational effective dose for minors be limited to one (1) mSv (not including medical and natural background exposure), with equivalent dose annual limits to the lens of the eye @fifteen (15) mSv and the skin, hands, and feet @ fifty (50) mSv.
VI. EQUIPMENT SAFETY
A. PERFORMANCE TESTING: All radiography/fluoroscopy units will be surveyed on an annual basis, in accordance with ODH rules and regulations (3701:1-66-04,07,10) by a physicist certified by the American Board of Radiology (ABR) in Radiological Physics (includes all areas) or in the area of Diagnostic Radiological Physics. Evidence of such certification shall be on file in the form of a photocopy of the ABR certificate. The survey shall include analysis of mR/mAs variations with time and current, determination of congruence of light localizer with the x-ray beam, measurement of half-value layers to determine filtration, and any other studies which may be necessary to meet local, state, and federal requirements and recommendations, as well as to assure the personnel and patients.
B. QUALITY ASSURANCE: Since quality assurance results in lower patient and personnel exposure, an important part of the radiation survey is the assurance of proper operation of the unit including checks of kVp, linearity of exposure with time and current, and focal spot size. These checks are also made on all radiographic units annually. All lead aprons and lead gloves shall be inspected at least annually for integrity. There must be documentation available suitable for review that deficiencies found during the survey have been corrected or are in the process of being corrected.
C. TECHNIQUE: The patient’s region of interest should be calibrated correctly and the appropriate technical factors should be selected/set properly on the control panel. The radiograph shall be accurately marked (patient ID, right/left marker, (etc.) prior to the exposure so as to be visible on the processed radiographic image. The patient shall be given specific instructions (holding breath, holding still, etc.) to minimize the number of exposures taken. During the exposure the main entrance door to the radiographic room shall be closed.
D. UNSAFE EQUIPMENT: Any unsafe equipment or operating condition shall be reported to the Radiology Supervisor. The supervisor will determine if the RSO or IRRP needs to be notified. Equipment shall not be operated when its operation involves a significant risk to patients and/or personnel. If there is any reason to suspect a defect in the leaded gloves or lead aprons, they shall be checked by fluoroscopy.
E. HOLDING OF PATIENTS: Patients should be immobilized as necessary to prevent retakes. Occupationally-exposed students shall not hold patients except in a true emergency. In such an emergency, or if a non-occupational exposed person (e.g. parent/guardian) holds, the person who is holding the patient shall not place any portion of their body in the useful beam. Appropriate protective clothing such as a lead apron and/or lead gloves shall be worn by anyone holding a patient. Radiographic image receptors shall not be held by anyone other than the patient during the radiographic examination.
F. PERSONNEL PRESENT DURING AN EXAMINATION: Only necessary persons shall be in the room during the radiographic procedure. However, many clinical facilities embrace the principles of Family Centered care and the presence of non-occupationally exposed persons (e.g. parent of guardian) are permitted in the radiographic room during their child’s examination. It is the responsibility of the operators of the radiographic equipment to assure that exposed persons are adequately protected from the radiation source. The operator shall also maintain a minimal distance of six (6) feet from the patient and the x-ray tube. In no case shall the operator(s) be permitted to stand in the primary beam. Protective leaded aprons shall be worn by all persons in the room.
G. RESTRICTED AREAS: The x-ray room is a restricted area during x-ray exposures. The authorized operator is responsible for controlling access to that room during exposures. The room is shielded so as to permit all adjacent areas to be treated as unrestricted areas. Most radiographic rooms have either radiation signs or warning lights above their entry doors that indicate radiation exposure is present. In addition, warning signs to alert potentially pregnant patients prior to exposure are posted throughout Radiology Departments.
H. PROPER SIGNAGE: Signage is important to operators, employees, and patient/visitors as it warns everyone of the possibility of radiation exposure. The clinical sites ensure that all areas involved in the production of ionizing radiation are properly signed, and that these signs are in plain site, and are appropriate for all to see and understand.
A. FIVE (5) MINUTE TIMER: The fluoroscopic units are equipped with a five (5) minute timer that will (a) initiate an audible alarm and (b) may disrupt the fluoroscopy. This timer is not to be reset without the permission of the supervising physician.
B. SHIELDING: Protective leaded aprons shall be worn by all persons in a fluoroscopy room or with a portable fluoroscopy unit. Protective lead gloves and/or protective lead collars should be worn as needed. Only necessary persons shall be in the room during fluoroscopy. Student Radiographers should not have any body part except their protected hand(s) within the useful beam. A protective glove of at least 0.25mm lead equivalent shall be worn whenever the hand is placed within or near the radiation field. If the student radiographer must hold during a fluoroscopic procedure, lead shielding (lead pad) must be placed at the appropriate location on the table. The student radiographer who is administering the barium for a large intestine (colon) study should stand at the foot of the table during fluoroscopy. Fluoroscopic examinations shall be performed with the beam limited to the area of clinical interest.
C. TECHNIQUE: Fluoroscopic examinations shall be performed with the minimum current and time consistent with adequate quality of the image and in obtaining a valid diagnostic study. In some Radiology Department there are single x-ray consoles that have the capability of controlling multiple x-ray tubes in different radiographic rooms. There is no situation where more than one (1) x-ray tube could simultaneously operate that room’s x-ray console. To assure proper x-ray tube selection in each room, radiographic exposure times cannot be selected (therefore, radiographic exposures cannot be imitated unless the fluoroscopy button is disengaged). To assure minimal repeated radiographs, dedicated technique charts specific to that x-ray unit are located in each radiographic room.
VIII. OPERATING ROOM
A. AUTHORIZED OPERATORS: Only qualified Staff Radiographers, Student Radiographers or surgeons shall operate radiation equipment during a procedure. It shall be the responsibility of the Student Radiographer to assure that all persons in the area of any ionizing radiation be informed of any radiation activity and protected as necessary. Radioactive materials are not to be handled by the Operating Room personnel.
B. DOSIMETRY: Radiation badges will be issued to Operating Room personnel that are deemed appropriate by the IRRP. At this time the IRRP does not feel that it is necessary for Operating Room personnel to issued radiation badges. When a lead apron is worn, the radiation badge will be worn at the collar outside of the lead apron. Radiation badge reports will be reviewed quarterly/monthly by the IRRP/RSO. Any Operating Room personnel wishing to review their radiation badge readings would contact the IRRP.
C. PREGNANT MEDICAL PROFESSIONALS: Pregnant medical professionals in the Operating Room will continue to work their normal work assignments. They may be relieved of their radiological assignments as Operating Room activity permits.
D. SHIELDING OF OPERATING ROOM PERSONNEL: Protective leaded aprons shall be worn by all operating room personnel who remain in the operating suite during a radiological procedure. In addition, thyroid shields, lead glasses, and lead gloves are available to be worn by the operating room personnel. When not in use lead aprons should be hung up or laid flat. Under no circumstances should they be folded. Shielded personnel remaining in the Operating Room during a radiologic procedure should be no closer than six (6) feet from the radiation source during the x-ray exposure.
E. SHIELDING OF PATIENTS: Shielding of the gonads will be done on all patients regardless of age, for all radiological procedures unless the shielding would interfere with the operation or radiographic examination.
F. UNSHIELDED PERSONNEL: If the wearing of a lead apron is not possible, any remaining personnel must use a portable lead shield in lieu of the lead apron during the x-ray exposure.
IX. MOBILE RADIOGRAPHY
A. AUTHORIZED PERSONNEL: Only qualified Staff Radiographers and Student Radiographers shall operate the radiation equipment during a procedure.
B. SHIELDING OF STAFF: All Student Radiographers shall wear lead aprons during the operation of all mobile radiographic units. All Student Radiographers shall stand back as far as possible (a minimum of six (6) feet from the patient and the x-ray tube during exposures. Students shall never be in the primary beam.
C. SHIELDING OF ASSISTANTS: It shall be the responsibility of Student Radiographers to assure that all persons assisting in the area of any ionizing radiation is protected as necessary. For example: any medical professional or family member who is helping to immobilize a patient must wear a lead apron and should keep their hands out of the primary beam.
D. SHIELDING OF NON-PARTICIPANTS: Hospital personnel, family members, and/or visitors in the critical care areas (e.g. Emergency Room, Intensive Care Units, etc.) will be either given a protective lead apron or instructed to leave the immediate area before an exposure is made. Any medical professional or family members who are not holding or directly involved with the radiographic procedure should be no closer than six (6) feet from the x-ray source during the radiologic exposure. Other patients in the room should be no closer than six (6) from the x-ray source during the radiographic exposure.
E. SHIELDING OF PATIENTS: The use of gonadal shields shall be used whenever possible to prevent irradiation to them. The majority of portable radiographic examinations performed are, however, either chest or abdominal x-rays. Neither of these examinations requires gonadal shielding. If a pelvis x-ray is ordered, no gonadal shielding will be used unless more than one (1) exposure is to be made or if the placement of the gonadal shielding would not obstruct the viewing of the region-of-interest. If there are any questions about whether gonadal shielding should be used or other radiation protection issue, the Student Radiographer should contact a departmental radiologist.
F. SOURCE-SKIN DISTANCE: The portable radiographic units shall not be operated with a source-skin distance (SSD) of less than twelve (12) inches.
X. PREGNANT PATIENTS
A. GENERAL: Protection of the embryo or fetus or the irradiation of women who may be pregnant shall be given special consideration. If the patient is pregnant or suspects that she is pregnant, the Student Radiographer will consult with the Radiologist prior to continuing the radiographic examination.
B. LAST MENSTRUAL PERIOD (LMP): Any female of reproductive age (ten (10+) years or younger in some situations) which is scheduled for a radiographic examination, will be asked the following questions:
1. What was the date of her last menstrual period (LMP)?
2. Do you have any reason to believe you are pregnant?
This information shall be recorded on the x-ray requisition. If the answer to the above questions indicates that the patient may be pregnant, the Student Radiographer will consult with the Radiologist before proceeding with the examination. The Radiologist may choose to:
1. Perform the examination because the patient’s medical condition indicates immediate need
2. Limit the number of views and/or restrict the field size that will yield the necessary clinical information
3. In the case of a known pregnancy, defer the examination until the pregnancy is concluded
4. In the case of a possible pregnancy, defer the examination until the pregnancy is ruled out. This assumes that the examination could be postponed until the pregnancy is concluded if the woman was found to be pregnant
5. Cancel the examination
C. SHIELDING: Shielding of all potentially pregnant patients is required unless it’s presence interferes with the examination.
D. MRI AND PREGNANCY: MRI is not known to have any effect on the fetus. However, as a safety precaution, if there is any question regarding pregnancy, the study should be rescheduled until the pregnancy question is resolved. In emergency situations, where no reasonable alternative exists, the study may be performed after discussion between the radiologist and referring physician.
XI. YOUR ROLE IN RADIATION SAFETY
A. The most important aspect in radiation safety is YOU!!!!!
1. YOU are controlling the radiographic equipment.
2. YOU are responsible for the patient’s safety in the Radiology Department.
3. YOU must think carefully before making each exposure.
4. YOU can prevent most repeats.
5. YOU must decide when to follow the established technique chart and when to make adjustments because of a patient’s body habitus, physical condition, and/or pathology.
A. National Council on Radiation Protection and Measurement: Limitation of Exposure to Ionizing Radiation. Report #116, 1993
B. National Council on Radiation Protection and Measurement: Radiation Protection for Medical and Allied Health Personnel, Report #105, 1989
C. National Council on Radiation Protection and Measurement: Radiation Structural Shielding Design and Evaluation for Medical, Use of X-Ray Gamma Rays of Energies Up to 10 MEV, Report #49, 1976
D. National Council on Radiation Protection and Measurement: Radiation Protection in Pediatric Radiology, Report#68, 1981
E. Nuclear Regulatory Guide #8.13, Instruction Concerning Parental Radiation Exposure, Nov/1975, Revision #3 Jun/1999
F. Ohio Department of Health: Ohio Radiation Protection Rules
Last revision date: November/2017
Last review date: February/2017