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Radiation Safety Manual - University of Mississippi Medical Center

1. 4 eee ee ee eee ee eee entente seen aset ense seen set se sten a essen ae 148 APPENDIX E eicere testem he t dne dte aspice esee p EE 152 Instructions for Therapeutic Administration of I 131 crece eee eres ee ee eee eerte etta aee ttaae 152 APPENDIX 0i im E 156 Radioiodine Bioassay Procedure eee eee ee eee eee ee eee eee ee sette seen aset easet ses tasse ense ette set ee seen aee 156 APPORT E sie aet pat pon Ra ANE te iced OST o pi NAM VDO EE Terre me ta Rea 160 Dose Calibrator Calibration Procedures cerei eee eee eee ee esee etate setas a snae ta sts eo seta sts sonia 160 PUPP EN II qu eT 167 Radiation Therapy Oncology Quality Management Program e eeee eee ee ee eee seen ae etnue 167 Page 4 of 185 University of Mississippi Medical Center APPENDIX NT 176 Instructions for Brachytherapy sccccsiccsssscccsssscssesscssososoonsssessesoossssoncssensessecessoeessenseseessssseesssesecsesnsooeess 176 APPENDIX T iain teen testietes VEE lowes tate r SEE S EE EE 179 HDR Emergency ProcedureSs sseessocssoossoossoossooccosecosccosecooseooseooseooseoossoseeooesoosesocesoeesoecsoessosesssesssoe 179 APPENDIX KuitodieetteciesetbessFetesetot s nis eetierhe da victo e r E r TE EEn S EE TEE ik 182 Procedure for Decommissioning Liquid Scintillation CountersS sesssescoesooecsoessoessoessscssscsssesssee 182 APPENDIX Liesecicec
2. eee eee eene eee nennt 14 LABELING AND T OSTENG iiri ter piss eate sse es S asis epokes roetes NND 20 PROCUREMENT OF RADIOACTIVE MATERIALS ecce sees esee e eene eene en nente en nente nn 22 SURVEY INSTRUMENTATION ooe et dre NIE ea E eit RD FORE HR E ME Rr ehes 24 DOSE CALIBRATORS siete teret SEIS PES INO SEIT EES R e NS E EOP SEINES NE So ESS iesea 27 GAMMA CAMERAS 4 iene oo peteE Rene Eu PEe Ea EMEN e n asao iones orines esros esir sses essani osi ko setae 29 lg JUL GM AORE EEE EES E EES 29 RADIOPHARMACEUTICALS siscssssssosssirsssssssissssssissssooiesseossssissnersssssosssssusnssesissoeosassirosssvsssesssss 30 HIGH DOSE RATE AFTERLOADER ssssoosesssseeesssesesssecsssseoeseseoecesssecsssseosssseosessooecesssecsssseosses 37 MANUAL BRACHYTHERAPY iiss ss fetes in id reti tocius oe a eoo aepo pedo o eed PR ke sepu ee codo Pago peas 45 PERMANENT IMPLANT SEEDS 2 enis esista curo as a epa eh ap exta naa eoe aaa p Cada ga da uk op Sakiniai aiast 51 THERAPEUTIC RADIATION SYS TEM po eeaeiusicuauu no sccveastiesvecapacnsedeplaaselsecdsacdeassavevses 52 ELECTRONIC BRACHYTHERAPY ee tite restat vae eosce skcea eec kar eiu chr ra ep ia cea saeua daa 53 X RAY GENERATING DEVIC HS ereeiuseccees euccteeut edet tuat ae vanta tee de sa eade d aea aede exea aqaa e saa vstati 59 RECORD KEEPING i siliouoca diede SM erai at Mtas e MS E ENNS tex s Seea Eana eais 69 INSTRUMENT QUALITY CONTRU OL et esse centies suo
3. A written directive by an Authorized User approved by the Radiation Safety Committee is required for treatments utilizing sealed sources for brachytherapy The Authorized User and the Medical Physicist must be physically present during the initiation of all patient treatments involving manual brachytherapy sources Only those persons needed for medical safety or training purposes shall be present during the implant procedure Brief the patient on radiation safety procedures for confinement to bed visitor control and other items as applicable consistent with good medical care Patients shall not leave the room during the treatment period Supply the nurses caring for brachytherapy patients with radiation monitoring badges pocket ionization chambers or an electronic alarming dosimeter and instruct them in the use of these monitoring devices Extremity dosimetry may also be supplied to nurses who must provide extended personal care to the patient Any individual who handles the sources must wear extremity monitoring in addition to a whole body badge Access will be limited for housekeeping and dietary personnel All bed linens must be checked with a radiation detection survey meter before being removed from the room to ensure that no dislodged sources are inadvertently removed from the room Visitors will not be allowed inside the treatment room except on a case by case basis and prior instruction and approval of the Radiation Safety Off
4. Page 127 of 185 University of Mississippi Medical Center Why do the regulations have a lower dose limit for the embryo fetus of a declared pregnant woman than for a pregnant worker who has not declared A lower dose limit for the embryo fetus of a declared pregnant woman is based on a consideration of greater sensitivity to radiation of the embryo fetus and the involuntary nature of the exposure Several scientific advisory groups have recommended that the dose to the embryo fetus be limited to a fraction of the occupational dose limit What are the potentially harmful effects of radiation exposure to my embryo fetus The occurrence and severity of health effects caused by ionizing radiation are dependent upon the type and total dose of radiation received as well as the time period over which the exposure was received Refer to Regulatory Guide 8 29 Instruction Concerning Risks from Occupational Exposure on file in the UMMC Radiation Safety Office for more information The main concern is embryo fetal susceptibility to the harmful effects of radiation such as cancer Are there any risks of genetic defects Although radiation injury has been induced experimentally in rodents and insects and in the experiments was transmitted and became manifest as hereditary disorders in their offspring radiation has not been identified as a cause of such effect in humans Therefore the risk of genetic effects attributable to radiation exposure i
5. B The investigational level will be 10 of the Annual Limit on Intake ALI ALI for I 131 is 50 uCi inhalation x 0 1 5 0 uCi ALI for 1 125 is 60 uCi inhalation x 0 1 6 0 uCi If the thyroid burden at any time exceeds 5 0 microcuries of I 131 or 6 0 microcuries of 1 125 the following actions must be taken 1 Carry out all steps as described in part A above 2 If practical daily measurements shall be made until a pattern of bodily retention and excretion can be established and the thyroid burden is less than 1 0 microcurie of I 131 or 1 2 microcuries of I 125 3 If a worker receives an intake in excess of the ALI the regulations prohibit any occupational exposure during the remainder of the year in which the limit is exceeded Page 158 of 185 University of Mississippi Medical Center For high intake readings refer the case to appropriate medical consultation as soon as possible for recommendations regarding therapeutic procedures that may be carried out to accelerate removal of radioiodine from the body If possible this shall be done within 2 3 hours after exposure so that a thyroid blocking agent would be effective Evaluation and investigational levels were taken from Regulatory Guide 8 9 Acceptable Concepts Models Equations and Assumptions for a Bioassay Program Revision 1 July 1993 Measurement A Measure Thyroid Gland 1 2 Perform measurements in a low background area Perform a background measu
6. Control of Radiation in Mississippi Irradiators A Devices must be surveyed annually by the Radiation Safety Office using a GM tube survey meter calibrated within the last year B Theresults of the survey will be recorded on the Equipment Survey Form Any suspect survey meter readings will be promptly reported to the device manufacturer and the Division of Radiological Health for investigation Irradiators Blood Transfusion Services A Training is required prior to the operation of irradiators B Operation instructions will be posted on the side of the irradiator along with a Notice to Employees form C A copy of the Irradiator Operating Manual must be kept near the irradiator When not in use or when not under direct supervision the irradiator keys are to be stored in a separate location to prevent unauthorized operation E All use of the irradiator in Blood Transfusion services must be coordinated through blood Transfusion Medicine and permission must be obtained All uses of the research irradiator will be coordinated with the Department of Surgery and or the Radiation Safety Office F Individuals not assigned to Blood Transfusion Services must maintain a use log The log must specify name department sample description e g biohazard radioactive material cells etc date and exposure time A log book is maintained in the room where the irradiator for research is housed G The Radiation Safety Office will leak
7. Individuals are responsible for making sure their badge is returned to their badge manager prior to leaving for vacation sabbatical maternity leave or any other absence that would prevent them from being present to return their badge at the appropriate time Required information Name printed DOB Social Security Number Gender Male or Female Employee ID Number Badge type Body Ring Fetal Department Ring size if applicable S M L By signing this form and initiating the order for a radiation monitoring badge I acknowledge that I understand that I must wear the badge that is issued I recognize that it is my responsibility to properly wear and return the badges as required to accurately monitor my occupational exposures to radiation I understand that failure to do so can lead to disciplinary action up to termination Signature Date TERMINATING A BADGE Name printed Date Badge Number ID Number Type of Badge Reason for termination Signature Supervisor s signature Submit both the Occupational Exposure History Form and the Statement of Employee Training with this change form ADDITIONS WILL NOT BE MADE WITHOUT ALL DOCUMENTS Page 108 of 185 University of Mississippi Medical Center NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES Patient s Name Room No Physician s Name Isotope Activity Date and Time of Administration Date and Time Sources are to be Remo
8. With a low range thin window G M survey meter check the area around the spill hands and clothing for contamination Alternatively perform a wipe test 5 Report Report incident to the Radiation Safety Office Major Spills 1 Clear the Area Notify all persons not involved in the spill to vacate the room 2 Prevent the Spread Cover the spill with absorbent pad but do not attempt to clean it up Confine the movement of all personnel potentially contaminated to prevent the spread Shield the Source If possible the spill should be shielded but only if it can be done without further contamination or without significantly increasing your radiation exposure Close the Room Leave the room and lock the door s to prevent entry Call for Help Notify the Radiation Safety Office immediately Personnel Decontamination Contaminated clothing shall be removed and stored for further evaluation by the Radiation Safety Officer If the spill is on the skin flush thoroughly and then wash with mild soap and lukewarm water Radiation Safety Office Office 601 984 1980 After Hours see On Call Scheduling for Radiation Safety or contact Emergency Dispatch 601 984 1420 Page 112 of 185 Qu rs sx m SOS 10 11 12 13 14 15 16 University of Mississippi Medical Center REMINDER OF GOOD RADIOISOTOPE LABORATORY SAFETY PRACTICES Never pipette by mouth No smoking or eating drinking or cosmetics application permitt
9. 80 6 abundance I 129 1 125 Correction Factor 0 754 Multiply the average counts per minute by the Ba 133 I 131 correction factor or the I 129 I 125 correction factor to correct for the difference in abundance Page 157 of 185 University of Mississippi Medical Center between the emissions of the two isotopes when using Ba 133 or I 129 sealed sources to calibrate the MCA Specifications for design of a neck phantom can be found in American National Standard ANSI N44 3 1973 Thyroid Radioiodine Uptake Measurements Using a Neck Phantom D Establish System Efficiency Average Standard CPM Background CPM Net Standard CPM Net Standard CPM 100 o Standard Activity uCi 2 2 106 DPM uCi 06 Efficiency Investigation Limits A The evaluation level will be 2 of the Annual Limit on Intake ALT ALI for I 131 is 50 uCi inhalation x 02 1 0 uCi ALI for I 125 is 60 uCi inhalation x 02 1 2 uCi Whenever the thyroid burden at the time of measurement exceeds 1 0 microcurie of I 131 or 1 2 microcuries of I 125 the following actions must be taken 1 Determine the causes of exposure and evaluate the potential for further exposures If further exposure is expected it will be necessary to restrict the worker from the area until the problem is corrected 2s Additional bioassay measurements will be taken to obtain the best estimate of actual intake
10. 9 5 2 of the User Manual when a Single Leader Button end Flexible Implant Tube is used 181 University of Mississippi Medical Center APPENDIX K Procedure for Decommissioning Liquid Scintillation Counters 182 University of Mississippi Medical Center Procedure for Decommissioning Liquid Scintillation Counters Purpose and Scope This procedure details the process of decommissioning of liquid scintillation counters LSC Included are good health physics practices for the disassembly removal of lead removal of sealed sources proper handling and storage of the seal source This procedure can only be performed by a manufacture representative or Radiation Safety personnel During disassembly good health physics practices will be utilized The unit will be surveyed for contamination before the decommissioning process begins Proper PPE including but not limited to gloves lab coat tongs and all appropriate dosimetry including finger ring s will be worn A calibrated survey meter will be present and used during the decommissioning The unit will be surveyed both before and after the decommissioning is complete 1 Disassembly of the LSC a Ensure that the unit is de energized b Removing the outer housing of the unit c Dismantle the lead shielding around the photomultiplier tubes d Locate the source safe e The sealed source and all lead must be removed before disposal of the unit 2 Removal of Sealed Source a The
11. RADIOACTIVE MATERIALS OUTSIDE OF NORMAL WORK HOURS All packages containing radioactive material that arrive between 4 30 p m and 7 a m or on Saturdays Sundays or holidays that is normally delivered to receiving should be taken to the storeroom and placed in a secure or constantly monitored location within the storeroom Shipping and Receiving personnel will retrieve the package on their next scheduled workday An inspection should be made of each package to determine if the package is damaged If the package is wet or appears to be damaged immediately contact the Physical Facilities Emergency Dispatch at 984 1420 or the Radiation Safety Office at 984 1980 or contact the radiation safety person on call via the on line On Call schedule Ask the carrier to remain in the hospital until it can be determined that neither he nor the delivery vehicle is contaminated Radiopharmaceuticals are typically delivered directly to Nuclear Medicine or Nuclear Cardiology from the nuclear pharmacy during hours when a technologist is present If a technologist is late or is held up the package should be taken to the Nuclear Medicine department and placed in the Hot Lab Campus Police should unlock the door place the package on the top of the counter and re lock the door Page 114 of 185 University of Mississippi Medical Center DAILY INCOMING RADIOACTIVE SHIPMENT INSPECTION DATE PRODUCT SUPPLIER TOTAL SOURCE PER CONTAINER EXTER
12. Radiation Oncology shall not release a patient with a permanent implant until the measured dose rate from the patient has been taken and is shown to be such that the total effective dose equivalent to any other individual from exposure to the released individual is not likely to exceed 5 millisievert 0 5 rem If the dose rate for a permanent implant patient is higher than allowed the authorized user authorized medical physicist and radiation safety office will determine an appropriate course of action Records of releases of patients with permanent implants shall be retained for three 3 years If a patient is authorized for release they will be provided with radiation safety guidance on how to maintain doses to other individuals such as family members and members of the public as low as reasonably achievable This guidance must include 1 The need to maintain distance from other individuals including sleeping arrangements and avoiding public transportation and public places 2 Avoiding close contact with children and expectant mothers 3 Thelength of time precautions are necessary and 4 Actions to be followed upon the discovery of a dislodged source including notification of Radiation Oncology or the Radiation Safety Office Radiation Oncology shall maintain a record of source accountability for permanent implants which shall include 1 The number and activity of sources removed from storage the date they were removed from
13. SDE and 4000 mrem extremity requires a review of the exposure report and evaluation of previously recorded exposures notification of the badge wearer and the badge wearer s supervisor in writing and a request that a review of workload and procedures be made Further preemptive investigation may be performed by the Radiation Safety Office on a case by case basis All Level II exposures will be presented in the next RSC meeting for review Page 136 of 185 University of Mississippi Medical Center ALARA Level III Cumulative exposures during the current calendar year greater than or equal to half the annual occupational limits 2500 mrem DDE 7200 mrem LDE 25000 mrem SDE and 25000 mrem extremity requires an investigation to be performed by the Radiation Safety Office to determine if the individual is likely to exceed the annual exposure limits If the individual s exposure has potential to exceed annual regulatory limits the investigation will be brought to the attention of the RSC and corrective actions will be taken to reduce the individual s exposure Cumulative fetal exposure during the gestational period that is greater than or equal to 250 mrem may require an investigation to be performed by the Radiation Safety Office If necessary provisions will be taken to ensure that the fetal exposure will not exceed 500 mrem If it is determined that medical consult is needed the individual will be referred to Student Employee Health Pri
14. University of Mississippi Medical Center b Average the three determinations The average value should be within 5 percent of the certified activity of the reference source mathematically corrected for decay c Repeat the procedure for other calibrated reference sources d Ifthe average value does not agree within 5 percent with the certified value of the reference source the dose calibrator may need to be repaired or adjusted The regulation requires repair or replacement if the error exceeds 10 percent e At the same time the accuracy test is done assay the source that will be used for the daily constancy test it need not be a certified reference source on all commonly used radioisotope settings Record the settings and indicated millicurie values with the accuracy data f Puta sticker on the dose calibrator that says when the next accuracy test is due 2 The Radiation Safety Officer must review and sign records of all accuracy linearity and geometrical tests 166 University of Mississippi Medical Center APPENDIX H Radiation Therapy Oncology Quality Management Program 167 University of Mississippi Medical Center University of Mississippi Medical Center Cancer Institute Radiation Oncology QUALITY MANAGEMENT PROGRAM For Administration of Radiopharmaceutical Brachytherapy and External Beam Radiation Therapy A OBJECTIVE The objective of this Quality Management Program QMP is to provide h
15. University of Mississippi Medical Center placed on the outside of each animal disposal as those labels will be collected by the Radiation Safety Office at the time of survey prior to final disposal Page 89 of 185 University of Mississippi Medical Center GLOSSARY Page 90 of 185 University of Mississippi Medical Center Definitions Absorbed Dose The energy imparted to matter by ionizing radiation per unit mass of irradiated material at the place of interest The units of absorbed dose are the rad and the gray Gy Accessible Surface The external surface of the enclosure or housing provided by the manufacturer ALARA As Low As is Reasonably Achievable means making every reasonable effort to maintain exposures to radiation as far below the dose limits as is practical consistent with the purpose for which the licensed or registered activity is undertaken taking into account the state of technology the economics of improvements in relation to state of technology the economics of improvements in relation to benefits to the public health and safety and other societal and socioeconomic considerations and in relation to utilization of nuclear energy and licensed or registered sources of radiation in the public interest Annual Limit on Intake ALI The derived limit for the amount of radioactive material taken into the body of an adult worker by inhalation or ingestion in a year ALI is the smaller value of intake of a given
16. an apron made of radiation absorbing materials used to reduce radiation exposure Protective Barrier A barrier of radiation absorbing material s used to reduce radiation exposure The types of protective barriers are as follows A Primary Protective Barrier The material excluding filters placed in the useful beam to protect anyone other than the patient from radiation exposure Page 95 of 185 University of Mississippi Medical Center B Secondary Protective Barrier A barrier sufficient to attenuate the stray radiation to the required degree Protective Glove A glove made of radiation absorbing materials used to reduce radiation exposure Qualified Expert An individual who has demonstrated to the satisfaction of MSDH Division of Radiological Health that such individual possesses the knowledge training and experience to measure ionizing radiation to evaluate safety techniques and to advise regarding radiation protection needs Rad A special unit of absorbed dose One rad is equal to an absorbed dose of 100 ergs per gram or 0 01 joule per kilogram 0 01 gray Radiation Gamma rays x rays alpha and beta particles high speed electrons neutrons high speed protons positrons and other atomic particles and electromagnetic radiation consisting of associated and interacting electric and magnetic waves and ultrasonic waves Radiation Area Any area accessible to individuals in which radiation levels could result i
17. and Employee Health Clinic or the Emergency Room Contamination of the Nose 1 Have the contaminated individual blow his her nose into a facial tissue or soft paper towel Check the nose for further contamination If contamination remains a damp cotton tipped swab will be used It is generally better if the contaminated individual performs this procedure a Insert the swab carefully into the nostril as far as possible Exercise caution so the swab does not touch the side during insertion b Press the swab lightly against the sides of the nostril and withdraw in a circular motion so all sides of the nostril are wiped Check the swab for contamination c Continue as long as effective or until the nostril becomes tender Personnel with contamination in the nose or mouth shall not eat drink or smoke until the Radiation Safety Office has determined the risk of internal contamination For personnel with contamination in the nose or mouth swabs will be taken and analyzed before and after decontamination to determine isotope activity and decontamination effectiveness Bioassays will be required for the determination of any biological uptake The results of these analyses will be documented on a Bioassay Record and maintained for review along with the Personnel Contamination Report Form Page 80 of 185 University of Mississippi Medical Center WASTE DISPOSAL Radioactive waste must be segregated and disposed of in accordance wit
18. any corrective action is required to prevent recurrence and c Retaining a record in auditable form for three 3 years of the relevant facts and what corrective action was taken Misadministration The Radiation Safety Office shall be contacted immediately upon determination that a misadministration has occurred The MS State Department of Health Division of Radiological Health MSDH DRH shall be notified by telephone no later than the next calendar day after discovery of the misadministration The Radiation Safety Office will submit a written report to MSDH DRH within 15 days after discovery of the misadministration The written report shall include the university s name and department the prescribing physician s name a brief description of the event why the event occurred the effect on the patient the actions taken or planned to prevent recurrence certification that UMMC has notified the patient or the patient s responsible relative or guardian and if not why not and what information was provided to the patient The report may not include the patient s name or other information that could lead to identification of the patient 171 University of Mississippi Medical Center The authorized user shall provide notification of the misadministration to the referring physician and also notify the patient or a responsible relative or guardian no later than 24 hours after its discovery unless the referring physician personally
19. be asked to enforce corrective or disciplinary action if necessary Disciplinary actions may include but are not limited to warnings by radiation safety office staff the institution of supervision by another authorized user and partial or full revocation of privileges to use radioactive materials or radiation generating devices Termination of an employee will be requested if the severity of the problem warrants such actions Page 9 of 185 University of Mississippi Medical Center Authorities A Make necessary immediate safety decisions in accordance with the rules and procedures established by the RSC as well as the Regulations Ensure compliance with all aspects of this manual and the Regulations by all personnel and individuals assigned to supervise the use of radiation or radiation generating devices 1 Inthe event of a conflict between the Radiation Safety Office and a department official the Chairman of the RSC may elect to call a meeting of the entire RSC to resolve the matter and the decision will be recorded 2 Inthe event of a conflict between the Radiation Safety Office and the RSC in policy matters not covered in this manual or the Regulations the matter will be referred to the Vice Chancellor for resolution and the decision recorded Issue temporary approvals to utilize sources of radiation based on properly submitted applications for use between meetings of the RSC provided such approvals are reviewed by the R
20. beam Comment The x ray technician operator other staff ancillary personnel and other persons required for the medical procedure but are not exposed to the useful beam shall be protected from the direct scatter radiation by protective apron or whole body protective barriers of not less than 0 25 millimeter lead equivalent material People who must move around the room during the procedure should wear a wraparound protective apron In those cases where the patient must hold the image receptor except during intraoral examination any portion of the body other than the area of clinical interest struck by the useful beam shall be protected by not less than 0 5 millimeter lead equivalent material Page 61 of 185 W University of Mississippi Medical Center The hand of the x ray technologist or fluoroscopist shall not be placed in the useful beam unless the patient and a protective glove of at least 0 25 mm lead equivalent material to attenuate the beam Film in darkrooms or in film storage areas should not be exposed to more than 0 0002 cGy 0 2 mrad of stray radiation prior to development Medical fluoroscopy should be performed only by or under the immediate supervision of physicians properly trained in fluoroscopy procedures Stationary Fluoroscopic Equipment In addition to the above mentioned general procedures stationary fluoroscopy equipment has a few specific guidelines that should be followed any time fluoroscopy is being p
21. dosage and route of administration b Forexternal beam radiation therapy the treatment site total dose dose per fraction number of fractions or overall treatment period c For high dose rate remote afterloading brachytherapy the treatment site radionuclide dose per fraction number of fractions and total dose d For sealed source brachytherapy 1 Prior to implantation the treatment site radionuclide and dose and 168 10 11 12 13 University of Mississippi Medical Center 2 After implantation but prior to the completion of the procedure the treatment site radioisotope number of sources and total source strength and exposure time or the total dose Note The above mentioned information is recorded on the patient s treatment chart and is summarized on the formal report completed by the authorized user caring for this patient Except in emergency situations no radiation dose shall be administered by any personnel in the absence of a signed written directive containing the above elements A written revision to an existing written directive may be made provided that the revision is dated and signed by an authorized user prior to the administration of the dosage of radiopharmaceutical the brachytherapy dose the external beam radiation therapy dose or next fractional dose If because of the emergent nature of the patient s condition a delay in order to provide a written directive would jeopardi
22. eese sh ose ep Anab ato epe co Ro oe Uo Sene Pase PR dad 70 PROCEDURES FOR THE USE OF RADIOACTIVE MATERIALS IN ANIMALS 71 AREA SURVEY PROCEDUMNRDBS 5n eR PRI NER reniet URS EN ERNVIRREXSREE ENTM V EM sieaa 73 DECOMMISSIONING AREAS AND EQUIPMENT eeeeee ee eee eene e eee en nennen nonet nonet 75 DECONTAMINATION METHSODBYS diets tute etie eit aae tabe e inre uere tnra coge eR edes teEe 76 WASTE DISPOSAL cn E oe Su Eo ESE REES eiee S Perren 8l GLOSSARY atasa eaaa e e aa E E anaa ASA eroas aaao saei 90 Page 3 of 185 University of Mississippi Medical Center AT TACHMENIS e oeeiettntuta ieu dicte toniertes eot inputs dens un ases ii Oo RU tai teer qe 99 APPLICATION FOR AUTHORIZATION TO USE RADIOACTIVE MATERIALS OR RADIATION GENERATING DEVICES FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES ponas t be teri cai ieri spun i s Reo EG VER RUP a Laso SSos EUR EE saias 100 APPLICATION FOR AUTHORIZATION TO USE RADIOACTIVE MATERIALS FOR RESEARCH PURPOSES y odit Tossa prex WoW pvo E S Er VPE FS PvE RH Hirn ve EE d 103 PREVIOUS OCCUPATIONAL EXPOSURE HISTORY FORM eee eese nete tn aeneo snneae 107 RADIATION BADGE ORDER TERMINATE FORM ee eeee seen enses tn tne ta snae en enses ensis eae 108 NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES e M ri RR TM MEUS 109 INSTRUCTIONS FOR PATIENTS TREATED WITH THERAPEUTIC DOSES OF IODINE 131 PHOSPHORUS 32 OR GOLD 198 s cscssessc
23. lower dose limits apply Page 129 of 185 14 15 16 17 18 University of Mississippi Medical Center No The requirement for lower limits applies only if you declare in writing that you are already pregnant What if I have a miscarriage or find out that I am not pregnant If you have declared your pregnancy in writing you must promptly inform the licensee in writing that you are no longer pregnant However if you have not formally declared your pregnancy in writing you need not inform the licensee of your non pregnant status How long is the lower dose limit in effect The dose to the embryo fetus must be limited until you withdraw your declaration in writing or you inform the licensee in writing that you are no longer pregnant If the declaration is not withdrawn the written declaration may be considered expired one year after submission If I have declared my pregnancy in writing can I revoke my declaration of pregnancy even if I am still pregnant Yes you may The choice is entirely yours If you revoke your declaration of pregnancy the lower dose limit for the embryo fetus no longer applies What if I work under contract at a licensed facility The regulations state that you should formally declare your pregnancy to the licensee in writing The licensee has the responsibility to limit the dose to the embryo fetus Where can I get additional information The Radiation Safety Office can provide more i
24. make these surveys D Survey instruments must have been calibrated within the last year E The Radiation Safety Office and the Nuclear Medicine Nuclear Cardiology PET personnel for each department will establish the dose rate action levels for the restricted and unrestricted areas of each department 1 Nuclear Medicine Nuclear Cardiology restricted area action level is 1 0 mR hr and unrestricted area action level is 0 2 mR hr 2 PET Imaging restricted area action level is 2 0 mR hr and unrestricted area action level is 0 5 mR hr Personnel performing area surveys shall immediately notify the Radiation Safety Office if a dose rate exceeds an action level Surveys for Contamination A Nuclear Medicine Nuclear Cardiology PET personnel shall survey for removable contamination each week of use all areas where radiopharmaceuticals are routinely prepared for use or administered and each week where radioactive materials are stored A survey instrument capable of detecting contamination on each wipe sample of 2000 disintegrations per minute dpm shall be used to perform wipe surveys Calculations Page 32 of 185 University of Mississippi Medical Center Gross Sample CPM Background CPM Net DPM Instrument Counting Efficiency C The Radiation Safety Office and the Nuclear Medicine Nuclear Cardiology PET personnel for each department will establish restricted and unrestricted area removable contamination action level
25. may request to remain in her current position whether or not the radiation exposure history shows doses below the maximum permissible dose Neither can the employee provide the employer with a waiver of liability as a condition of remaining on the job If the employee chooses to remain in a position where a radiation exposure potential exists the department will request an additional radiation monitoring device for the fetus to monitor prenatal exposures The fetal monitor shall be worn on the abdomen of the mother behind a lead apron if one is required If over exposure potential is great a personal dosimeter will be provided for daily determination of exposure levels Exposure Limits Everyone is exposed to radiation every day People are continuously exposed to low level radiation found in food soils building materials the air and from outer space All of this radiation originates from naturally occurring sources For example bananas contain naturally occurring radioactive potassium 40 and air contains radon a radioactive gas Your average natural background radiation dose is about 300 millirem each year In addition to natural background radiation you may be exposed to radiation from medical x rays and medical radiation tests or treatments throughout each year As an occupational worker in an area where sources of radiation are used you may be exposed to more radiation than the general public The amount of radiation an occupationa
26. not be removed by the Radiation Safety Office for storage or disposal until the contents have been properly identified The Radiation Safety Office will not pick up drums containing biological waste in red bags unless it is a designated drum for biological waste Red bags found in the short half life containers held for decay and disposal at the landfill will delay pickup until the waste has been sorted properly The Radiation Safety Office will replace filled drums after notification that the container is full The container will be surveyed sealed documented and disposed of in accordance with the methods specified in this manual and meeting all regulatory requirements E Liquid Waste Disposal 1 Liquid waste containing hazardous chemicals in addition to radioactive materials shall be collected in a glass or plastic container with a lid and labeled with a Caution Radioactive Material tag and have the principal investigator date isotope activity and chemical compounds noted on the container The Radiation Page 84 of 185 University of Mississippi Medical Center Safety Office will pick up the container and make arrangements with the Hazardous Materials Office for disposal in accordance with applicable state and federal regulations Liquid wastes known to contain infectious biological waste shall not be released into the sanitary sewage system However a Due to the extremely small quantity of human cells found in RIA s
27. permitted by the license Radiation Safety Officer a representative of the nursing service and a representative of management who is neither an authorized user nor a Radiation Safety Officer Other members will be appointed by the Vice Chancellor for Health Affairs as he deems appropriate for equal representation of varying facets of institutional uses and needs The Radiation Safety Committee meets as often as necessary to conduct its business but not less than once every six months When the committee meets it is required that a quorum must be present A quorum is defined as any number greater than 50 of the appointed members including the Radiation Safety Officer and the management s representative Authorities The Radiation Safety Committee has the authority to implement policies governing the use of radioactive materials radiation from radioactive materials and radiation generating devices and enforce compliance with these policies Responsibilities The Radiation Safety Committee shall A Ensure that licensed material is used safely This includes review as necessary of training programs equipment facility supplies and procedures Page 7 of 185 D E Duties University of Mississippi Medical Center Ensure that licensed material is used in compliance with the Mississippi State Board of Health Regulations for Control of Radiation In Mississippi and the radioactive material license Ensure that the use of
28. possession of a sealed source shall conduct a physical inventory of all such sources at intervals not to exceed three 3 months These records shall be retained for three 3 years and shall include l The model number and serial number of each source if one has been assigned The identity of each source radionuclide and its nominal activity The location of each source The name of the individual performing the inventory 2 3 4 The date of the inventory 5 6 The signature of the Radiation Safety Officer and 7 Nuclear Medicine Nuclear Cardiology PET personnel shall annotate on the inventory any sealed source that is in storage and not being leak tested Nuclear Medicine Nuclear Cardiology PET personnel shall contact the Radiation Safety Office before purchasing and shipping radioactive sources 1 Verification must be made that sealed sources being returned to the manufacturer for disposal has had a leak test performed within the last six 6 months 2 Every effort will be made to have the manufacturer agree to dispose of old sources when purchasing new check sources This will help lower disposal costs for radioactive sources Nuclear Medicine Nuclear Cardiology PET personnel must contact the Radiation Safety Office before transport of radioactive material and sealed sources between the Jackson Medical Mall and the UMMC campus to assure that Department of Transportation Regulations are followed HIGH DOSE RATE AFTERLO
29. source and source safe may be removed together and stored as a self shielded unit or b The source may be removed for the safe and placed in an appropriate lead pig c The source should not be handled directly with the hands Long tongs should be utilized to move the source d Source information must be transferred to either the lead pig or the removed source safe containing the material e A survey meter will be used to verify the sources removal from the unit 3 Storage a The source will be kept shielded in a secure storage area until proper disposal can be arranged b The source will be transferred from the equipment inventory to the Radiation Safety Office s sealed source inventory c The source will be leak tested before transfer or disposal in accordance with DOT regulations The lead will either be repurposed or safely stored Any disposal of lead will be thorough a licensed broker 183 University of Mississippi Medical Center APPENDIX L Procedure for Exchange of Gadolinium 153 Rod Sources in Siemens ECAM Gamma Camera 184 University of Mississippi Medical Center Procedure for Exchange of Gadolinium 153 Rod Sources in Siemens ECAM Gamma Camera Purpose and Scope The procedure details the process of exchanging the partially decayed gadolinium 153 Gd 153 transmission rod sources in a Siemens ECAM gamma camera Included are good health physics practices for the removal rearrangement replacement and disposal o
30. specified material Kerma is measured in the same unit as absorbed dose The SI unit of kerma is joule per kilogram and its special name is gray Gy Kerma can be quoted for any specified material at a point in free space or in an absorbing medium Kilovolt kV kilo electron volt keV The energy equal to that acquired by a particle with one electron charge in passing through a potential difference of one thousand volts in a vacuum Kilovolts Peak kVp The maximum value of the potential difference across the x ray tube during an exposure kWs Kilowatt second Lead Equivalent The thickness of the material in question affording the same attenuation under specified conditions as lead Page 94 of 185 University of Mississippi Medical Center Lens Dose Equivalent LDE The external exposure of the lens of the eye that is taken as the dose equivalent at a tissue depth of 0 3 centimeter 300 mg cm License A license issued by the Mississippi State Department of Health Division of Radiological Health in accordance with the regulations adopted by the state of Mississippi UMMC holds a Broad Scope Medical License and several other licenses and registrations with MSDH DRH for operations involving both medical and research uses of radiation Licensed Material Radioactive material received possessed used transferred or disposed of under a general or specific license issued by the Agency mA milliampere mAs milliampere se
31. storage and the name of the individual who removed them from storage 2 The number and activity of sources returned to storage the date they were returned to storage and the name of the individual who returned them to storage and 3 The number and activity of sources permanently implanted in the patient Page 51 of 185 University of Mississippi Medical Center Radiation Oncology shall retain a record of permanent implants for three 3 years Permanent implant seeds will be stored in their manufacturer s shipping container inside a secure storage area Sources will be entered on the inventory log upon receipt and source information to include the isotope activity and number of seeds will be verified against the shipping label THERAPEUTIC RADIATION SYSTEMS Written safety procedures and rules shall be developed by an Authorized Medical Physicist and shall be provided to each individual operating a therapeutic radiation machine including any restrictions of the operating technique required for the safe operation of the particular therapeutic radiation machine Individuals shall not be exposed to the useful beam except for medical therapy purposes and unless such exposure has been ordered in writing by a licensed practitioner of the healing arts who is specifically identified on the Certificate of Registration This provision specifically prohibits deliberate exposure of an individual for training demonstration or other non h
32. survey meter sufficiently sensitive to detect 0 1 mrem hr in exposure reading or to read in cpm or cps for surface contamination and or A series of wipe tests to measure removable contamination levels The method of performing wipe tests must be sufficiently sensitive to detect 200 dpm per 100 cm for the contaminant involved A permanent record must be kept of all survey results including negative results using the appropriate survey results log in the EHS software interface Locations found to be contaminated must be decontaminated and resurveyed Results of the resurvey must be noted on the appropriate section of the software interface Areas must be cleaned when the contamination level exceeds 200 dpm 100 cm if the counting instrument efficiency is known for the involved contaminate If the efficiency of the instrument is not known for the involved contaminate contamination levels are indicated at twice normal background measured in an area free of any radiation sources Through the federal and state regulations varying contamination levels are permissible based on the radioisotope and severity of health risk from exposure however for UMMC s purposes all areas posted for the use or storage of radioactive materials shall be subjected to the contamination limits for an unrestricted area due to the following considerations a X Although posted for radioactive material use laboratories are accessible to workers in surrounding
33. test the irradiator source semiannually and ambient surveys will be performed quarterly PROCEDURES FOR THE USE OF RADIOACTIVE MATERIALS IN ANIMALS Animal Housing Areas Housing Animals Containing Radioactive Materials shall be A Properly posted with the following signs and notices contact the Radiation Safety Office to obtain any of these signs 1 Caution Radioactive Material and or Caution Radiation Area on the outer door as required 2 Notice to Employees Page 71 of 185 C D University of Mississippi Medical Center 3 No Eating Drinking or Smoking on the outer door or inside the room and 4 Good Laboratory Practices and Emergency Procedures inside the room Constructed of durable easily cleanable surfaces including the surfaces of animal cages Cleaned periodically to guard against the build up of contamination and Surveyed in accordance with the frequency established in this manual Laboratory Technicians Laboratory Technicians or Technologists primary handlers of animals containing radioactive materials shall A Be instructed in the safe use of radioactive materials and precautionary measures as specified in the training requirements of this manual Be instructed in safe working conditions with animals as required by Animal Facilities and Wear protective clothing coveralls shoe covers and gloves when working in possibly contaminated animal areas or handling animals or carcasses
34. the Radiation Safety Office if you find out that you are not pregnant your pregnancy is terminated or after the birth in order to discontinue the fetal monitoring badge Training information will be sent to the individual signing below to allow for greater understanding of fetal risks from exposure to radiation Any questions that may arise following a review of the training information may be addressed to a supervisor or to the Radiation Safety Office Signature Printed Name Date Page 122 of 185 University of Mississippi Medical Center RADIATION EXPOSURE AND PREGNANCY Introduction The developmental risks associated with radiation exposure to an unborn child during gestation are the focus of this training information However you must understand that even under normal physiological conditions the healthy development of a child is not a 100 guarantee There are many factors that can affect the healthy conception and development of children In addition to radiation exposure some of the other factors may include poor nutrition age heredity certain chemicals certain drugs legal and illegal cigarettes some viruses alcohol and many other factors Everyone is exposed to these factors at work at home for medical diagnosis or treatment or in the community These factors can cause reproductive or developmental problems such as infertility miscarriage birth defects low birth weight abnormal growth and development an
35. the bag and making a slipknot 5 Place the tagged bag into the appropriate freezer unit marked Caution Radioactive Material 6 Prior to releasing a package for disposal the UMMC Radiation Safety Office must be contacted to survey the animal carcass Based on the survey results the UMMC Radiation Safety Office will decide to release the waste for disposal as medical waste retain the waste in storage for additional radioactive decay or package the waste for shipment to a radioactive waste broker UMMC RADIATION SAFETY OFFICE EXTENSION 41980 Page 118 of 185 University of Mississippi Medical Center GUIDE FOR RADIOLOGICAL PROPERTIES OF ISOTOPES Isotope Half Life Decay Time Primary Energy MeV Survey t 12 10 t 12 Particle Ray Instrument of Emitted Choice H 3 12 32 years 123 years Beta 0 019 LSC C 14 5715 years 57150 years Beta 0 157 GM or LSC LSC preferred Na 22 2 6 years 26 years Beta Gamma 0 546 1 274 GM Nal p 32 14 28 days 4 7 months Beta 1 709 GM P 33 25 3 days 8 43 months Beta 0 249 GM S 35 87 2 days 2 39 years Beta 0 167 GM Ca 45 162 7 days 4 46 years Beta 0 258 GM Cr 51 27 7 days 9 23 months Gamma 0 320 GM Nal Ni 63 101 years 2 77 years Beta 0 067 GM Nal Ge 68 170 8 days 4 67 years Positron Gamma S11 GM 1 125 59 4 days 1 63 years Gamma 0 035 LSC GM Gamma Counter 1 131 8 02 days 2 64 months Beta Gamma 0 606 0 3
36. the use of the licensed material Bioassays may be either in vivo or in virto measurements however the licensee must maintain on file bioassay procedures results for review by the MSDH DRH b In accordance with NRC Regulatory Guide 8 9 Acceptable Concepts Models Equations and Assumptions for a Bioassay Program Revision 1 July 1993 periodic bioassays such as quarterly may be required of personnel working with radioiodine but not likely to receive more than 10 of the ALI Page 18 of 185 University of Mississippi Medical Center in a calendar year This determination will be made based on previous bioassay results for personnel performing the same or very similar procedures c Inthose laboratories working only with I 125 radioimmunoassay RIA kits the quantities of I 125 are very small and will not meet the requirements for bioassays Thyroid monitoring is not required 2 Inthose instances where there is some doubt as to the volatile dispersible nature of the iodine used the regularity of work with activities requiring bioassays or the proximity of workers to iodine use areas the Radiation Safety Office has the authority to require at least annual bioassays of workers in order to document safe working conditions B Evaluation and investigational levels and corresponding actions 1 Whenever the thyroid burden at the time of measurement exceeds 2 of the Annual Limit on Intake ALI which equals 1 2 microcuries of I 12
37. to obtain any of these signs A Any radiation area where a major portion of the body head eyes or gonads is likely to receive in any one hour a dose in excess of 100 mrem 0 1 sievert shall be posted with a sign containing the conventional radiation symbol and the words Caution High Radiation Area These signs shall be posted so that they can be seen and read from any entrance to the high radiation area Any radiation area where a major portion of the body head eyes or gonads is likely to receive in any one hour an exposure of 5 mrem 0 5 sievert is a Radiation Area and it shall be posted with a sign containing the conventional radiation symbol and the words Caution Radiation Area These signs shall be posted so that they can be seen and read from any entrance to the radiation area Airborne radioactivity areas must be posted with a sign bearing the radiation caution symbol and the words Caution or Danger Airborne Radioactivity Area Page 20 of 185 University of Mississippi Medical Center Each area room hood or incubator in which radioactive material is used or stored in an amount exceeding the quantity of radioactive material specified in the Regulations for Control of Radioactive Material in Mississippi must be posted with a sign bearing the radiation caution symbol and the words Caution or Danger Radioactive Materials Each refrigerator or freezer where radioactive material is stored or used
38. two 2 forms with which the patient was identified the date of the identification and the name of the person making the identification This record will be maintained for three 3 years The determination of which two identifiers to use shall be based on departmental policy that complies with all regulatory entities applicable to the nuclear medicine treatment programs If the information obtained from any two of these methods does not correspond to the information on the written directive the radiation dose SHALL NOT be administered until conclusive verification of the patient s identity is obtained A Nuclear Medicine Nuclear Cardiology PET CT technologist shall read the written directive before preparing or administering the radiopharmaceutical If any portion of the written directive is unclear he she must contact the specific authorized user who provided the written directive for clarification a The radiopharmaceutical shall not be administered until the intent of the written directive is thoroughly understood by the technologist If the person preparing the dose is different from the person administering the dose both shall read and understand the written directive b The technologist shall verify that the specific details of the administration i e radiopharmaceutical dose route of administration are in accordance with the written directive The actual dose calibrator assay shall be verified with the dosage listed on the
39. unrestricted areas the limits for members of the public A record of each patient survey will be maintained for three 3 years The record will include 1 The time and date of the survey 2 Asketch of the area or list of points surveyed Page 45 of 185 H University of Mississippi Medical Center 3 The measured dose rate at several points expressed in milliroentgen mR per hour 4 The instrument used to make the survey and 5 The initials of the individual who made the survey Immediately after removing the last temporary implant source from a patient the Medical Physicist or Radiation Safety Office shall perform a radiation survey of the patient with a radiation detection survey instrument to confirm that all sources have been removed Radiation Oncology shall maintain a record of patient surveys for three 3 years Each record shall include 1 The date of the survey 2 The name of the patient 3 Theexposure rate from the patient expressed as milliroentgens mR per hour measured on contact and at 1 meter from the patient 4 The survey instrument used and 5 Theinitials of the individual who made the survey The Medical Physicist or Radiation Safety Office shall make a radiation survey of the patient s room to confirm that no sources have been misplaced A patient treated by temporary implant shall not be released from confinement for medical care until all sources have been removed and surveys have been
40. used for dose rate measurements but the instrument must be calibrated with that particular probe Proper Use of Portable Survey Instruments A mo A Select appropriate survey instrument and detector Perform battery check or battery test Verify calibration date is within the last year Set meter to slow response with audio on if audio available Remove all covering from probe that may interfere with detection if probe may become contaminated it is advisable to cover the probe with some form or protection that will not reduce the efficiency of detection capabilities of the probe for the isotope in use Set meter on lowest scale setting Establish a background reading in a clean area and record on survey form Hold probe close to the surface of an object or area being surveyed and move slowly across the surface at a consistent distance and speed approximately 1 2 from the surface at a rate of 1 2 inches per second If survey instrument dial exceeds maximum level on lowest scale turn the dial to the next scale and survey area again Repeat until the readings do not exceed the maximum level of the scale in use Document meter readings on survey reports multiplying meter reading by the scale setting used Record the survey results in either 1 Counts per minute cpm If survey results are greater than twice background clean and resurvey Page 26 of 185 University of Mississippi Medical Center 2 Disintegration
41. written directive In the case of pure beta emitting radiopharmaceuticals calculation of the dosage amount shall be based on the manufacturer s assay calibration and verified by the administering personnel Following the administration of the radiopharmaceutical dose a dated and signed note is entered into the patient s record documenting the administration and dosage Any therapeutic administration must be recorded into the patient s permanent medical record These records must be retained for at least three 3 years Department Procedures shall contain protocols for all radiopharmaceutical procedures which require written directives and be available for review Nuclear Medicine Nuclear Cardiology PET CT technologists shall be familiar with the contents of these procedures Technologists shall be instructed to refer to the Department Procedures before proceeding with any non routine procedure or in any case in which the protocol is not completely familiar to them Page 143 of 185 15 University of Mississippi Medical Center The Chief of Nuclear Medicine shall approve any change in protocol before that change is implemented and always before the change is incorporated into the procedure manual Each technologist shall be instructed in the change before it is implemented or incorporated into the procedure manual If a deviation from the written directive is identified such as a misadministration an investigation of the incident sh
42. 2 University of Mississippi Medical Center 2 The records of each review will be retained for three 3 years These records shall be available for inspection by the MSDH DRH The results of the annual review will also be distributed to appropriate management officials 3 Following the annual review the Radiation Safety Committee will determine if the policies and procedures of the Quality Management Program are effective or require modification Any modifications in the QMP will be submitted to the MSDH DRH within 30 days after the modifications have been made IMPLEMENTATION The policies and procedures specified in this document will be implemented upon approval by the Radiation Safety Committee Chair Radiation Safety Committee Date Chairman Radiation Oncology Date Radiation Safety Office Date 173 University of Mississippi Medical Center Reporting Requirements for Radiation Oncology Recordable Event 1 Administration of an external beam radiation therapy dose when the calculated weekly administered dose is 15 percent greater than the weekly prescribed dose Misadministration 1 Administration of an external beam radiation therapy dose a Involving the wrong patient wrong treatment modality or wrong treatment site b When the treatment consists of three or fewer fractions and the calculated total administered dose differs from the total prescribed dose by more than 10 percent of the total prescri
43. 5 or 1 microcurie of I 131 the following evaluation actions must be taken a Determine the causes of exposure and evaluate the potential for further exposures If further exposure is expected it will be necessary to restrict the worker from the area until the problem is corrected b A repeat bioassay shall be taken within 2 weeks of the previous measurement and shall be evaluated within 24 hours after the measurement c Reports or notification must be provided as required by the regulations d Note The ALI for I 131 is 50 uCi inhalation and for I 125 is 60 uCi inhalation 2 Ifthe thyroid burden at any time exceeds 10 of the Annual Limit on Intake ALD which equals 6 microcuries of I 125 or 5 microcuries of I 131 the following investigational actions must be taken a Carry out all steps as described in part 1 a above b As soon as possible refer the case to appropriate medical consultation for recommendations regarding therapeutic procedures that can be carried out to accelerate removal of radioiodine from the body If possible this will be done within 2 3 hours after exposure so that a thyroid blocking agent would be effective c Perform repeated measurements at weekly intervals until the thyroid burden is less than 1 2 microcuries of I 125 or 1 microcurie of I 131 C Conditions under which urine bioassay is necessary 1 Individuals involved in operations that utilize more than 100 millicuries of hydrogen 3
44. 64 GM Nal Ba 133 10 53 years 105 3 years Gamma 0 356 GM Nal Sc 46 83 81 days 2 30 years Beta Gamma 0 357 1 12 GM Nal Co 57 271 8 days 7 45 years Beta Gamma 0 122 GM Nal Co 60 5 27 Years 52 7 years Beta Gamma 0 1173 0 1332 GM Nal Tc 99m 6 01 hours 60 1 hours 2 5 Gamma 0 1405 GM Nal days T1 201 3 04 days 30 4 days Gamma 0 167 GM Nal In 111 2 80 days 28 days Gamma 0 245 GM Nal Ga 67 3 26 days 32 6 days Gamma 0 093 GM Nal 1 123 13 2 hours 5 5 days Gamma 0 159 GM Nal Y 90 2 67 days 26 7 days Beta 2 281 GM F 18 1 83 hours 18 3 hours Beta 0 635 GM Sr 89 50 52 days 1 4 years Beta Gamma 1 488 0 909 GM Nal Pd 103 16 99 days 5 66 months Beta Gamma 0 223 0 039 GM Cs 131 9 69 days 3 23 months X ray 0 033 LSC GM Sm 153 1 92 days 19 2 days Beta Gamma 0 960 0 103 GM Nal Gd 153 241 6 days 6 61 years Gamma 0 097 GM Ir 192 73 8 days 2 02 years Beta Gamma 0 672 0 316 GM Nal Ra 223 11 4 days 3 8 months Alpha Gamma 5 71 0 269 GM Ra 226 1 599 years 15 990 years Alpha Gamma 4 78 186 2 GM Note Half life and energy ranges were taken from the Chart of the Nuclides 17 Edition Radioactive Decay Data Tables by David C Kocher 1981 LSC Liquid Scintillation Counter GM Geiger Mueller NaI Sodium Iodide Page 119 of 185 University of Mississippi Medical Center UMMC can hold waste for total decay if the half life is less than 120 days Any isotope with a half life more than 120 days must be disposed of through a licensed broker who will deliver i
45. ADER Facility A A remote video system permitting continuous observation of the patient from outside the HDR afterloader treatment room during patient treatment is required An intercom system between the treatment room and the operating console is required A door at each entrance shall control access to the room housing the HDR afterloader Such doors shall normally be closed Page 37 of 185 University of Mississippi Medical Center Each door to the room housing the HDR afterloader will be posted with a Caution Radioactive Materials and Caution High Radiation Area sign If the HDR afterloader unit is housed in a treatment room with an accelerator or other source of radiation controls will be in place so that only one source of irradiation can be utilized at any one time Radiation Oncology personnel shall secure the unit the console the console keys and the treatment room when not in use or unattended The entrance to the irradiation room shall be equipped with an electrical interlock system that will cause the source to return to the shielded position immediately upon opening of the entrance door The interlock system shall be connected in such a manner that the source cannot be placed in the irradiation position until the entrance door is closed and the source on off control is reset at the control panel The electrical interlocks on the entrance to the irradiation room shall be tested for proper operation at l
46. LA VLB VILA VILB VIL C VIILA VIII B VIILC Decay in storage followed by landfill disposal by a licensed landfill operator Decay in storage followed by disposal as medical wastes Prepare collection container and ship to waste broker for disposal Prepare collection container and ship to waste broker for disposal Prepare collection container and ship to waste broker for disposal Solidify liquids in container when necessary and ship to waste broker for disposal as biological or non biological contaminated waste Tag identify and store for decay Drain disposal if non biological and medical waste disposal if biological Ship to waste broker for destruction Tag identify and store liquids for decay Dispose of a chemical waste or organic chemical waste Collect survey and dispose of as medical waste Collect package and ship to broker Tag identify store in freezer for decay followed by disposal as medical waste Prepare collection container and ship to waste broker for disposal Decay in storage followed by landfill disposal by a licensed landfill operator Dispose of as ordinary waste glass in designated boxes Please keep in mind that all wastes disposed of via the landfill broker for animal carcasses or medical wastes must have all radioactive markings defaced prior to disposal Deface all labels prior to placing them in the collection containers with the exception of the label Page 88 of 185
47. Lawson by someone other than the authorized user the Radiation Safety Office must be informed of which authorized user the material is being purchased for C The Radiation Safety Office will review requests ensure that only individuals approved by the Radiation Safety Committee request radioactive material and verify that isotopes ordered are those approved by the RSC The Radiation Safety Office will then approve the order in Lawson Page 22 of 185 University of Mississippi Medical Center Package Surveys Packages delivered to the Shipping and Receiving Department are surveyed by the Radiation Safety Office prior to delivery to the laboratory The packages will have been opened the date of the receipt survey and the initials of the surveyor will be noted on the outside of the package and the radiation symbols on the outer shipping container will have been defaced prior to delivery to the lab If a package is received by laboratory personnel without the above indications that surveys were completed please contact the Radiation Safety Office immediately for the completion of the receipt survey Nuclear Medicine Nuclear Cardiology PET personnel shall survey all incoming packages from the radiopharmacy The monitoring shall be performed as soon as practicable after receipt of the package but no later than three 3 hours after the package is received if received during normal working hours If the package was received after working hours
48. MC throughout the rest of this document is committed to the program described herein for keeping individual and collective doses as low as is reasonably achievable ALARA In accord with this commitment we hereby describe an administrative organization for radiation safety and will develop the necessary written policy procedures and instructions to foster the ALARA concept within our institution The organization will include a Radiation Safety Committee RSC appointed by the Vice Chancellor and a Radiation Safety Officer RSO hired through the Department of Environmental Health and Safety 2 A formal annual review of the radiation safety program including ALARA considerations will be performed and reported to administration through the RSC This will include reviews of operating procedures and past dose records inspections etc and consultations with the radiation safety staff or outside consultants 3 Modifications to operating and maintenance procedures and to equipment and facilities will be made if they will reduce exposures unless the cost in our judgment is considered to be unjustified We will be able to demonstrate if necessary that improvements have been sought that modifications have been considered and that they have been implemented when reasonable If modifications have been recommended but not implemented we will be prepared to describe the reasons for not implementing them 4 In addition to maintaining doses
49. NAL RADIATION SURVEY MR HR Surface 3ft WIPE TEST DPM BKG Outside Inside INTERNAL RADIATION SURVEY MR HR SOURCE REMOVED TECH Records may be found digitally on Pinestar Software Page 115 of 185 University of Mississippi Medical Center IN HOUSE WASTE DISPOSAL RECORD INSTRUMENT SERIAL NUMBER METHOD DATE DATE STORED DATE DISPOSED OF BKG STARTED ENDED MR HR DISPOSED MR HR DISPOSAL MR HR TECH Page 116 of 185 University of Mississippi Medical Center RADIOACTIVE WASTE DISPOSAL RECORD Instructions It is mandatory that radioactive waste be accounted for regardless of the disposal method Use this form to record the disposal of radioactive waste materials This form is taped to the top of the drum or attached with a clipboard to cardboard collection containers Log in an estimate of the type of waste and amount of radioactive material each time a disposal is made into the container When the container is full call the Radiation Safety Office The container will be collected and replaced with an empty container This Disposal Record must be collected with the container and will remain with the container until final disposal whether it is by decay or by a waste broker that handles radioactive wastes Name
50. SC during the next committee meeting Responsibilities A B Duties A Over all administrative direction of the Radiation Safety Program for UMMC Advise the RSC in establishing radiation safety policy as it applies specifically to UMMC Act as a liaison between the Division of Radiological Health and UMMC Produce and circulate radiation safety procedures Ensure compliance with the conditions of all licenses and registrations this manual and the Regulations Ensure that unsafe activities involving radioactive materials or radiation generating devices are stopped Maintain documentation that demonstrates that the dose to individual members of the public does not exceed the limit specified in state and federal regulations and complies with ALARA principles Ensure that up to date radiation protection procedures in the daily operation of the radiation safety program are developed distributed and implemented Ensure that the possession use and storage of licensed material is consistent with the limitations in the license the regulations the SSDR certificates and the manufacturer s recommendations and instructions Page 10 of 185 University of Mississippi Medical Center Ensure that individuals installing relocating maintaining adjusting or repairing devices containing sealed sources are trained and authorized by an NRC or Agreement State license Ensure personnel training is conducted and is commensurate wi
51. SIBILITIES OF THE AUTHORIZED USER An authorized user uses or directly supervises the use of licensed material or registered devices To be an authorized user training and experience must meet the criteria of The Regulations for the Control of Radiation in Mississippi For the use of licensed materials for diagnostic or therapeutic purposes an applicant must show himself to be qualified and approved by a recognized accrediting or licensing body For research programs an applicant will be approved by the Radiation Safety Committee based upon training and experience to use the material in question for the purpose s requested Training and experience must be proven to use radiation generating devices Authorized user status is granted after the applicant has been approved by the Radiation Safety Committee to use or supervise the use of licensed material or registered devices Authorities A Although the authorized user may delegate specific tasks to supervised personnel he she is responsible for the safe use of radioactive materials radioactive sources or radiation generating devices B Using radioactive materials sources or x ray generating devices in a safe manner that is compliant with licenses and registrations and with federal and state regulations Responsibilities A Ensuring that all radioactive material radioactive sources or x ray generating devices are being used under the conditions and terms of the license or registration and i
52. University of Mississippi Medical Center UNIVERSITY OF MISSISSIPPI MEDICAL CENTER RADIATION SAFETY MANUAL Page 1 of 185 University of Mississippi Medical Center UMMC RADIATION SAFETY MANUAL Developed by UMMC Radiation Safety Committee And Environmental Health and Safety Revised August 1990 July 1991 February 1997 April 2001 March 2004 January 2006 February 2008 April 2009 April 2011 October 2012 December 2014 For Information Contact Radiation and Laser Safety Office Phone 601 984 1980 Page 2 of 185 University of Mississippi Medical Center Contents INTRODUCTION nose roi rn tee st o Dat s I ieee Monete tav sd si v D EE 6 AEARA CONCEP YD CR Et 6 INSTITUTIONAL RADIATION SAFETY COMMITTEE RSQC ceeeee esee eene ener 7 CHAIRMAN OF THE RADIATION SAFETY COMMITTEE e eeee eese eene eee nnne nn 9 RADIATION SAFETY OFEICER 2 iice tesieetvente tea bape setae vaauu PL axe sex hu ESn ep RE Reda v seso tasi kosest snese 9 RESPONSIBILITIES OF DEPARTMENT CHAIRMEN DEANS AND ADMINISTRATONRUS ree ce seasuce cesses ceuxceue ose duns eee as eod unu oy euh aan eo dunes dev n ep Ra up va ERE E nw uu eo coats 11 RESPONSIBILITIES OF THE AUTHORIZED USER eeeeeee esee ee eene eee en nente een nonet nn 12 RESPONSIBILITIES OF INDIVIDUAL USERS e eeeeeeee eese eee eene eee enne eee enses estesa sesto 13 RADIATION EXPOSURE PROTECTION AND MONITORING
53. a or x ray emitters Cr I 6Sc isotopes used for nuclear medicine etc lead is used when exposure rates are significant 2 Internal Exposure Protection Page 137 of 185 University of Mississippi Medical Center To ensure that internal exposures are ALARA engineering and procedural controls will be utilized to prevent introduction of radioactive materials into the body through inhalation puncture ingestion and absorption a c Inhalation A chemical fume hood which has been certified for radioactive materials work is highly recommended when using potentially volatile compounds Certain equipment is capable of generating radioactive aerosols Use centrifuges vortex mixers shakers and chromatography plate scraping procedures etc in such a way that production of and exposure to radioactive aerosols is minimized Puncture Dispose of syringes and pipettes promptly and in appropriate containers Guard against glass breakage and puncture injury during use and disposal Do not attempt to recap needles before disposal Ingestion Never introduce any food or drink intended for human consumption into a posted restricted area even for temporary storage DO NOT eat or drink in any area where radionuclides are used never pipette by mouth and never store food and drinks in a cold room or refrigerator that is designated for radioactive material storage Absorption Use measures that prevent the contamination of skin and eye
54. ader source To satisfy this requirement one of the following two conditions shall be met 1 The system shall have been calibrated using a system or source traceable to the National Institute of Standards and Technology or by a calibration laboratory accredited by the American Association of Physicists in Medicine The calibration shall have been performed within the previous 2 years and after any servicing that may have affected system calibration or 2 Thesystem shall have been calibrated within the previous 4 years From 18 to 30 months after that calibration the system shall have been inter compared with another dosimetry system that was calibrated within the past 24 months by the National Institute of Standards and Technology or by a calibration laboratory accredited by the American Association of Physicists in Medicine The inter comparison meeting shall be sanctioned by a calibration laboratory or radiologic physics center accredited by the American Association of Physicists in Medicine The results of the inter comparison meeting must have indicated that the calibration factor of the system had not changed by more than 2 percent The inter comparison result shall not be used to change the calibration factor B Radiation Oncology shall maintain a record of each calibration inter comparison and comparison for the duration of the license For each calibration inter comparison or comparison the record shall include 1 The date 2 Th
55. adionuclide source or calibrated pulser and check sources at least annually and following repair A The source shall be an approximate point source B The source activity shall be traceable within 5 accuracy to the National Institute of Standards and Technology NIST calibrations C Calibration for linear readout instruments shall be performed at two points on each scale The two points shall be approximately s and of full scale Logarithmic scale and digital instruments will be checked at mid range of each decade and at two 2 points of at least one decade Page 24 of 185 University of Mississippi Medical Center The exposure rate measured by a linear readout meter shall differ from the true exposure rate by less than 10 of full scale or the meter manual will be used to make the necessary adjustments to bring the meter into calibration Readings within 20 will be considered acceptable if a calibration chart or graph is prepared and attached to the meter Instruments designed to read out in units of neutron dose equivalent or dose equivalent rate shall be calibrated with an accuracy of 30 for ranges from 0 10 mR hr and 20 accuracy for ranges from 10 mR hr and above Survey meters used for contamination control in laboratories with readouts in cpm or cps will be checked for proper operation by 1 Using a pulse meter to test meter circuits and 2 Using a calibration check source to test the function of the meter probe
56. ainer in a properly functioning fume hood Waste Decay In Storage A Nuclear Medicine Nuclear Cardiology PET personnel shall hold radioactive material for decay in storage before disposal in ordinary trash B Radioactive waste shall be monitored at the container surface before disposal as ordinary trash to determine that its radioactivity cannot be distinguished from background Page 33 of 185 University of Mississippi Medical Center radiation levels Surveys will be performed with a radiation detection survey instrument set on its most sensitive scale and with no interposed shielding All radiation labels shall be removed or obliterated before disposal in ordinary trash For radioactive material held for decay in storage a record of each disposal shall be retained for a period of three 3 years Disposal records must include 1 The date of the disposal The date on which the radioactive material was placed in storage The radionuclides disposed of The model and serial number of the survey instrument used The background dose rate The radiation dose rate measured at the surface of each waste container and pd NAY he The name of the individual who performed the disposal survey and final disposal Disposal of Non Decayed Waste A D Unused doses and used syringes are returned in their shielded containers to the radiopharmacy for disposal Disposal of waste into the sanitary sewer system must comply with the mont
57. all be made Documenting and reporting of the deviation shall be in accordance with the reporting requirements of the Regulations for Control of Radiation in Mississippi Misadministration The Radiation Safety Office shall be contacted immediately upon determination that a misadministration has occurred The MS State Department of Health Division of Radiological Health MSDH DRH shall be notified by telephone no later than the next calendar day after discovery of the misadministration The written report shall include the university s name and department the prescribing physician s name a brief description of the event why the event occurred the effect on the patient the actions taken or planned to prevent recurrence certification that UMMC has notified the patient or the patient s responsible relative or guardian and if not why not and what information was provided to the patient The report may not include the patient s name or other information that could lead to identification of the patient The authorized user shall provide notification of the misadministration to the referring physician and also notify the patient or a responsible relative or guardian no later than 24 hours after its discovery unless the referring physician personally informs the authorized user either that he or she will inform the patient or that based on medical judgment telling the patient would be harmful The authorized user is not required to no
58. amples the lengthy sewage treatment process the limited survival of most pathogens outside the human body and the low probability that the virulent pathogens are present in significant numbers RIA samples containing traces of radioactive material but free of hazardous and flammable chemicals can be released into the sewage system b This will reduce the need for both storage of bulk liquid wastes for decay and the extremely difficult solidification of liquids for expensive broker disposal Liquids containing trace amounts of radioactive material but free of any hazardous or flammable chemicals and readily soluble or dispersible in water will be disposed of via the sanitary sewer system provided a The daily disposal of radioactive material by a single radioactive material user when averaged over a one month period must be limited to the quantities listed below unless otherwise specified by the Radiation Safety Office Calcium 45 5 uCi Carbon 14 10 uCi Chlorine 36 1 uCi Chromium 51 10 uCi Cobalt 57 5 uCi Gallium 67 10 uCi Hydrogen 3 50 uCi Indium 111 10 uCi Iodine 125 10 uCi Iodine 131 10 uCi Iron 55 uCi Iron 59 uCi Phosphorus 32 20 uCi Phosphorus 33 10 uCi Rubidium 86 1 uCi Scandium 46 uCi Sodium 22 1 uCi Sulfur 35 25 uCi Technetium 99m 25 uCi Thallium 201 10 uCi Yttrium 90 1 uCi Page 85 of 185 University of Mississippi Medical Center 1 The above values are conservativ
59. and the isotopes involved using surveys and swipes Put on two pair of disposable gloves one pair over the other Spray the affected area with a fine mist of a commercial decontamination solution Radiac Wash for example or a strong soap and water solution and let the contaminated surface soak briefly If the surface cannot be sprayed without dripping and spreading contamination it is possible to spray the cloths or towels used for decontamination directly Place a small plastic bag nearby to hold contaminated trash Using disposable paper or cloth towels wipe the contaminated surface from the outer edges to the center folding the towel repeatedly to prevent the spread of contamination If outer gloves become contaminated remove by turning the first glove inside out Place Page 76 of 185 J University of Mississippi Medical Center the first glove in a ball in the palm of the second glove Remove the second glove by turning it inside out Both contaminated gloves are now bagged one inside the other If a thin window survey meter can detect the isotopes the towel can be surveyed following each application of decontamination solution to check for removable contamination Survey and or swipe the contaminated area following each decontamination procedure to measure the effectiveness of the procedure If the area cannot be successfully decontaminated to Background levels contact the Radiation Safety Office Deposit all conta
60. ard or Health Stream c Radiologists radiology residents physicians and certified x ray technologists are exempted from the above noted training Please indicate these titles above on this form Additions will not be made without all documents Page 107 of 185 University of Mississippi Medical Center RADIATION BADGE ORDER TERMINATE FORM REQUESTING A NEW BADGE Occupational limits are set by federal regulation The annual limit for whole body deep dose is 5 000 mrem for lens dose is 15 000 mrem shallow dose is 50 000 mrem and fetal dose is 500 mrem for the entire gestational period Radiation monitoring badges are required for personnel likely to receive greater than 10 of the annual limits as indicated above If you are receiving a radiation monitoring badge it is understood that you could during the course of your work exceed 10 of the limit Therefore you are expected to wear the radiation monitoring badge at all times while working Failure to wear your radiation monitoring badge correctly and at all times results in inaccurate or incomplete exposure records Radiation monitoring badges are issued monthly or bi monthly To exchange the badge return it to the departmental badge manager and pick up the new badge Old badges are expected to be returned to the badge manager prior to the 5 of each month so they will be able to check all badges and have them returned to the Radiation Safety Office by the 10 of each month Note
61. are irradiated and the committed dose equivalent to each of these organs or tissues Computed Tomography CT means the production of a tomogram by the acquisition and computer processing of x ray transmission data Contamination A radioactive substance dispersed in materials or on surfaces where it is undesirable and particularly in any place where its presence can be harmful The accepted level of beta gamma surface contamination for release to an unrestricted area is 200 dpm 100 cm Control Panel That part of the x ray control upon which are mounted the switches knobs pushbuttons and other hardware necessary for setting the technique factors Cooling Curve The graphical relationship between heat units stored and cooling time Counts Per Minute CPM As detected by the radiation detecting instrument counts per minute are not equal to disintegrations of the radionuclide atoms per minute Simple conversions can be made by multiplying counts minute alpha x 2 and counts minute beta gamma x 10 to be approximately equal to disintegrations per minute Remembering that 2 2 x 10 dpm equals one microcurie and 2 2 dpm equals one picocurie can make translations easier On beta gamma instruments Geiger Mueller type 2500 counts minute are approximately 1 mR hr Many survey instruments are calibrated in mR hr Curie A unit of quantity of radioactivity One curie Ci is that quantity of radioactive material which decays at the
62. be available for inspection by the MSDH DRH The results of the annual review will also be distributed to appropriate management officials Following the annual review the Radiation Safety Committee will determine if the policies and procedures of the Quality Management Program are effective or require modification Any modifications in the QMP will be submitted to the MSDH DRH within 30 days after the modifications have been made Page 145 of 185 University of Mississippi Medical Center IMPLEMENTATION The policies and procedures specified in this revised document will be implemented upon approval by the Radiation Safety Committee Chair Radiation Safety Committee Date Chief of Nuclear Medicine Date Radiation Safety Office Date Page 146 of 185 University of Mississippi Medical Center Reporting Requirements for Nuclear Medicine Nuclear Cardiology PET CT Misadministration I Other than events that result from intervention by a patient Nuclear Medicine Nuclear Cardiology PET CT shall report any event in which the administration of a radiopharmaceutical results in a A dose that differs from the prescribed dose by more than 5 Rem effective dose equivalent 50 Rem to an organ or tissue or 50 Rem shallow dose equivalent to the skin and the total dosage delivered differs from the prescribed dosage by 20 percent or more or falls outside the prescribed dosage range A dose that exceeds 5 Rem effectiv
63. be retained for three 3 years The record shall include 1 The date of the check 2 Notation that the monitor indicates when the source is exposed and 3 Theinitials of the individual who performed the check Page 38 of 185 University of Mississippi Medical Center Maintenance A Installation and replacement of the sealed source contained in the HDR afterloader shall only be performed by the manufacturer s representatives B Only the manufacturer s representatives shall perform maintenance or repair on the HDR afterloader involving work on the source safe the source drive unit or other mechanism that could expose the source reduce the shielding around the source or compromise the safety of the unit and result in increased radiation levels Surveys A Priorto initiation of a treatment program using the HDR afterloader and subsequent to each source exchange a radiation survey shall be made of 1 The HDR afterloader housing with the source in the shielded position The maximum radiation levels at 10 centimeters 4 inches from the nearest accessible surface of the main source safe shall not exceed 1 milliroentgen per hour 2 All areas adjacent to the treatment room with the source in the irradiation position This area survey shall clearly establish that radiation levels in restricted areas are not likely to cause personnel exposure in excess of the limits for adult occupational workers or in unrestricted areas the li
64. bed dose c When the calculated weekly administered dose is 30 percent greater than the weekly prescribed dose or d When the calculated total administered dose differs from the total prescribed dose by more than 20 percent of the total prescribed dose 2 Other than events that result from intervention by a patient Radiation Oncology shall report any event in which the administration of radioactive material or radiation from radioactive material results in a A dose that differs from the prescribed dose by more than 5 Rem effective dose equivalent 50 Rem to an organ or tissue or 50 Rem shallow dose equivalent to the skin and either 1 The total dose delivered differs from the prescribed dose by 20 percent or more 2 The total dosage delivered differs from the prescribed dosage by 20 percent or more or falls outside the prescribed dosage range or 3 The fractionated dose delivered differs from the prescribed dose for a single fraction by 50 percent or more A dose that exceeds 5 Rem effective dose equivalent 50 Rem to an organ or tissue or 50 Rem shallow dose equivalent to the skin from any of the following 1 An administration of a wrong radiopharmaceutical 2 An administration of a radiopharmaceutical by the wrong route of administration 174 University of Mississippi Medical Center 3 An administration of a dose or dosage to the wrong individual 4 An administration of a dose or dosage delivere
65. ble tolerances 3 Tests will be completed at the indicated frequency noted below a Constancy checks will be completed at least once each day prior to assay of patient dosages 5 percent b Linearity tests will be completed at installation and at least quarterly thereafter 5 percent c Geometry dependence will be completed at installation 5 percent d Accuracy tests will be completed at installation and at least annually thereafter 5 percent 4 After repair adjustment or relocation of the dose calibrator repeat the Accuracy and Geometrical Variance tests as appropriate Constancy means reproducibility in measuring a constant source over a long period of time 1 To perform a constancy check assay at least one relatively long lived source such as Cs 137 Co 60 or Co 57 using a reproducible geometry each day before using the calibrator Consider the use of two or more sources with different photon energies and activities Use the following procedure a X Assay each reference source using the appropriate dose calibrator setting 1 e use the Cs 137 setting to assay Cs 137 b Measure background at the same setting and subtract or confirm the proper operation of the automatic background subtract circuit if it is used c For the Cs 137 source record and initial the net activity of the Cs 137 setting Results must be 5 of the present activity d Repeat the above procedure for all commonly used rad
66. body Declared pregnant individuals working in areas where radioactive materials or x ray generating devices are used and stored in the case of radioactive materials shall be provided a whole body personal dosimetry device and a fetal monitoring dosimetry device A The whole body personal dosimetry device must be worn on the front portion of the upper body and must be placed on the outside of any protective shields worn on the body When using two badges to determine the whole body exposure one badge will be placed outside the apron at the collar and the other under the apron at the waist line Page 17 of 185 B University of Mississippi Medical Center The fetal monitoring dosimetry device must be worn on the front of the lower abdomen underneath any protective shields such as lead aprons to obtain exposures potentially received only by the fetus Personal dosimetry devices in the form of rings will be issued to employees whose hands are at increased risk of exposure in comparison to the whole body A Ring dosimetry devices must be worn by employees who are handling or manipulating unsealed or unshielded sources with tongs or forceps or who are holding partially shielded containers of radioactive material with their hands if the potential for exceeding 1096 of the annual limit exists At the discretion of the Radiation Safety Office ring dosimetry devices will be required for monitoring exposures to the hands of individual
67. cal examinations and measurements of levels of radiation or concentrations of radioactive material present Technique Factors The following conditions of operation A Forcapacitor energy storage equipment peak tube potential in kV and quantity of charge in mAs B Forfield emission equipment rated for pulsed operation peak tube potential in kV and number of x ray pulses C For CT x ray systems designed for pulsed operation peak tube potential in kV scan time in seconds and either tube current in mA x ray pulse width in seconds and the number of x ray pulses per scan or the product of tube current x ray pulse width and the number of x ray pulses in mAs D For CT x ray systems not designed for pulsed operation peak tube potential in kV and either tube current in mA and scan time in seconds or the product of tube current and exposure time in mAs and the scan time when the scan time and exposure time are equivalent and E Forall other equipment peak tube potential in kV and either tube current in mA and exposure time in seconds or the product of tube current and exposure time in mAs Total Effective Dose Equivalent TEDE The sum of the effective dose equivalent for external exposures and the committed effective dose equivalent for internal exposures Page 97 of 185 University of Mississippi Medical Center Total Organ Dose Equivalent TODE The sum of the deep dose equivalent and the committed dose equival
68. cator lights viewing and intercom system applicators source transfer tubes and transfer tube applicator interfaces and source positioning accuracy as applicable and The name and signature of the individual who performed the check Treatment Planning A Where applicable the Authorized Medical Physicist shall perform acceptance testing on the treatment planning system of therapy related computer systems in accordance with published protocols accepted by nationally recognized bodies At a minimum the acceptance testing shall include as applicable verification of 1 The source specific input parameters required by the dose calculation algorithm 2 The accuracy of dose dwell time if applicable and treatment time calculations at representative points 3 The accuracy of isodose plots and graphic displays 4 The accuracy of the software used to determine source positions from images and 5 Ifthe treatment planning system is different from the treatment delivery system the accuracy of electronic transfer of the treatment delivery parameters to the treatment delivery unit from the treatment planning system Page 58 of 185 University of Mississippi Medical Center The position indicators in the applicator shall be compared to the actual position of the source or planned dwell positions as appropriate at the time of commissioning Prior to each patient treatment regimen the parameters for the treatment shall be evaluat
69. ccupational exposures for an employee who is a minor are 5mSv 0 5 rem deep dose equivalent 15 mSv 1 5 rems eye dose equivalent 50 mSv 5 rems shallow dose equivalent to the skin 50 mSv 5 rems shallow dose equivalent to any extremity Declared Pregnant Workers Declared pregnant women who are likely to receive an annual dose from occupational exposures in excess of 0 5 mSv 0 05 rem deep dose equivalent will be required to wear a personal dosimetry device and a fetal monitor Fetal exposure limits are listed below S5mSv 0 5 rem deep dose equivalent for the duration of gestation period 0 5 mSv 0 05 rem deep dose equivalent in any one month of monitoring NOTE Female employees who wish to declare their pregnancy must complete a Declaration of Pregnancy form and return it to the Radiation Safety Office Once this form has been completed training information will be provided and a fetal dosimetry device will be ordered Ordering Personal Dosimetry Devices Departments are required to notify the Radiation Safety Office if employees in the area are likely to receive exposures to radiation in excess of 10 of the annual limits noted above If in doubt contact the Radiation Safety Office for a consultation to determine the risk Departments are also required to designate a specific individual to be responsible for A Collecting the necessary information and making arrangements with the Radiation Safety Office to order d
70. ces must at a minimum assure proper operation of Radiation exposure indicator lights on the electronic brachytherapy unit and on the control console 2 Viewing and intercom systems in each electronic brachytherapy facility if applicable 3 Radiation monitors if applicable and 4 The integrity of all cables catheters or parts of the device that carry high voltages Spot checks of dosimetry must include Page 57 of 185 University of Mississippi Medical Center 1 Checks that the output of the x ray source falls within 3 of expected values which might include as appropriate for the unit 2 Output as a function of time or 3 Output as a function of setting on a monitor chamber 4 Verification of the consistency of the dose distribution to within 3 of that found during calibration 5 Validation of the operation of positioning methods to assure that the treatment dose exposes the intended location within 1 mm and 6 Inspection of all treatment components e g connecting guide tubes transfer tubes transfer tube applicator interfaces treatment spacers on the day of use for any imperfections Records A record of each check shall be retained for three 3 years The record shall include A B D The date of the check The manufacturer s name model number and serial number of the electronic brachytherapy unit Notations indicating the operability of radiation monitors source exposure indi
71. cessary to prevent accidental exposure to the beam A qualified expert shall calibrate all therapeutic radiation machines before being used for the treatment of patients Page 52 of 185 University of Mississippi Medical Center I X Therapeutic radiation equipment and installations shall be subjected to a complete radiation protection survey by a qualified expert prior to use on patients to establish radiation safety status of the installation J Interlocks shall be provided such that all entrance doors including doors to any interior booths shall be closed before treatment can be initiated or continued If any door opening interrupts the radiation beam it shall not be possible to restore the machine to operation without closing the door and reinitiating irradiation by manual action at the control panel K Periodic quality assurance checks shall be performed on therapeutic radiation machines in accordance with procedures established by the Authorized Medical Physicist L Appropriate survey and quality assurance testing instrumentation shall be available within the department Such equipment shall be maintained and calibrated as required by the regulations ELECTRONIC BRACHYTHERAPY Facility Each location where electronic brachytherapy is performed shall be provided with such primary and or secondary barriers as are necessary to ensure compliance with ALARA principles Shielding plans will be required to determine the necessity of s
72. completed Quarterly Surveys of Storage Areas A Radiation Oncology shall survey all areas where manual brachytherapy sources are stored with a radiation survey instrument at intervals not to exceed three 3 months The record shall include 1 The date of the survey 2 A sketch of each area that was surveyed 3 The measured exposure rate at several points in each area expressed in milliroentgens mR per hour 4 The model number and serial number of the survey instrument used to make the survey and 5 The name or the individual performing the survey Radiation Oncology shall retain a record of each storage area survey for three 3 years Page 46 of 185 University of Mississippi Medical Center Inventories A Patient Administration Radiation Oncology shall make a record of brachytherapy source utilization which includes prior to implant insertion information 1 The names of the individuals permitted to handle the sources The number and activity of sources removed from storage The patient s name The room number of use The time and date they were removed from storage The number and activity of sources in storage after the removal and a or eco S The initials of the individual who removed the sources from storage AND promptly after removing the brachytherapy sources from a patient the Medical Physicist shall return the sources to the secured storage area and record 8 The number and activity
73. cond Minor An individual less than 18 years of age Occupational Dose The dose received by an individual in the course of employment in which the individual s assigned duties involve exposure to radiation and or radioactive material from licensed and unlicensed sources of radiation whether in the possession of the licensee registrant or other person Occupational dose does not include doses from background radiation from any medical administration the individual has received from exposure to individuals administered radioactive material and released in accordance with the regulations from voluntary participation in medical research programs or as a member of the public Operator An individual who is certified or qualified to operate x ray generating equipment by the terms of their professional scope of practice and meets the terms of federal and or state regulations and UMMC s licenses and registrations Patient An individual or animal subjected to healing arts examination diagnosis or treatment Penetrating Radiation A general term used to describe external radiations with sufficient penetrating power that the absorbed dose from exposures to man is delivered in significant quantities to tissues and organs other than the skin It refers to gamma x ray and neutron radiations Phantom A volume of material behaving in a manner similar to tissue with respect to the attenuation and scattering of radiation Protective Apron means
74. containing radioactive materials Animal Facilities Personnel Animal Facility personnel shall A Wear protective clothing when working in possibly contaminated animal areas or handling animals or carcasses containing radioactive materials Be given specific instructions by Animal Facilities on cage cleaning and the handling of contaminated animal waste Radioactive Animal Waste Disposal Radioactive animal waste disposal shall be accomplished by A Washing animal waste contaminated with radioactive materials urine and feces into the floor drains leading to the sanitary sewer system unless otherwise instructed by the Radiation Safety Office or the principal investigator for the research being carried out if waste samples are to be collected Contaminated animal carcasses and parts shall 1 Be segregated by isotope H 3 and C 14 items are to be deposited in the designated containers in the freezer on 8 floor of the Research Wing 2 Be packaged and identified with a tag with the radiation symbol name of the principal investigator isotope activity in mCi or uCi and date of disposal Page 72 of 185 University of Mississippi Medical Center 3 Be held for decay in storage until surveyed and released by the Radiation Safety Office after they have decayed below regulatory release limits Note Carcasses containing H 3 and C 14 that are at activities below 0 05 uCi gram are disposed of as non radioactive along wi
75. contaminated hair may be cut off 2 If washing is required the hair is washed in the sink that is approved for radioisotope usage with the individual in a position that precludes the spread of contamination to other parts of the body eyes ears etc 3 Dry the hair and check for remaining contamination Also check the face neck and other areas where contamination could have spread Rewash as necessary Page 79 of 185 4 University of Mississippi Medical Center If three washings do not remove the contamination cutting the contaminated hair will be required Contamination of the eyes or mouth l The eye or mouth will be flushed with tap water but no other action is to be taken Flushing of the mouth will be done over a sink to prevent swallowing of the water Further action will be taken only under the direction of a physician in the Student and Employee Health Clinic Contamination of the ear 1 Contamination in the outer ear will be removed with soap and water on a cotton tipped swab using care not to get any water in the ear canal The swabs shall only be damp and the individual shall tilt his her head so the ear is downward Do not flush the ear with water since this would contaminate the ear canal Take care not to puncture the eardrum Contamination in the inner parts of the ear or other methods of decontamination of the outer ear will be accomplished only under the direction of a physician from the Student
76. conventional radiographic projections the direct exposure of the gonads to the useful beam does not occur and the use of a lead apron is not indicated In proper dental radiography gonadal exposure of the patient is due almost always to the scattered radiation alone Although the gonadal exposure of the dental patient is extremely small when these recommendations are followed a further reduction in gonadal exposure is possible with the use of gonadal shielding The x ray films used should be as sensitive as is practical and consistent with the requirements of the examination Comment The use of high speed film is an effective means of reducing the exposure to both the patient and the operator and the use of fast film lowers the workload in most private dental installations enough to eliminate the need for protective barriers However lower speed films having higher resolution may be necessary for some examinations requiring radiography of fine detail The x ray beam and the film shall be aligned very carefully with the area to be radiographed Comment Improper technique that results in faulty image geometry increases the exposure of the patient and personnel by requiring the examination to be repeated Film processing materials and techniques should be those recommended by the x ray film manufacturer or those otherwise tested to ensure maximum information content of the processed x ray film Where practical quality control methods should b
77. cordance with the written directive Both manual and computer generated dose calculations must be checked for accuracy Any unintended deviation from the written directive shall be identified and evaluated so that appropriate action can be taken The Radiation Safety Office will be notified of the deviation Records of the written directives shall be retained for a period of three 3 years Prior to administration of I 131 sodium iodide greater than 30uCi or a radiopharmaceutical therapy the patient s identity shall be verified by more than one method as the patient named in the written directive The person responsible for administering the radiation will complete the verification by at least two of the following methods a Asking the patient to state his her name b Comparing patient to a recent photograph of same c Asking the patient to state his her birth date d Asking the patient to state his her Social Security Number e Asking the patient to state his her address f Asking the patient for identification such as a driver s license Social Security card or similar g Checking the patient s wrist identification band for name birth date or UMMC ID number or h For patients unable to respond an accompanying relative or friend may attest to the identity Page 142 of 185 12 13 14 University of Mississippi Medical Center Documentation of the verification of the patient s identity shall include the
78. ctive Material label on the door No blood vials syringes needles paper gloves etc are to be placed in these units All animal carcasses parts and tissue shall be double bagged in red biowaste bags tied shut and tagged with a Caution Radioactive Material tag CRM tapes will not stick to plastic subjected to temperature changes and is therefore not acceptable for package tagging Items other than animal carcasses and parts excluding sharps contaminated with radioactive materials and also contaminated with blood or other biological fluids are to be bagged in a red biowaste bag These bags are to be sealed shut to prevent odors and placed in the appropriate radioactive waste storage container for disposal by the Radiation Safety Office Animal carcasses or tissue will be held for decay and then shipped off site via the broker used by LAF for all normal carcass disposal Carcasses containing less than 0 05 uCi per gram of weight of C 14 or H 3 will be disposed of via this method as well H Disposal of Non Radioactive Waste l Non radioactive waste is not to be disposed of in the radioactive waste disposal drums a When using high energy beta gamma isotopes gloves paper plastics etc must be surveyed for radioactive contamination with a thin window GM tube survey meter and if uncontaminated must be disposed of as ordinary trash b When using low energy beta gamma isotopes C 14 or H 3 determine which item
79. d the floors cannot be swept until all sources have been removed and accounted for Before the patient may be discharged and the room released for another patient a dismissal survey must be performed by the Medical Physicist or the Radiation Safety Office 177 University of Mississippi Medical Center 13 The physician caring for each patient may institute certain restrictions specific for a particular type of brachytherapy Read these instructions prior to caring for any brachytherapy patient EMERGENCY PROCEDURES Never touch needles capsules or containers holding brachytherapy sources If a source becomes dislodged do not touch it or pick it up with your hands A If the applicator or sources fall out l Using long forceps place the applicator immediately into the lead container in the corner of the room 2 If only the sources fall out follow the same procedure as in item 1 above 3 Record the time on the Intracavitary Application Sheet 4 Immediately notify the physician in charge of the case the Medical Physicist Extension 42550 and the Radiation Safety Office Extension 41980 On Line On Call Schedule or Emergency Dispatch at extension 41420 B If the patient dies or requires emergency procedures immediately notify the physician in charge of the case the Medical Physicist and the Radiation Safety Office VISITOR PRECAUTIONS 1 No pregnant visitors Female visitors must be asked whether or not the
80. d as necessary B Thecalibrated dosimetry system for fluoroscopic devices shall be traceable to a national standard Dental X Ray Devices A Devices should be evaluated annually by a qualified expert and calibrated as necessary B The calibrated dosimetry system for dental x ray devices shall be traceable to a national standard Research X Ray Devices and Electron Microscopes A The Radiation Safety Office using an ion chamber type survey meter calibrated within the last year must survey research x ray devices and electron microscopes annually B The survey results must be recorded for review on the X Ray Device Survey Form Any suspect survey meter readings will be promptly reported to the device manufacturer and MSDH DRH for investigation C Devices must be operated in accordance with the Regulations for Control of Radiation in Mississippi Accelerators A Accelerators used for human treatment must be calibrated at intervals not to exceed one year and after any change or replacement of components Calibrations must be in accordance with the Regulations for Control of Radiation in Mississippi B Accelerators must be surveyed after any change in the facility or equipment Surveys shall be in accordance with the Regulations for Control of Radiation in Mississippi Page 70 of 185 University of Mississippi Medical Center C Accelerators must be periodically spot checked in accordance with the Regulations for
81. d by the wrong mode of treatment or 5 Aleaking sealed source c A dose to the skin or an organ or tissue other than the treatment site that exceeds by 50 Rem to an organ or tissue and 50 percent of the dose expected from the administration defined in the written directive excluding for permanent implants seeds that were implanted in the correct site but migrated outside the treatment site Radiation Oncology shall report any event resulting from intervention of a patient in which the administration of radioactive material or radiation from radioactive material results or will result in unintended permanent functional damage to an organ or a physiological system as determined by a physician 175 University of Mississippi Medical Center APPENDIX I Instructions for Brachytherapy 176 10 11 12 University of Mississippi Medical Center Detailed Instructions for Attending Brachytherapy Patients Attendants shall not give nursing care to a brachytherapy patient until they have read these precautions Only personnel necessary to the care of this patient shall enter the patient s room while the sources are in place No declared pregnant attendants or nurses are allowed to attend the patient while the brachytherapy sources are implanted in the patient No attendants less than 18 years of age Attendants and nurses shall wear personal dosimetry devices pocket ion chambers or an electronic alarming dosim
82. d childhood cancer As you complete this training keep in mind that there are many factors in your environment that may affect the development of your child Occupational exposures to radiation are of minimal increased risk when the UMMC safety polices are adhered to and regulatory limits are maintained in accordance with the institutional ALARA program The UMMC Radiation Safety Office closely monitors fetal exposures to assure they are below the limitations specified in the regulations Institutional policies are in place to assure the workplace environment is safe for occupationally exposed workers and their unborn children and efforts shall be made to keep prenatal exposures below the maximum permissible dose Background In a 1998 review article the Agency for Toxic Substances Disease Registry ATSDR estimated that Onein 12 US couples are infertile Forty percent or more of conceptions are lost before the 28 week Two to three percent of newborns suffer a major developmental defect Seven percent of newborns are of low birth weight Five percent of newborns are premature i e born before 37 weeks and An undetermined number suffer from developmental or functional problems The extent to which workplace exposures contribute to reproductive and developmental health problems has not been determined to any degree of certainty However it is certain that some workplace chemicals and physical factors may cause certain ad
83. d for leakage Nuclear Medicine Nuclear Cardiology PET departments in possession of a sealed source shall assure that 1 The source is tested for leakage before its first use unless the department has a certificate from the supplier indicating that the source was tested within six 6 months before transfer to UMMC Page 35 of 185 University of Mississippi Medical Center The source is tested for leakage at intervals not to exceed six 6 months or at intervals approved by the U S Nuclear Regulatory Commission in the Sealed Source and Device Registry an Agreement State or a Licensing State Leak tests shall be capable of detecting the presence of 0 005 microcuries of radioactive material on the test sample The test samples are to be taken from the source or from the surfaces of the device in which the source is mounted or stored on which radioactive contamination might be expected to accumulate These samples should be taken with the source in the off or shielded position Leak test records shall be retained for five 5 years These records shall include a The model number and serial number if assigned of each source tested b The identity of each source radionuclide and its estimated activity c The measured activity of each test sample expressed in microcuries d A description of the method used to measure each test sample e The date of the test and f Thesignature of the Radiation Safety Officer If a leak test revea
84. d in a manner that will not spread contamination to other parts of the body or into wounds Page 77 of 185 University of Mississippi Medical Center When washing caution must be exercised to prevent breaking the skin as this creates the potential for internal contamination When drying do not rub the skin as pores will be opened or the contamination will be impressed into the skin Never use water that is warmer than body temperature for washing as this opens body pores which absorb contamination creating a more difficult internal contamination However to prevent discomfort do not use water that is excessively cold B Localized skin contamination ly Inspect the area adjacent to the contamination for any breaks in the skin If breaks exist and the break is a A minor scratch or cut allow the wound to bleed removing any possible contamination and proceed with decontamination of the area b A major cut contact the Radiation Safety Office and escort the individual to the Student and Employee Health Clinic or to the UMMC Emergency Department if the injury occurs when the Student and Employee Health Clinic is closed Document the contamination incident and the actions taken using the Personnel Contamination Report Note the level of contamination the isotope the approximate area of contamination in square inches the location of the contaminated area on the body and the time if known between exposure and the removal o
85. d in the labeled sharp container for radioactive waste disposal D Disposal of Waste in the Collection Areas 1 Each collection area has multiple containers for different types of waste Each waste container in each waste collection area bears a drum disposal log that identifies the solid radioactive waste to be deposited in that particular drum or container Do not put waste in the incorrect drum this unnecessarily increases disposal charges and may even prevent the pickup and disposal of a container Personnel not sorting waste properly may be called upon to under the supervision of the Radiation Safety Office sort through the container and sort the waste properly to allow for disposal Otherwise a department will have to fund the disposal of a container that because of improper sorting costs much higher than normal charges The individual depositing waste in a disposal container or drum must ensure that a Only the waste specified on the drum and sorted by appropriate type is deposited in the drum b Each deposit is recorded on the drum log including the date of disposal principal investigator s name isotope and activity in mCi or uCi c Ensure all information entered onto the drum log is clearly legible and transferred to the carbon copy and d The Radiation Safety Office is notified if the drum is filled or the form needs to be replaced Mixed radioactive waste or drums with improperly identified contents will
86. d tests must be completed following adjustment relocation or repair of the dose calibrator GAMMA CAMERAS As a minimum quality control procedures frequencies and tolerance results limits shall comply with those recommended by the equipment manufacturer prior to patient imaging If not recommended by the manufacture these procedures will require Nuclear Medicine and Nuclear Cardiology personnel to perform flood checks on gamma cameras before each day of use and resolution checks on gamma cameras weekly with a bar phantom PET CT As a minimum quality control procedures frequencies and tolerance results limits shall comply with those recommended by the equipment manufacturer prior to patient imaging Page 29 of 185 University of Mississippi Medical Center RADIOPHARMACEUTICALS Training Nuclear Medicine Nuclear Cardiology PET or Radiation Safety Office personnel shall provide oral and or written radiation safety instruction for all personnel caring for patients undergoing radiopharmaceutical therapy Refresher training shall be provided at intervals not to exceed one 1 year A The instruction shall describe 1 Procedures for patient control 2 Procedures for visitor control 3 Procedures for contamination control 4 Procedures for waste control 3 Notification process of the Radiation Safety Office or authorized user in case of the patient s medical emergency or death and 6 Training for workers as required by th
87. ded to reduce radiation levels in the laboratory Full containers shall be sealed with tape and the principal investigator s name date isotope and activity shall be noted on the label of the container Place the sharp container in the departmental collection room or call the Radiation Safety Office for pickup and disposal G Disposal of Radioactive Animal Wastes Freezers are specifically designated in the Research Building 8 floor animal area for the short term storage of radioactive animal wastes Instructions for radioactive animal disposals are posted in the freezer area These freezers will be used exclusively for radioactive animal carcasses and parts disposal Locks on the doors must be kept locked at all times Keys to the locks can be obtained through the Radiation Safety Office 1 Multiple bins are provided in the walk in freezers unit designated for use by the laboratories These bins are in place for sorting the animals or tissues by isotope When the bins are full call the Radiation Safety Office Page 86 of 185 University of Mississippi Medical Center Radioactive tags are available in the area Complete the information requested on the tag prior to placing items in the freezer Be sure to include the principal investigator s name the date isotope and activity in uCi or mCi Only animal carcasses parts and tissue containing radioisotopes are to be placed in the 8 floor freezer units posted with a Caution Radioa
88. determine that all activities are being conducted safely in accordance with the regulations and the conditions of the license and consistent with the ALARA program and philosophy Recommend remedial action to correct any deficiencies identified in the radiation safety program Maintain written minutes of all Committee meetings including members in attendance and members absent discussions actions recommendations decisions and results of all votes taken Page 8 of 185 University of Mississippi Medical Center I Ensure that the radioactive material license is amended if required prior to any changes in facilities equipment policies procedures and personnel CHAIRMAN OF THE RADIATION SAFETY COMMITTEE The Chairman of the Radiation Safety Committee shall serve as the administrative officer in promulgating the policies established by the committee Authorities The Chairman of the Radiation Safety Committee shall have the authority to A Issue temporary approvals to utilize sources of radiation based on properly submitted applications for use between meetings of the RSC provided such approvals are reviewed by the RSC during the next committee meeting B Temporarily limit or completely prohibit any further use of radiation sources by an individual when such use poses the possibility of a significant threat to the health of personnel students the public or the environment pending a hearing by the RSC at the earliest oppo
89. dical Center Application STATEMENT OF AGREEMENT The individual named below agrees without reservation of any kind to abide by the University of Mississippi Medical Center Radiation Safety Manual and the Mississippi State Department of Health Regulations and hereby waives any right to or recourse against the University of Mississippi for any damage whatsoever resulting from any failure to fully conform to said manual regulation or policies Name printed Date Signature Date Approved Disapproved by RSC RSC Chairman Signature If disapproved explanation or conditions Page 102 of 185 University of Mississippi Medical Center APPLICATION FOR AUTHORIZATION TO USE RADIOACTIVE MATERIALS FOR RESEARCH PURPOSES Please type or print legibly Return to UMMC Radiation Safety Office Department of Environmental Health and Safety Name Department Employee ID Campus Email Title Telephone Please indicate training Duration of Type of Training Institutions Dates Training p tie Jop Formal hours raining Course Principles and Practices of Yes No Yes No Radiation Safety Radioactivity Monitoring Yes No Yes No Technique and Instruments Mathematics Basic to the use of Yes No Yes No Radiation Biological Effects of Radiation Yes No Yes No 1 List all previous experience with radioactive materials including isotopes and activity
90. e Regulations for Control of Radiation in Mississippi The Radiation Safety Office shall keep a record of Personnel receiving instruction for radiopharmaceutical therapy 2 Adescription of the instruction 3 The date of the instruction and 4 The name of the individual who provided the instruction and or the method in which the instruction was delivered Radiopharmaceutical therapy training records shall be retained for inspection for three 3 years Safety Precautions A Each patient receiving radiopharmaceutical therapy will be provided a private room with a private bathroom The patient s room entrance will be posted with a Caution Radioactive Materials sign A radioactive precaution flag will be placed in the patient s chart in EPIC indicating the activity and isotope administered to the patient and duration of precautions Personnel will promptly after administration of the dosage measure the dose rates in contiguous restricted and unrestricted areas with a radiation measurement survey instrument Page 30 of 185 University of Mississippi Medical Center Records of these surveys shall be retained for three 3 years Survey records shall include 1 The time and date of the survey A plan of the area or list of points surveyed The measured dose rate at several points expressed in millirems per hour mR hr The instrument used to make the survey and Oe umm ole The initials of the individual
91. e returned to the Radiation Safety Office for submission to the Radiation Safety Committee Approval for the use of radioactive material or radiation sources will be based upon Fulfillment of training and experience requirements established in The Regulations for the Control of Radiation in Mississippi www msdh state ms us and Nuclear Regulatory Commission NRC guidelines The minimum guidelines shall include but shall not be limited to adequate formal training and or experience in the safe handling of radioisotopes radiation dose units and biological hazards of radiation and characteristics of ionizing radiation 2 The applicant s agreement in writing to follow all UMMC state and federal requirements governing the use of radioactive materials and to accept all responsibility for personal injury resulting from failure to comply with such requirements RADIATION EXPOSURE PROTECTION AND MONITORING Personnel monitoring is required when it is likely that an individual will receive a total effective radiation dose in excess of ten percent of the annual limits given in the following paragraphs The total effective dose includes a summation of the separate exposures from internal dose as well as external dose Normally exposure from radiation sources external to the body will be determined through the use of monitoring devices worn by the individual These will be whole body monitors to measure several components of a radiation e
92. e activities to ensure that the facility s monthly sewer release limits are maintained below regulatory limits Likewise the total quantity of radioactive material released into the sewage system in any one month when diluted by the average monthly quantity of water released by the facility will not result in an average concentration exceeding the limits specified in the regulations The total activity of radioactive material excluding Hydrogen 3 and Carbon 14 released into the sewage system in any one year must not exceed one curie The quantities of Hydrogen 3 and Carbon 14 released into the sewage system shall not exceed 5 curies and 1 curie respectively F Sharps Disposal l All syringe needles and other sharps used with radioisotopes shall be placed in a sharps container and maintained in each research laboratory a These sharp containers shall be designated only for sharps contaminated with radioactive material Radioactive and non radioactive sharps shall not be mixed for disposal Sharps contaminated with isotopes having less than 120 day half lives shall be segregated from sharps contaminated with longer lived isotopes All sharp containers must be labeled with a Caution Radioactive Material sticker and must indicate the principal investigator s name date isotopes present and activity of each isotope If deemed necessary by the Radiation Safety Office based on surveys the sharp containers will be shiel
93. e designated waste container All clothes and bed linens used by the patient must be placed in the plastic bag designated for laundry and must be left in the patient s room to be checked by the Radiation Safety Office All non disposable items must be left in the patient s room to be checked by the Radiation Safety Office Surgical dressings should be changed only as directed by the physician Such dressing must not be discarded as ordinary medical waste but must be deposited in the marked containers in the room and turned over to the Radiation Safety Office When handling these dressings wear disposable gloves For Iodine 131 Nal patients treated for thyroid carcinoma a Urine from Iodine 131 patients will be disposed of by release into the sanitary sewer system If the patient is bedridden a separate urinal or bedpan must be provided The urinal or bedpan must be flushed several times with water after use b Ifthe nurse helps to collect the excreta disposable gloves must be worn Afterwards hands must be washed with the gloves on and again after the gloves are removed The gloves must be placed in the designated waste container for disposal by the Radiation Safety Office c Disposable plates cups eating utensils and food trays will be used when possible by patients who are treated with Iodine 131 d Vomiting within 48 hours after oral administration urinary incontinence or excessive sweating within the first 48 hours may
94. e dose equivalent 50 Rem to an organ or tissue or 50 Rem shallow dose equivalent to the skin from any of the following 1 An administration of a wrong radiopharmaceutical 2 An administration of a radiopharmaceutical by the wrong route of administration 3 An administration of a dosage to the wrong individual 4 An administration of a dosage delivered by the wrong mode of treatment or 5 A leaking sealed source A dose to the skin or an organ or tissue other than the treatment site that exceeds by 50 Rem to an organ or tissue and 50 percent of the dose expected from the administration defined in the written directive Nuclear Medicine Nuclear Cardiology PET CT shall report any event resulting from intervention of a patient in which the administration of radioactive material results or will result in unintended permanent functional damage to an organ or a physiological system as determined by a physician Page 147 of 185 University of Mississippi Medical Center APPENDIX D Nursing Instructions for I 131 Therapy Page 148 of 185 University of Mississippi Medical Center INSTRUCTIONS TO NURSES ASSIGNED TO PATIENTS RECEIVING THERAPEUTIC RADIOPHARMACEUTICALS Personnel involved in direct care must wear a digital dosimeter provided by the Radiation Safety Office a Before entering the patient s room the attendant will turn on the dosimeter and clip the dosimeter to the uniform pocket b Upon leaving th
95. e employed to ensure optimum results Individuals operating dental x ray equipment may request a personal dosimetry device if they wish to monitor their exposure Also personnel who become pregnant and wish to declare their pregnancy will be issued personal dosimetry devices for both mother and child Comment The Radiation Safety Office has reviewed several years worth of exposure records for personnel performing dental x rays and did not see any personnel exposures that exceeded the 10 of the annual limit that requires monitoring Therefore the requirement for monitoring of all dental x ray personnel has been rescinded and dosimetry is provided on an as needed basis as determined by the departmental management and the Radiation Safety Office Page 66 of 185 University of Mississippi Medical Center Analytical X Ray Equipment A Each device shall be labeled Caution Radiation This Equipment Produces Radiation when Energized Each room housing such a device will be posted to alert workers to the possible use of an x ray device Open beam devices must not be used unless 1 The device is designed to prevent the entry of any portions of the body 2 The device tube and shutter status is clearly displayed prominently for the device user 3 The device shutter cannot be opened unless a collimator or coupling has been connected to the radiation port and 4 The radiation measured at a distance of 5 cm from the surface of th
96. e manufactures name model numbers and serial numbers of the instruments that were calibrated inter compared or comparison 3 Thecorrection factors that were determined 4 The names of the individuals who performed the calibration inter comparison or comparison and 5 Evidence that the inter comparison meeting was sanctioned by a calibration laboratory or radiologic physics center accredited by the American Association of Physicists in Medicine Calibration A The Authorized User or Authorized Medical Physicist shall perform the calibration and checks on the HDR afterloader before the first medical use of the unit following replacement of the source or reinstallation of the unit in a new location outside the facility following any repair of the unit that includes the removal of the source or major repair of the components associated with the source exposure assembly and at intervals not to exceed one 1 quarter Page 41 of 185 University of Mississippi Medical Center B Each new source installed into the HDR afterloader shall be verified with a calibrated well chamber before the unit is used for patient treatment The difference between the calculated activity and the measured activity must be within 5 percent C A source positioning check will be performed to ensure that the accuracy of source positioning in the catheter guide tube is accurate to within 1 millimeter to the programmed position A film can be used to verify t
97. e patient s room return the dosimeter to the nursing station The attendant will press the LED button and read the numbers on the lighted display window Exposure will be displayed in mR c The attendant will use the exposure log to record date name dosimeter and reading before turning off the dosimeter d Ifthe dosimeter alarm sounds there is no reason for concern This alarm signifies that it is time to complete your tasks in the patient s room This is not an indication of harmful exposure Silence the alarm by pressing the LED button and reading the mR display Upon leaving the room press the LED button and read the mR display again for the exposure log record e The dosimeter and exposure log will be picked up by the Radiation Safety Office at the conclusion of the patient s treatment Exposure records will be maintained by the Radiation Safety Office f Nurses must spend only that amount of time near the patient required for essential nursing care Call the Radiation Safety Office with any question about the care of these patients Ext 41980 Visitors will be limited to those 18 years of age or over unless other instructions are given by the Radiation Safety Office A boundary line will be marked on the floor at the entrance to the patient s room Visitors will be instructed to remain behind the boundary line The patient will be instructed to remain in bed when visitors are present and to ask visitors to move out of the
98. e source housing port or tube housing is less than 2 5 millirems in one hour Only those individuals approved by the Radiation Safety Committee shall operate analytical x ray devices Device interlocks shall not be bypassed Upon failure of interlocks operation of the device will cease immediately until a qualified service representative completes repairs Individuals operating analytical x ray equipment may request a personal dosimetry device if they wish to monitor their exposure Also personnel who become pregnant and wish to declare their pregnancy will be issued personal dosimetry devices for both mother and child Comment The Radiation Safety Office has reviewed several years worth of exposure records for personnel performing analytical x rays and did not see any personnel exposures that exceeded the 10 of the annual limit that requires monitoring Therefore the requirement for monitoring of all analytical x ray personnel has been rescinded and dosimetry is provided on an as needed basis as determined by the departmental management and the Radiation Safety Office Personnel Training Program Individuals who will be operating x ray systems or x ray generating devices shall be adequately instructed in the safe operating procedures and be competent in the safe use of the equipment Subject matters pertinent to this requirement include but are not limited to the following A Familiarization with equipment 1 Identification o
99. ealing arts purposes All individuals associated with the operation of a therapeutic radiation machine shall be instructed in and shall comply with the provisions of the Quality Management Program Provision shall be made to permit continuous observation of the patient during irradiation and shall be so located that the operator can observe the patient from the control panel The therapeutic radiation machine shall not be used for patient irradiation unless at least one viewing system is operational Provision shall be made for continuous two way aural communication between the patient and the operator at the control panel Persons other than the patient shall not be present in the treatment room when radiation of energy greater than 150 keV is being used At operating potentials of 150 kV or below other persons may be in the treatment room for good reason but only if they are provided with leaded aprons leaded gloves and or portable shields and their surface air kerma dose is monitored If the x ray tube of a contact therapy unit is hand held during irradiation the user shall wear protective gloves and apron A cap of at least 0 5 mm lead equivalent should cover the aperture window of the tube housing of such apparatus when the apparatus is not being used Comment Because the kerma rate in air at the beam output surface of contact therapy and beryllium window machines may be more than 100 Gy min 10 000 rad min extreme precautions are ne
100. east once each day of use Records of interlock tests shall be retained for inspection by the MSDH DRH for three 3 years In the event of a malfunction of the door interlock the HDR afterloader shall be locked in the off position and not used except as is necessary for repair or replacement of the interlock system until the interlock system is shown to be functioning properly The irradiation room shall be equipped with a radiation monitoring device which continuously monitors the radiation level and is equipped with a back up battery power supply for emergency operation This device shall energize a visible signal to make the operator continuously aware of the radiation level in order that appropriate emergency procedures can be instituted to prevent unnecessary radiation exposure This monitor shall be tested for proper operation at the beginning of each day of use Whenever the continuous radiation monitoring device is not operational any person entering the room following an irradiation shall enter with an operable calibrated radiation survey meter or audible alarming personal dosimeter to monitor for any malfunction of the source exposure mechanism The instrument or dosimeter shall be checked with a dedicated check source for proper operation at the beginning of each day of use Prompt repair or replacement of the radiation monitor shall be required if it is inoperable A record of the radiation monitor or instrument checks shall
101. ed and approved by the Authorized User and the Authorized Medical Physicist for correctness through means independent of that used for the determination of the parameters Training A Instruction shall be provided initially to all individuals who operate the unit as appropriate to the individual s assigned duties in operating the unit If the interval between patients exceeds one year retraining of the individuals shall be provided The Authorized Users and Authorized Medical Physicists shall receive device specific instruction from the manufacturer initially and from trained persons annually The training shall be specific for the treatment unit and of a duration as recommended by a national professional society e g the American Association of Physicists in Medicine if applicable otherwise as specified by the device manufacturer and shall include but nor be limited to 1 Unit specific radiation safety requirements 2 Unit operation and 3 Emergency procedures including an emergency drill Records of individuals receiving instruction required by this section shall be retained for three 3 years The record shall include a list of the topics covered the date of the instruction the name s of the attendee s and the name s of the individual s who provided the instruction X RAY GENERATING DEVICES These procedures are taken from the NCRP Report No 102 Medical X Ray Electron Beam and Gamma Ray Protection for Ene
102. ed in the work area Gloves and laboratory coat must be worn when using radioisotopes If issued personnel monitors must be worn Hands shoes and clothing shall be frequently monitored Work with radioactive materials in an approved hood or glove box unless the safety of working on an open bench can be demonstrated Radioisotope work should be conducted in an impervious tray or pan lined with absorbent paper Utilize shielding and distance whenever possible Dispose of liquid and solid radioactive waste in the approved manner Refrigerators containing isotopes shall not be used for storing food Work areas shall be monitored regularly for contamination Thoroughly wash hands after manipulating isotopes before eating or smoking and on completion of work Maintain records of receipt use transfer and disposal of radioactive materials Report accidental inhalation ingestion injury or spills to your supervisor and the Radiation Safety Office Review pertinent safety practices frequently especially before using a new radionuclide Assure compliance with The University of Mississippi Medical Center Radiation Safety Manual and the MSDH DRH Regulation for Control of Radioactive Material in Mississippi Radiation Safety Office Office 601 984 1980 After Hours see On Call Scheduling for Radiation Safety or contact Emergency Dispatch 601 984 1420 Page 113 of 185 University of Mississippi Medical Center RECEIPT OF
103. ed to be in the room should step back from the table and behind portable shields during cine fluorographic and serial radiography procedures Page 64 of 185 University of Mississippi Medical Center Comment This action can decrease the exposure of the fluoroscopist and other near personnel by a factor of three or more In serial radiography the number of images per second and the duration of the procedure should be kept to a minimum consistent with the needs of the examination All personnel not required in the room shall leave the room during serial radiographic exposures Computed Tomography Equipment In addition to the above mentioned general procedures computed tomography equipment has a few specific guidelines that should be followed any time radiography or fluoroscopy is being performed A D The slice thickness should be as great as practicable and the number of slices per study should be as few as practicable Contrast studies should be made only when necessary for obtaining critical diagnostic information The user shall be familiar with the relationship between the patient dose both the maximum value and its distribution and the operation technique factors KVp mAs per scan slice thickness for the computed tomographic unit This information as well as information describing the absorbed dose per scan and the absorbed dose distribution for multiple scans for various appropriate phantoms technique factors and
104. edical Center When working in areas where radiation generating devices may be energized ancillary personnel are required to leave the immediate area during the procedure and can only return when the device has been turned off RECORD KEEPING X Ray Devices The following information must be kept on file for each x ray device or system and made available for inspection by MSDH DRH upon their request A Room number or locations model and serial numbers of all major components and user s manuals for those components B Tube rating charts and cooling curves C Records of surveys calibrations maintenance and modifications performed on the x ray system s and D A copy of all correspondence with MSDH DRH regarding each x ray system Each department shall maintain an x ray log containing the patient s name the type of examinations and the dates the examinations were performed When the patient or film imaging must be provided with human auxiliary support the name of the human holder shall be recorded Therapeutic Radiation Systems All records required by the Regulations for Control of Radiation in Mississippi shall be retained until disposal is authorized by MSDH DRH unless another retention period is specifically authorized All required records shall be retained in an active file from at least the time of generation until the next inspection by MSDH DRH Any required record generated prior to the last inspection may be archi
105. el who prepare or administer radiopharmaceuticals shall use a syringe radiation shield unless the use of the shield is contraindicated for that patient Page 31 of 185 University of Mississippi Medical Center Unless utilized immediately personnel shall conspicuously label each syringe or syringe radiation shield that contains a syringe with a radiopharmaceutical with the radiopharmaceutical name or its abbreviation the type of diagnostic study or therapy procedure to be performed or the patient s name Personnel preparing or handling a vial that contains a radiopharmaceutical shall keep the vial in a vial radiation shield Personnel shall conspicuously label each vial radiation shield that contains a vial of a radiopharmaceutical with the radiopharmaceutical name or its abbreviation Surveys Ambient Radiation Dose Rate A Nuclear Medicine Nuclear Cardiology PET personnel shall survey with a radiation detection survey instrument at the end of each day of use all areas where radiopharmaceuticals are routinely prepared for use or administered This includes the hot lab injection areas holding rooms camera rooms and treadmill areas Nuclear Medicine Nuclear Cardiology PET personnel shall survey with a radiation detection survey instrument at least once each week all areas where radiopharmaceuticals or radioactive wastes are stored A survey instrument capable of measuring dose rates as low as 0 1 millirem per hour shall be used to
106. elation to other day to day risks to the unborn child during pregnancy Page 126 of 185 University of Mississippi Medical Center There is no need to be concerned about sterility that is loss of your ability to bear children The radiation required to produce this effect is more than 100 times greater than the Nuclear Regulatory Commission s basic dose limits for adults of 5 rems per year Questions and Answers Listed below are some questions and answers excerpted from the Nuclear Regulatory Commission s NRC Regulatory Guide 8 13 Instruction Concerning Prenatal Radiation Exposure Note Each time the word licensee is used in this section consider this to mean the University of Mississippi Medical Center 1 Why am I receiving this information The NRC s regulations in 10 CFR 19 12 Instructions to Workers require that licensees instruct individuals working with licensed radioactive materials in radiation protection as appropriate for the situation The instruction below describes information that occupational workers and their supervisors should know about the radiation exposure of the embryo fetus of pregnant women The regulations allow a pregnant woman to decide whether she wants to formally declare her pregnancy to take advantage of lower dose limits for the embryo fetus This instruction provides information to help women make an informed decision whether to declare a pregnancy If I become pregnant am I required t
107. ensed landfill Mixed solids vials containing isotopes with half lives less than 120 days and free of any hazardous chemicals biodegradable non hazardous scintillation fluids acceptable but containing biological agents This drum will be Page 82 of 185 II III IV University of Mississippi Medical Center prepared for decay in storage followed by shipment to a waste broker as medical waste Uncompacted solids containing isotopes with half lives greater than or equal to 120 days and free of hazardous chemical or biological wastes This drum will be prepared for shipment to a waste broker Mixed solids vials containing isotopes with half lives greater than or equal to 120 days and free of hazardous chemicals but containing biological or animal wastes This drum will be prepared for shipment to a waste broker Vials containing isotopes with half lives greater than or equal to 120 days containing either aqueous fluids or hazardous chemicals but lacking biological or animal wastes The broker will not process a vial drum if it contains general laboratory wastes such as gloves bags paper towels etc Only vials can be placed in this container Note Animal carcasses are stored in the freezer units on 8 floor of the research wing and are divided by isotope as the storage containers within the freezer unit indicated Containers Required by Each Laboratory l Each laboratory posted for radioactive material must have ap
108. ent to the organ receiving the highest dose as described in the regulations Tube An x ray tube unless otherwise specified Tube Rating Chart The set of curves that specify the rated limits of operation of the tube in terms of the technique factors Useful Beam The radiation emanating from the tube housing port or the radiation head and passing through the aperture of the beam limiting device when the exposure controls are in a mode to cause the system to produce radiation Weighting Factor W 1 The proportion of risk of stochastic effects probable effects for an organ or tissue resulting from irradiation of that organ or tissue compared to the total risk of stochastic effects when the whole body is irradiated uniformly X Ray A penetrating form of electromagnetic radiation emitted either from the inner orbit electrons of an excited atom as the electrons return to their normal state orbital shells or when a metal target usually tungsten is bombarded with high speed electrons X ray devices X rays are always generated outside the atom s nucleus X Ray Equipment An x ray system subsystem or component thereof Types of x ray equipment are as follows A Mobile X Ray Equipment X ray equipment mounted on a permanent base with wheels and or casters for moving while completely assembled B Portable X Ray Equipment X ray equipment designed to be hand carried C Stationary X Ray Equipment X ray equipment that is i
109. eous fluids or hazardous chemicals but lacking biological or animal wastes i e scintillation fluids Bulk liquid wastes generated or collected during analyses and free of any hazardous chemicals This category can be further subdivided at the collection points into Liquids containing isotopes with half lives greater than or equal to 120 days including liquids containing trace amounts of biological or animal wastes blood serum and other fluids and Liquids containing isotopes with half lives less than 120 days including liquids containing possible trace amounts of biological or animal wastes Bulk liquid wastes generated or collected during analyses and containing hazardous chemicals This group can be further subdivided at collection points into Page 81 of 185 Type VII a University of Mississippi Medical Center Liquids containing isotopes with half lives greater than or equal to 120 days including liquids with traces of biological or animal wastes Liquids containing isotopes with less than 120 day half lives including liquids with trace amounts of biological or animal wastes Animal carcasses and tissue can be subdivided at the time of storage into Animal carcasses tissue containing 0 05 microcuries per gram of weight or less of C 14 or H 3 Animal carcasses tissue containing greater than 0 05 microcuries per gram of weight of C 14 or H 3 and or other isotopes with half lives greater t
110. epresentative must not in any way delay the completion of the quarterly survey If such a delay appears probable the representative of the Radiation Safety Office completing the survey has the authority to begin the survey in the area s in question immediately DECOMMISSIONING AREAS AND EQUIPMENT Rooms designated for radioactive material use or storage will only be returned to general use after the Radiation Safety Office has completed a decommissioning survey documented the survey on a Decommissioning Form and determined that contamination was not present Equipment will not be transferred from a restricted area an area designated for radioactive material use to an unrestricted area until after the Radiation Safety Office certifies that there is no threat of residual radioactive contamination on surfaces Small handling devices and tools that can be easily cleaned by the researcher are exempt from this provision provided the researcher thoroughly cleans and surveys these instruments prior to transfer to another area Examples of equipment that cannot be relocated from a posted room without Radiation Safety Office approval includes but is not limited to the following Sub zero freezers Refrigerators Centrifuges Microfuges Incubators Speedvacs Page 75 of 185 University of Mississippi Medical Center Liquid Scintillation Counters Gamma Counters Water baths Survey instruments Prior to releasing such a room or equipment item it w
111. erformed A Fluoroscopy should not be used as a substitute for radiography but should be reserved for the study of dynamics or spatial relationships or for guidance in spot film recording of critical details The exposure rate used in fluoroscopy should be as low as is consistent with the fluoroscopic requirements Comment In cineradiography special care should be taken to limit patient exposure when as is often the case tube currents and potentials employed are higher than those normally used in fluoroscopy The exposure rates to which patients are normally subjected shall be determined periodically X ray films intensifying screens and other image recording devices should be as sensitive as is consistent with the requirements of the examination Measurements of fluoroscopic tabletop or patient entrance air kerma rates shall be made by a qualified expert and documented at least annually Measurements shall also be made of air kerma rates for typical spot image exposures Comment Fluoroscopic air kerma rate measurements are especially necessary on apparatus employing imaging devices in which brightness is automatically controlled Such measurements require the use of an attenuation block in the fluoroscopic beam The air kerma rate used in fluoroscopy should be as low as is consistent with the fluoroscopic requirements and should not normally exceed 5 rad min g cGy min measured in air at the position where the beam enters the
112. ernal radiation doses of authorized users and workers to determine that their doses are ALARA in accordance with the provisions of this program and will prepare a summary report for the RSC c Quarterly the Radiation Safety Office will review radiation surveys in unrestricted and restricted areas to determine that dose rates and amounts of contamination were at ALARA levels during the previous quarter 2 Education Responsibilities for ALARA Program a The Radiation Safety Office will provide training sessions to inform workers of ALARA program efforts b TheRadiation Safety Office will ensure that authorized users workers and ancillary personnel who may be exposed to radiation will be instructed in the ALARA philosophy 3 Cooperative Efforts for Development of ALARA Procedures Radiation workers will be given opportunities to participate in formulating the procedures that they will be required to follow a The Radiation Safety Office will be in close contact with all users and workers in order to develop ALARA procedures for working with radioactive materials b The Radiation Safety Office will consider the suggestions of individual workers for improving ALARA practices in their respective areas 4 Reviewing Instances of Deviation from Good ALARA Practices The Radiation Safety Office will investigate all known instances of deviation from good ALARA practices and if possible will determine the causes When the cause is kno
113. est A D Leak tests shall be performed on all brachytherapy sources before any medical use or transfer unless the sources have been tested for leakage within six 6 months before the date of use or transfer Leak tests shall be performed on all sealed brachytherapy sources at intervals not to exceed six 6 months The leak test records shall contain 1 The model number The serial number if assigned of each source tested The identity of each source radionuclide and its estimated activity 2 3 4 The measured activity of each test sample expressed in microcuries 5 The date of the test 6 Theequipment used to count the sample and 7 The signature of the Radiation Safety Officer Leak test records will be retained for five 5 years Calibration A Prior to the first medical use of a brachytherapy sealed source the Medical Physicist shall determine the source activity using a calibrated well chamber and determine the source positioning accuracy within applicators 1 The Medical Physicist may use measurements provided by the source manufacturer 2 The Medical Physicist shall mathematically correct the activity of the source for physical decay at intervals consistent with 1 096 physical decay i e 159 68 days for Cs 137 3 An Authorized Medical Physicist shall perform or review the calculation measurements Page 48 of 185 University of Mississippi Medical Center B Radiation Oncology will retain a
114. eter provided by the Radiation Safety Office Note If personal dosimetry devices are provided they cannot be exchanged between personnel Each device is assigned to one person to be worn by that person only Observe the posted time limits Nurses shall spend only the minimum time necessary near a patient for routine nursing care Special restrictions will be noted on the precaution sheet on the patient s chart Patients shall occupy a private room unless approved by the Medical Physicist Brachytherapy patients must stay in bed unless orders to the contrary are written In any event patients will remain in their assigned rooms during the entire treatment period Bed baths shall not be given while the sources are in place After the sources have been removed bed baths will be permitted Do not change bed linens packing surgical dressings or perineal pads while the sources are in place All bed linens dressings and other waste material from the patient must be monitored with a survey meter before they are removed This will ensure that no dislodged source is disposed of accidentally The Medical Physicist or the Radiation Safety Office must monitor items away from the patient s bed an area with low background radiation levels prior to release from the patient s room Only food trays are permitted to leave the room without a survey Do not allow the room to be cleaned by Hospital Housekeeping Services The trash cannot be emptie
115. ew specific guidelines that should be followed any time radiography or fluoroscopy is being performed A Measurements of fluoroscopic tabletop or patient entrance air kerma rates shall be made by a qualified expert and documented at least annually Measurements shall also be made of air kerma for typical spot image exposures Comment Fluoroscopic air kerma rate measurements are especially necessary on apparatus employing imaging devices in which brightness is automatically controlled Such measurements require the use of an attenuation block in the fluoroscopic beam The air kerma rate used in cardiac and special procedures fluoroscopy should be as low as is consistent with the fluoroscopic requirements and should not normally exceed 5 rad min 5 cGy min measured in air at the position where the beam enters the patient Total fluoroscopic time should be kept as short as possible consistent with cardiac and special procedures imaging requirements Comment The fluoroscopist should be aware of the air kerma levels associated with the various modes of operation In cine and serial imaging procedures where spot image cameras are used and where multiple images are easily obtained this individual must be fully aware of the manner in which exposures are made and must exercise great care to assure that only required exposures are made Non intensified fluoroscopy shall not be used When possible the fluoroscopist and all other personnel requir
116. f a declared pregnant woman shall not exceed 0 5 rem 500 mrem or 5 millisieverts The dose equivalent to an embryo fetus shall be taken as the sum of a The deep dose equivalent to the declared pregnant woman and b The dose equivalent to the embryo fetus from radionuclides in the embryo fetus itself and radionuclides in the declared pregnant woman Dose Limits for Individual Members of the Public The total effective dose equivalent to individual members of the public from the licensed or registered operation shall not exceed 0 1 rem 100 mrem or 1 millisievert in a year Investigational Levels The vendor producing and analyzing the monitoring badges provides exposure reports monthly or bi monthly determined by the frequency of the badges These reports are reviewed very closely by the Radiation Safety Office and a copy is provided to each department for personnel review Unusual exposures and or errors are noted on the copy of the report maintained within the Radiation Safety Office As a backup for the review an email is generated by the vendor notifying the Radiation Safety Office of any exposures greater than 400 mrem on any one badge approximately 1 12 of the yearly exposure limit ALARA Level I Exposures of less than 400 mrem DDE 1200 mrem LDE 40 mrem fetal 4000 mrem SDE and 4000 mrem extremity requires no action ALARA Level II Exposures of greater than or equal to 400 mrem DDE 1200 mrem LDE 40 mrem fetal 4000 mrem
117. f controls 2 Function of each control Page 67 of 185 University of Mississippi Medical Center 3 How to use a technique chart B Radiation protection 1 Collimation 2 Filtration 3 Gonad shielding and other patient protection devices if used 4 Restriction of x ray tube radiation to the image receptor 5 Personnel protection 6 Grids C Image processing 1 Image receptor speed as related to patient exposure 2 Image processing parameters 3 Quality Assurance program D Emergency procedures 1 Termination of exposure in event of automatic timing device failure E Proper use of personnel dosimetry if required F Understanding units of radiation Initial training at the time of hire may require one or more of the following A Completion of on line training on the intranet B Site specific training with the authorized user C Training with Radiation Safety Office staff Annual refresher training may require one or more of the following A Completion of on line training on the intranet B Site specific training with the authorized user or lab management C Training with Radiation Safety Office staff Training requirements for ancillary personnel Ancillary personnel are informed of the presence of signs and postings in areas where sources of ionizing radiation are kept or stored when attending orientation as new employees Annual refresher training is also provided to ancillary personnel Page 68 of 185 University of Mississippi M
118. f releases of patients administered radiopharmaceuticals shall be retained for three 3 years Sealed Source Requirements A Nuclear Medicine Nuclear Cardiology PET departments are permitted to receive possess and use the following radioactive material for check calibration and reference use 1 Sealed sources manufactured and distributed by persons specifically licensed by the U S Nuclear Regulatory Commission Agreement State or Licensing State and that do not exceed 30 millicuries each 2 Any radioactive material with a half life of 120 days or less in individual amounts not to exceed 15 millicuries 3 Any radioactive material with a half life greater than 120 days in individual amounts not to exceed the smaller of 200 microcuries or 1000 times the quantities listed in Appendix B of Subchapter 3 in the Regulations for Control of Radiation in Mississippi 4 Technetium 99m in individual amounts as needed Personnel in possession of a sealed source shall survey with a radiation survey instrument at intervals not to exceed three 3 months all areas where such sources are stored Survey records shall be retained for three 3 years and shall include l The date of the survey 2 The measured dose rate in each area expressed in millirems per hour 3 The model number and serial number of the survey instrument used to make the survey and 4 The name of the person performing the survey Sealed sources must be teste
119. f sources This procedure can only be performed by a manufacture representative or Radiation Safety personnel During the procedure good health physics practices will be utilized Proper PPE including but not limited to gloves and all appropriate dosimetry including finger ring s will be worn A calibrated survey meter will be present and used during the source transfer The transmission sources are arranged in two arrays of fourteen 14 sources each and are mounted to the gamma camera Two 2 sources in each array will be replaced semi annually Procedure for Source Exchange 1 The technologist will position the detector 1 array for removal from the gamma camera 2 Radiation Safety personnel or manufacture representative will remove the array from its housing 3 The two 2 oldest sources are removed from the array and individually leak tested The remaining sources are rotated within the array The two 2 new sources are installed The entire array is leak tested The array is then repositioned in the camera housing The technologist will position the detector 2 array for removal from the gamma camera and steps 2 through 7 are repeated 9 The technologist will perform QC tests of the transmission sources po pug ur ae The four 4 removed sources are shipped according to DOT regulations to the manufacturer for disposal Sources are removed from inventory once the source disposal receipt is received from the manufac
120. f the contamination If the areas contaminated are the hands or other areas that can be washed without potentially spreading the contamination to other areas of the body or into breaks in the skin washing with soap and water is acceptable Avoid excessive roughness that abrades the skin abrasion increases risk of absorption through the skin If contamination has been spread to other parts of the body or if skin breaks are possible the following methods shall be used a Ifthe area has sparse hair coverage and is dry press masking tape to the contaminated area Remove the tape carefully to prevent extraction of hair Check the tape for contamination to determine effectiveness b If contamination remains or tape is not practical wipe the area with a damp gauze square or cotton tipped swab and soap Dry the area and check for residual contamination Repeat as often as effective using clean gauze or swab for each application c If l and 2 are not effective sprinkle powdered soap on a gauze square moisten and make into a paste and gently rub the affected area Rinse with clean gauze dipped in water Dry the area and check for residual Page 78 of 185 University of Mississippi Medical Center contamination Repeat as often as effective using clean gauze for each application Save all materials used for disposal as radioactive waste Wash water will be discarded down the drain provided the sink is flushed for several minutes wit
121. fy plans doses and deviations F Documentation of each check dose administration deviation and action is made in the patient Radiotherapy Medical Record G The patient s Radiotherapy Medical Record shall be retained at least five 5 years Procedures A A written directive by an Authorized User approved by the Radiation Safety Committee is required for treatments utilizing the HDR afterloader B The Authorized User and the Authorized Medical Physicist must be physically present during the initiation of all patient treatments involving the HDR afterloader C An Authorized Medical Physicist and either an Authorized User or a physician under the supervision of an Authorized User who has been trained in the operation and emergency Page 44 of 185 University of Mississippi Medical Center response for the unit is required to be physically present during continuation of all patient treatments involving the unit D Only the patient is allowed in the treatment room during the afterloader use Radiation Oncology personnel shall notify the Radiation Safety Office and the Authorized User immediately if the patient has a medical emergency or dies MANUAL BRACHYTHERAPY Facility A Patients being treated with temporary manual brachytherapy sources will be treated in a private room with a private bathroom B This room shall be placed as far away from the nursing station and heavy traffic hallways as possible and may be lined with lead t
122. h running water 5 Ifthe above methods are not effective a more vigorous method will be required If so one of the following steps may be used a C Form a paste using water powdered soap and cornmeal Massage the contaminated area with this paste for five minutes using a surgical brush for fingernails and callused areas rinse dry and monitor Apply a solution of 30 powdered soap and 70 liquid soap with added water Rub vigorously for one minute rinse dry and monitor Apply mechanic s waterless hand cleaner wipe dry and monitor C General body contamination 1 Individuals with general body contamination shall shower immediately in an area that can be controlled and monitored for area contamination a Caution must be exercised to prevent contamination from entering bodily openings or skin breaks Washing shall start from the neck and proceed downward to ensure all contamination is washed away from previously decontaminated areas Hair decontamination is covered separately below 2 Dry and check the individual carefully to determine if any contamination remains Be sure to check in folds of skin and in areas where contamination may be hidden Areas not previously contaminated shall also be checked as contamination may have spread to these areas 3 Iflocalized areas of contamination remain follow the procedure for localized skin contamination D Hair contamination 1 If present in only a small area
123. h state and federal regulations Radioactive waste disposal is accomplished by decay in storage release to the sanitary sewer system provided the release limits and conditions specified in the Regulations for Control of Radiation in Mississippi are met and broker disposal using a licensed and approved radioactive waste broker A Radioactive Waste Classification Radioactive waste is divided into the following categories based on isotopes isotope properties waste form and the presence of other waste components chemical biological etc Type I Type II Type III Type IV Type V Type VI Mixed solids vials containing isotopes with less than 120 day half lives and free of any hazardous chemicals biodegradable non hazardous scintillation fluids acceptable This category can be further subdivided at the collection points into Dry uncompacted solids and vials of liquids free of biological or animal components and Dry uncompacted solids and vials contaminated with biological or animal components Uncompacted solids containing isotopes with half lives greater than 120 days and free of any hazardous chemical or biological or animal wastes Mixed solids vials containing isotopes with half lives greater than or equal to 120 days and free of hazardous chemicals but containing biological or animal wastes Vials containing isotopes with half lives greater than or equal to 120 days and containing either aqu
124. han or equal to 120 days Animal carcasses tissue containing isotopes with less than 120 day half lives Type VIII Damaged laboratory supplies and utensils glassware containers etc can be subdivided at the time of disposal into Items contaminated with isotopes having half lives greater than or equal to 120 days Items contaminated with isotopes having half lives less than 120 days Items decontaminated free of any residual contamination or exhibiting less than 200 dpm 100 cm when the surface is wipe tested Containers Required by Each Department The method of radioactive waste disposal varies with the type of waste generated Each department has access to central collection sites for commonly generated radioactive wastes These collection areas are posted with Caution Radioactive Material signs Notice to Employee signs No Eating Drinking Smoking signs and emergency posters Each of these areas shall be secure with a door that can be locked Refer to section A above to determine the type of waste generated then refer to the methods of disposal as listed below to determine which storage container in the departmental collection area to use LA LB Mixed solids vials containing isotopes with half lives less than 120 days and free of any biological waste or hazardous chemicals biodegradable non hazardous scintillation fluids acceptable This drum will be prepared for decay in storage and disposal at a lic
125. he accuracy of the source positions D The timer accuracy and linearity over the typical range of use will be checked after each new source installation E A test of the source retraction utilizing the backup battery system when power to the unit is removed will be performed The length of the source transfer tubes will be checked G Thelength of the applicators will be measured H Check the functions of the source transfer tubes applicators and the transfer tube applicator interfaces I Calibration records will include 1 The date of the calibration The manufacturer s name Model number and serial number of the HDR unit The isotope activity and serial number of the sealed source C des ob ae The model and serial number of the well chamber and electrometer used for the calibration 6 Theresults of the calibration and 7 The signature of the Authorized Medical Physicist who performed the calibration J A record of the HDR afterloader calibration shall be maintained for three 3 years Daily Spot Checks A Atthe beginning of each day of use and after each source installation the following checks will be performed 1 The function of electrical interlocks at each HDR afterloader unit room entrance 2 The source exposure indicator lights on the remote afterloader unit on the control console and in the facility 3 Viewing and intercom systems shall be checked 4 Emergency response equipment will be in
126. hly average concentration for the isotope listed in the Regulations for Control of Radiation in Mississippi The waste must be readily soluble or dispersible in water Records of sewer disposals shall include 1 The date of the disposal 2 The radionuclide and 3 Anestimated activity that was released in millicuries or microcuries Excreta from patients undergoing medical diagnosis or therapy are exempt from all limitations listed in the Regulations Release of Therapy Patients Containing Radiopharmaceuticals A Personnel shall not authorize release from confinement for medical care any patient administered a radiopharmaceutical until the exposure rate from the patient has been taken and verification has been made that the total effective dose equivalent to any other individual from the patient s release is not likely to exceed 5 millisievert 0 5 rem Nuclear Regulatory Commission NUREG 1556 Vol 9 Appendix U Table U 1 lists the Page 34 of 185 University of Mississippi Medical Center release activity for I 131 as 33 millicuries the release exposure rate at 1 meter is listed as 7 millirem per hour Patients may be released with I 131 dose rates greater than 7 millirem per hour at 1 meter and activities greater than 33 millicuries in accordance with the guidelines for patient release in NRC Regulatory Guide 8 39 Release of Patients Administered Radioactive Materials and NUREG 1556 Vol 9 Appendix U Records o
127. hrough 5 below must be completed within 6 minutes Put the base and sleeve 1 in the dose calibrator with the vial Record the sleeve number and indicated activity Remove sleeve 1 and put in sleeve 2 Record the sleeve number and indicated activity Continue for all sleeves Or on a sheet of semilog graph paper label the logarithmic vertical axis in millicuries and label the linear horizontal axis in hours elapsed At the top of the graph note the date and the model number and serial number of the dose calibrator Plot the data using the equivalent decay time associated with each sleeve 163 University of Mississippi Medical Center 8 Draw a best fit straight line through the data points For the point farthest from the line calculate its deviation from the value on the line Deviation activity observed activity value from best fit line activity value from best fit line 9 If the worst deviation is more than 0 05 the dose calibrator should be repaired or adjusted If this cannot be done it will be necessary to make a correction table or graph that will allow you to convert from activity indicated by the dose calibrator to true activity 10 Puta sticker on the dose calibrator that says when the next linearity test is due D Geometry independence means that the indicated activity does not change with volume or configuration l This test should be done using a syringe that is normally used for injec
128. iation does not include sources of radiation from radioactive materials regulated by the Regulations for Control of Radiation in Mississippi Background radiation can also be defined as the radiation arising from sources other than the one directly under consideration Beam Limiting Device A device that provides a means to restrict the dimensions of the x ray field Also called a collimator Becquerel The SI unit of activity One becquerel is equal to 1 disintegration or transformation per second dps or tps Bioassay The determination of kinds quantities or concentrations and in some cases the locations of radioactive material in the human body whether by direct measurement in vivo counting or by analysis and evaluation of materials excreted or removed from the human body Page 91 of 185 University of Mississippi Medical Center Calibration The determination of 1 the response or reading of an instrument relative to a series of known radiation values over the range of the instrument or 2 the strength of a source of radiation relative to a standard Committed Dose Equivalent HT 50 Means the dose equivalent to organs or tissues of reference T that will be received from an intake of radioactive material by an individual during the 50 year period following the intake Committed Effective Dose Equivalent HE 50 The sum of the products of the weighting factors applicable to each of the body organs or tissues that
129. iation after a pre set time interval or integrated charge on a dosimeter based monitor l A dwell duration display timer or integrator shall be provided at the treatment control panel The dwell duration display timer or integrator shall indicate planed setting as well as the time or signal elapsed or remaining The dwell duration display timer or integrator shall be a cumulative device that activates with an indication of the treatment delivery beam in use and retains its reading after irradiation is interrupted or terminated The dwell duration display timer or integrator shall terminate irradiation when a pre selected time or integrated signal has elapsed if any dose monitoring system present has not previously terminated irradiation Page 54 of 185 University of Mississippi Medical Center 4 The dwell duration display timer or integrator shall permit setting of exposure times as short as 0 1 second 5 The dwell duration display timer shall not permit an exposure if set at zero 6 Thedwell duration display timer shall be accurate to within 1 percent of the selected value or 0 1 second whichever is greater Authorized Medical Physicist Support The Authorized Medical Physicist shall be responsible for A B Evaluation of the output from the electronic brachytherapy source Generation of the necessary dosimetric information Supervision and review of treatment calculations prior to initial treatment of any trea
130. ically to them and bearing their name or a spare badge if one has been issued Return each dosimetry device at the end of the monitoring period to the departmental badge manager for return to the Radiation Safety Office Note It is the individual dosimetry wearer s responsibility to arrange returns despite vacations personal leave or shift hours The departmental badge manager is expected to contact delinquent individuals in efforts to collect the badges not returned but they are not expected to chase people down to get them and Report any lost dosimetry devices immediately to the departmental badge manager or the Radiation Safety Office 1 For lost dosimetry badges the Radiation Safety Office will make arrangements with the vendor to assign an estimated exposure based on an average of prior exposures Repeated lost badges will cause an inaccurate estimation of exposure to radiation 2 Repeated losses of dosimetry devices and continued failure to return dosimetry devices for processing will result in written notification of departmental administration manager chairman etc and notification of Human Resources as a matter of non compliance with safety policies Proper Use of Personal Dosimetry Devices All personal dosimetry devices designed for whole body monitoring must be worn on the front portion of the upper body area of the internal organs and eyes and must be worn outside any protective shields such as lead aprons worn on the
131. ice while sources are implanted Visitors will be instructed to maintain a safe distance from the patient No one under the age of 18 will be allowed to enter the patient s room while the sources are implanted Brachytherapy sources will be transported in a shielded container between their storage location and the treatment room Emergency Procedures A Emergency equipment consisting of remote handling tools forceps and a shielded storage container Pig will be located in the far corner of the room during the brachytherapy treatment Never touch needles capsules or containers holding brachytherapy sources If a source becomes inadvertently dislodged from the patient or inadvertently lodged within the patient following removal of the source applicators use long forceps to grab the source and place it in the shielded container in the corner of the room Page 50 of 185 University of Mississippi Medical Center If a source becomes dislodged immediately contact Radiation Oncology at 984 2550 and the Radiation Safety Office at 601 984 1980 After hours and weekends see online On Call schedule or contact Emergency Dispatch at 601 984 1420 Note the time the source was found dislodged and the location of the source from the patient when found Personnel shall notify the Radiation Safety Office and Authorized User immediately if the patient has a medical emergency or dies PERMANENT IMPLANT SEEDS Release Requirements A
132. iese zteva eebescio ia n outa S VE ES ES Er SENE S EE EiS 184 Procedure for Exchange of Gadolinium 153 Rod Sources in Siemens ECAM Gamma Camera 184 Page 5 of 185 University of Mississippi Medical Center Radiation Safety Manual INTRODUCTION Purpose The purpose of this manual is to establish radiation safety policies for the University of Mississippi Medical Center UMMC and all programs affiliated with licenses and registrations of UMMC This manual summarizes the procedures necessary to meet the requirements of the radioactive material license issued for human and non human use of radioisotopes This manual was developed with the assistance of the Radiation Safety Office Radiation Safety Committee and appropriate legal counsel This is hereby published as the official policy of UMMC for the use of radiation for diagnostic therapeutic or investigational purposes Adherence to the procedures practices and recommendations described herein is essential if UMMC is to meet its obligation of providing a safe and healthful environment for our patients visitors students and personnel All faculty staff employees and students engaged in work involving radioactive materials or radiation generating devices are expected to be familiar with and comply with the policies presented in this manual License The Mississippi State Department of Health Division of Radiological Health MSDH DRH has issued a Medical Broad Scope License and other license
133. igh confidence that radioactive material or radiation from radioactive sources or external beam sources will be administered as directed by the authorized user and thereby eliminate misadministrations and recordable events AUTHORITY AND RESPONSIBILITY The authority and responsibility to establish and implement this Quality Management Program shall be given to the Department of Radiation Oncology and to the Radiation Safety Office Directives contained herein are added to existing Department Procedures and the facility ALARA Program POLICY This policy is for the administration of radiopharmaceuticals brachytherapy and external beam radiation therapy at UMMC A written directive means an authorized user s written order for the administration of radioactive material or radiation from radioactive material or a therapeutic radiation machine to a specific patient or human research subject Electronic signatures from the authorized user on the written directive are only acceptable for therapeutic radiation machines 1 A written directive must be dated and signed by an authorized user prior to administration of I 131 sodium iodide greater than 30 uCi any therapeutic dosage of radioactive material or any therapeutic dose of radiation from radioactive material or external beam 2 The written directive must contain the patient s name and the following information a For an administration of a radiopharmaceutical the pharmaceutical isotope
134. ill be necessary to contact the Radiation Safety Office and request a radiation survey and swipe test Surveys will be performed using a thin window GM tube survey meter capable of reading 0 1 mR hr Swipes will be taken of a 100 cm area using a filter paper wipe or smear dampened with isopropyl alcohol and subjected to liquid scintillation counting Action levels requiring decontamination will be any survey meter reading greater than twice background or swipe results of equal to or greater than 200 dpm 100 cm Decontamination if necessary will be in accordance with procedures listed in the decontamination section of this manual Once a room or equipment item has been determined to be below stated levels of radioactive contamination all surveys and swipes measuring less than the action level specified above the Radiation Safety Office will complete a Decommissioning Form A copy of this form will be sent to the area supervisor or to the department chairman concerned at their request A copy of this form will be maintained in the Radiation Safety Office files DECONTAMINATION METHODS Decontamination of Laboratory Surfaces When contamination is detected on laboratory surfaces and equipment as a result of regularly scheduled area surveys surveys at the conclusion of work with radioisotopes decommissioning surveys or surveys initiated by a spill these procedures are to be followed A B Identify the area contaminated
135. informs the authorized user either that he or she will inform the patient or that based on medical judgment telling the patient would be harmful The authorized user is not required to notify the patient without first consulting with the referring physician If the referring physician or the patient cannot be reached within 24 hours they shall notify the patient as soon as possible thereafter Radiation Oncology may not delay any appropriate medical care for the patient including any necessary remedial care as a result of the misadministration because of any delay in notification If the patient was notified a written report will be furnished to the patient within 15 days after discovery of the misadministration The report will either be a copy of the report that was submitted to MSDH or a brief description of both the event and the consequences as they may affect the patient If a letter describing the event and the consequences not the report submitted to MSDH is sent to the patient it will include a statement to the effect that a copy of the report submitted to MSDH will be made available to the patient if requested A copy of this report shall be provided to the referring physician within 15 days after discovery of the misadministration Radiation Oncology shall retain a record of each misadministration for five 5 years The record must contain the university s name and department the names of all individuals involved including the pre
136. ing x ray generating devices shall establish and make available to x ray technologist or operators written safety procedures including patient holding and any restrictions of the operating technique required for the safe operation of the particular x ray system The technologist or operator shall be familiar with these procedures Particular care should be taken to limit the useful beam to the smallest area consistent with clinical requirements and to align accurately the x ray beam with the patient and image receptor Sensitive body organs e g lens of the eye gonads should be shielded whenever they are likely to be exposed to the useful beam provided that such shielding does not eliminate useful diagnostic information or proper treatment Comment Gonadal shielding of not less than 0 5 millimeter lead equivalent material should be used for patients who have not passed the reproductive age during radiographic procedures in which the gonads are in the useful beam except for cases in which this would interfere with the diagnostic procedure However shielding should never be used as a substitute for adequate beam collimation and alignment Protection of the embryo or fetus during radiological examination or treatment of women known to be pregnant should be given special consideration When a patient must be held in place for radiography or fluoroscopy mechanical supporting or restraining devices should be used If an individual must physica
137. ioisotope settings Plot or log the results e Establish an action level or tolerance for each recorded measurement at which the individual performing the test will automatically notify the chief technician or authorized user of suspected malfunction of the calibrator 161 C University of Mississippi Medical Center These action levels are set at 1096 of the recorded values The regulations require repair or replacement if the error exceeds 10 percent 2 Inspect the instrument on a quarterly basis to ascertain that the measurement chamber liner is in place and that the instrument is zeroed according to the manufacturer s instructions Linearity means that the calibrator is able to indicate the correct activity over the range of use of that calibrator This test is done using a vial or syringe of Tc 99m whose activity is at least as large as the maximum activity normally assayed in a prepared radiopharmaceutical kit in a unit dosage syringe or in a radiopharmaceutical therapy whichever is largest a Decay Method 1 2 3 4 5 6 7 Assay the Tc 99m syringe or vial in the dose calibrator and subtract background to obtain the net activity in millicuries Record the date the time to the nearest minute and net activity This first assay should be done in the morning at a regular time for example 8 a m Repeat the assay about noon and again at 4 p m Continue on subsequent days until the assayed activit
138. ious thicknesses to test for linearity it will first be necessary to calibrate them 1 2 3 4 5 6 7 8 9 Begin the linearity test as described in the decay method described above After making the first assay the sleeves can be calibrated as follows Steps 2 through 4 below must be completed within 6 minutes Put the base and sleeve in the dose calibrator with the vial Record the sleeve number and indicated activity Remove sleeve 1 and put in sleeve 2 Record the sleeve number and indicated activity Continue for all sleeves Complete the decay method linearity test steps 2 through 7 above From the graph made in step 4 of the decay method find the decay time associated with the activity indicated with sleeve 1 in place This is the equivalent decay time for sleeve 1 Record that time with the data recorded in step 2 Find the decay time associated with the activity indicated with sleeve 2 in place This is the equivalent decay time for sleeve 2 Record that time with the data recorded in step 3 Continue for all sleeves The table of sleeve numbers and equivalent decay times constitutes the calibration of the sleeve set The sleeve set may now be used to test dose calibrators for linearity 1 2 3 4 5 6 7 Assay the Tc 99m syringe or vial in the dose calibrator and subtract background to obtain the net activity in millicuries Record the net activity Steps 3 t
139. is UMMC s policy to maintain worker exposure to sources of ionizing radiation as low as is reasonably achievable ALARA The permissible dose requirements of state and federal regulations will be followed with regard to worker exposures and exposures to members of the public These maximum allowable exposure values are provided below Adult Occupational Exposures Adults who are likely to receive an annual dose in excess of any of the following each evaluated separately will be required to wear a personal dosimetry device 5 mSv 0 5 rem deep dose equivalent 15 mSv 1 5 rems eye dose equivalent 50 mSv 5 rems shallow dose equivalent to the skin 50 mSv 5 rems shallow dose equivalent to any extremity Maximum permissible occupational exposures for adult employees are 50 mSv 5 rem deep dose equivalent 150 mSv 15 rems eye dose equivalent 500 mSv 50 rems shallow dose equivalent to the skin 500 mSv 50 rems shallow dose equivalent to any extremity Exposures to Minors Minors under the age of 18 who are likely to receive an annual dose in excess of any of the following each evaluated separately will be required to wear a personal dosimetry device 0 5 mSv 0 05 rem deep dose equivalent 1 5 mSv 0 15 rems eye dose equivalent 5 mSv 0 5 rems shallow dose equivalent to the skin 5 mSv 0 5 rems shallow dose equivalent to any extremity Page 15 of 185 University of Mississippi Medical Center Maximum permissible o
140. is to be posted with a sign stating Caution Radioactive Material No Food or Beverage May Be Stored In This Unit Each laboratory waste container used to temporarily store radioactive waste until transferred to a waste drum shall be labeled with a sign stating Caution Radioactive Material Do Not Empty Each sink used for liquid waste disposal or cleaning of contaminated glassware shall be posted with a sign stating Caution Radioactive Waste Disposal Sink Each room housing a x ray device used for research purposes shall 1 Be posted with a sign stating Caution X rays This Equipment Produces X rays When Energized 2 Have the device control panel labeled Caution X rays This Equipment Produces X rays When Energized Containers of radioactive materials must be labeled to identify the radioactive contents 1 The label must bear the radiation caution symbol and the words Caution or Danger Radioactive Material 2 Prior to the disposal of an empty uncontaminated container or relocation to unrestricted areas the radioactive material label must be removed or made illegible to indicate that the container no longer contains radioactive material The Radiation Safety Office must be contacted to verify that items in a restricted area are not contaminated prior to removing the label and relocation of the item to an unrestricted area Work Station Setup Each workstation where radioactive materials are used i
141. ived in any one month Excerpt from Centers for Disease Control web site article Possible Health Effects of Radiation Exposure on Unborn Babies 3 Excerpt from Centers for Disease Control web site article Possible Health Effects of Radiation Exposure on Unborn Babies Page 125 of 185 University of Mississippi Medical Center Higher radiation doses doses greater than that received from 500 chest x rays during sensitive stages of development between weeks 2 and 15 can cause birth defects The brain is particularly sensitive during this stage of development and brain damage may occur During the later stages of development weeks 16 25 effects from low doses of radiation exposure are unlikely Higher doses of radiation would be required to cause birth defects but the doses would have to be greater than about 5 000 chest x rays received at one time After the 26 week of gestation the radiation sensitivity of the unborn baby is similar to that of a newborn baby At the 26 week of pregnancy the unborn baby is fully developed though not fully grown This means that birth defects are not likely to occur and only a slight increase in the risk of having cancer later in life is expected Decisions During Pregnancy It is your responsibility to decide whether the risks to you or to your unborn child are acceptable It is up to you to compare the benefits of your employment against the possible risks involving occupational radiation ex
142. l be retained for three 3 years Page 154 of 185 13 14 University of Mississippi Medical Center Before a therapy patient s room is reassigned to another patient the room will be surveyed for contamination and decontaminated if necessary and all radioactive waste linen and contaminated equipment will be removed In accordance with The Regulations for Control of Radiation in Mississippi within six 6 to seventy two 72 hours after administration of a dose of liquid or gelatin capsule I 131 to a patient the thyroid burden of all personnel who helped prepare or administer the dose will be measured Retain a record of the bioassay for three 3 years The record will include a The name of the individual whose thyroid burden was measured b The measurement c The date of the measurement and d The initials of the individual who made the measurements Page 155 of 185 University of Mississippi Medical Center APPENDIX F Radioiodine Bioassay Procedure Page 156 of 185 University of Mississippi Medical Center RADIOIODINE BIOASSAY PROCEDURE Multi Channel Analyzer Calibration The Ludlum System Acquisition and Analysis Software and a Ludlum model 732 2x2 Nal probe is used to measure the thyroid burden for radioactive iodine The system will be calibrated annually Allow the system to warm up for about 30 minutes before proceeding with the calibration A Region of Interest The region of interest is
143. laboratories other researchers and visitors and b In some cases individuals not involved in the use of radioactive materials other students technicians or researchers share laboratories E The Radiation Safety Office shall perform quarterly surveys in each area using or storing radioactive materials Page 74 of 185 University of Mississippi Medical Center Each survey shall consist of a A measurement of radiation levels with a survey meter sufficiently sensitive to detect 0 1 mrem hr in exposure reading or to read in cpm or cps for surface contamination and or A series of wipe tests to measure removable contamination levels The method of performing wipe tests must be sufficiently sensitive to detect 200 dpm per 100 cm for the contaminant involved Results of these quarterly surveys will be documented and maintained in the Radiation Safety Office files Positive contamination findings will be reported to radioactive material users for action Quarterly surveys by the Radiation Safety Office are to be unannounced in order to accurately assess the safety precautions being taken in each area using or storing radioactive material a A representative of the Radiation Safety Office shall have access at any time to any area where radioactive materials are used or stored If the department or the radioactive material user wishes to provide an escort during these quarterly surveys the provision of such an escort or r
144. lations orders requirements and conditions of the Regulations for Control of Radiation in Mississippi Interlock A device used to assure proper and safe use of a radiation installation by monitoring usually by electrical devices the status presence or position of various associated devices such as source position collimator opening beam direction door closure filter presence and preventing the production or emission of radiation if the potential for an unsafe condition is detected Internal Dose That portion of the dose equivalent received from radioactive material taken into the body Investigational Level The level at which an intake shall be investigated beyond the initial bioassay measurement and the evaluation level precautions For I 125 this will be implemented at an uptake level of 6 uCi and for I 131 this will be implemented at an uptake level of 5 uCi Irradiation The exposure of a living being or matter to ionizing radiation Isotopes One of two or more atoms with the same atomic number same chemical element but with different atomic weights An equivalent statement is that the nuclei of isotopes have the same number of protons but different numbers of neutrons Isotopes usually have very nearly the same chemical properties but somewhat different physical properties Kerma The sum of the initial kinetic energies of all the charged ionizing particles liberated by uncharged ionizing particles per unit mass of as
145. licensed material is consistent with the ALARA philosophy and program Establish a table of investigational levels for individual occupational radiation exposures and Identify program problems and solutions The Radiation Safety Committee shall A Be familiar with all pertinent regulations the license application the license and amendments Review the training and experience of the proposed authorized users the Radiation Safety Officer and medical physicists to determine that their qualifications are sufficient to enable the individuals to perform their duties safely and are in accordance with the regulations and the license Review on the basis of safety and approve or deny consistent with the limitations of the regulations the license and the ALARA philosophy all requests for authorization to use radioactive material within the institution Prescribe special conditions that will be required during a proposed method of use of radioactive material such as requirements for bioassays physical examinations of users and special monitoring procedures Establish a program to ensure that all persons whose duties may require them to work in or frequent areas where radioactive materials are used e g nursing security housekeeping physical plant are appropriately instructed as required in the state regulations Review at least annually the Radiation Safety Office s summary report of the entire radiation safety program to
146. lly exposed worker is allowed to receive is 5 000 millirem per year Page 124 of 185 University of Mississippi Medical Center Individuals under the age of 18 and members of the general public are only permitted to be exposed to 500 millirem per year which is one tenth of the annual limit of an occupationally exposed adult The amount of radiation a fetus is allowed to receive is 500 millirem during the entire gestation period not to exceed 50 millirem in one month Prenatal Effects of Radiation As an individual whose occupation requires that you work directly with radiation sources or at times work in locations designated as restricted areas it is important that you have a basic understanding of potential biological effects to an unborn baby associated with prenatal radiation exposure The possibility of health effects depends on the gestational age of the unborn baby at the time of exposure and the amount of radiation it is exposed to Unborn babies are less sensitive to radiation during some stages of pregnancy than others Unborn babies are particularly sensitive to radiation during their early development between weeks 2 and 15 of pregnancy However since the baby is shielded by the mother s abdomen the radiation dose to the unborn baby is lower than the dose to the mother for most radiation exposure events A pregnant woman who accidentally swallows or breathes in radioactive materials may absorb that substance into her bloodstrea
147. lly hold the patient that individual shall be protected with appropriate shielding devices such as protective gloves apron and thyroid shield The individual should be so positioned that the useful beam will strike no part of the body and that the body is as far as possible from the edge of the useful beam Only persons whose presence is necessary shall be in the radiographic or fluoroscopic room during exposure All such persons shall don all appropriate protective apparel The x ray technologist or fluoroscopist shall stand behind the protective barrier during radiographic exposures The x ray technologist or fluoroscopist should use the maximum source to skin distance SSD consistent with medical requirements of the procedure Special care shall be taken to ensure adequate filtration in radiographic or fluoroscopic machines Page 60 of 185 University of Mississippi Medical Center Particular care shall be taken to ensure adequate filtration in any machine equipped with a beryllium window tube Appropriate added filter is required to provide the recommended filtration values Radiation source systems and imaging systems as well as film and xerographic processors should be subjected to appropriate quality assurance programs with documentation in order to minimize the unproductive application of radiation The image receptor used in a given radiographic examination should have the highest speed consistent with the diagnostic objec
148. ls the presence of 0 005 microcuries or more of removable contamination personnel shall a Immediately withdraw the sealed source from use and store it in a shielded container b Seal the source container in a plastic bag to prevent the spread of radioactive contamination and c Notify the Radiation Safety Office of the leaking source d The Radiation Safety Office will file a report with the MSDH DRH within five 5 days of receiving the leak test results revealing the presence of 0 005 microcuries or more of removable contamination The written report will include the model and serial number of the leaking source if assigned the radionuclide and its estimated activity the results of the test the date of the test and the action taken Leak tests are not required on the following sources a Sources containing only radioactive material with a half life of less than 30 days b Sources containing 100 microcuries or less of beta or photon emitting material or 10 microcuries or less of alpha emitting material and Page 36 of 185 University of Mississippi Medical Center c Sealed sources except teletherapy and brachytherapy sources which are stored not being used and identified as in storage However leak tests are required for each such source before any use or transfer unless it has been tested for leakage within six 6 months before the date of use or transfer Nuclear Medicine Nuclear Cardiology PET departments in
149. m From the mother s blood radioactive materials may pass through the umbilical cord to the baby or concentrate in areas of the mother s body near the womb such as the bladder and expose the unborn baby to radiation Unborn babies are especially sensitive to the cancer causing effects of radiation However the increased risks depend on the amount of radiation to which the baby was exposed and the amount of time that it was exposed For example if the radiation dose to the unborn baby was roughly equivalent to 500 chest x rays at one time the increase in lifetime cancer risk would be less than 296 above the normal lifetime cancer risk of 40 50 During the first 2 weeks of gestation the baby is made up of only a few cells Damage caused to one of these cells can have a greater impact at this delicate stage than during later stages of gestation when the baby has more cells and damage to one cell is not such a large fraction of the baby s body Damage to one of only a few cells can lead to the death of the baby before the mother even knows she is pregnant Of the babies that survive however few will have birth defects related to the exposure regardless of how much radiation they were exposed to The National Council on Radiation Protection and Measurement recommended in NCRP Report No 91 Recommendations on Limits for Exposure to Ionizing Radiation June 1 1987 that no more than 0 05 rem 0 5 millisievert to the embryo fetus be rece
150. minated trash resulting from decontamination in the appropriate radioactive waste container provided in the department waste collection area following the container instructions or contact the Radiation Safety Office for assistance and Report all spills that result in contaminated surfaces to the Radiation Safety Office Decontamination of Glassware For the decontamination of glassware and other washable containers these procedures are to be followed A Soak washable containers in a diluted decontamination solution and B Release rinse water into the sink drain rinse the container flush the inside surfaces of the sink with running water and survey or swipe the container if residual contamination is suspected repeat decontamination C Forlodine 125 contamination on glassware soaking in a strong bleach solution 5096 overnight has proven effective in reducing contamination levels Decontamination of Personnel For the decontamination of personnel these procedures are to be followed A General Procedures 1 Personnel decontamination shall be done only under the direct supervision of the Radiation Safety Office 2 Instruments used must be checked for proper operation and must be calibrated within the past year 3 Personnel assisting in decontamination shall use necessary precautions and protective clothing to prevent the spread of contamination to them or the surrounding area 4 Decontamination shall be performe
151. mits for members of the public B Records of the above surveys shall be retained for three 3 years Leak Test A The sealed source Ir 192 is tested for leakage before it is shipped from the manufacturer B The Medical Physicist will keep the sealed source certificate containing the leak test information on file in Radiation Oncology C The Medical Physicist or Radiation Safety Office shall verify that the source was tested within the previous six 6 months before shipment of the source back to the manufacturer for disposal D Theleak test records shall be retained for five 5 years Inventories A Radiation Oncology shall conduct a physical inventory of all sealed sources installed in the HDR afterloader and awaiting installation or shipment for disposal at intervals not to exceed three 3 months B The inventory records shall contain 1 The model number of each source 2 Serial number of the source if one has been assigned Page 39 of 185 D University of Mississippi Medical Center The identity of each source radionuclide and its nominal activity The location of each source Date of the inventory and Qu ivt nb O9 The signature of the Radiation Safety Officer The Medical Physicist shall annotate on the inventory any sealed source that is in storage and not being leak tested Inventory records shall be retained for three 3 years Quarterly Surveys A C The Medical Physicist shall su
152. n Safety Manual You may use that letter or write your own letter To declare my pregnancy do I have to have documented medical proof that I am pregnant NRC regulations do not require that you provide medical proof of your pregnancy However NRC regulations do not preclude the licensee from requesting medical documentation of your pregnancy especially if a change in your duties is necessary in order to comply with the 0 5 rem 5 mSv dose limit Can I tell the licensee orally rather than in writing that I am pregnant No The regulations require that the declaration must be in writing If I have not declared my pregnancy in writing but the licensee suspects that I am pregnant do the lower dose limits apply No The lower dose limits for pregnant women apply only if you have declared your pregnancy in writing The United States Supreme Court has ruled in United Automobile Workers International Union v Johnson Controls Inc 1991 that Decisions about the welfare of future children must be left to the parents who conceive bear support and raise them rather than to the employers who hire those parents The Supreme Court also ruled that your employer may not restrict you from a specific job because of concerns about the next generation Thus the lower limits apply only if you choose to declare your pregnancy in writing If I am planning to become pregnant but am not yet pregnant and I inform the licensee of that in writing do the
153. n a pancake probe and lower removable contamination levels can be determined with the use of smears or swipes of surfaces For detecting beta emitters with maximum beta energies of less than 150 keV such as H 3 a liquid scintillation counter is the only detector that can be used For surveying radiation sources which generate x or gamma rays with energies greater than 30 keV a GM pancake GM thin end window or a GM side window detector is usually adequate As mentioned above the pancake style is preferable since it has a Page 25 of 185 University of Mississippi Medical Center larger window surface area which assists in monitoring large areas for contamination However solid detectors i e NaI are usually much more efficient and may be more appropriate if very low levels of radiation need to be detected For surveying for radiation sources which generate x or gamma rays with energies less than 30 keV i e I 125 a thin window Nal scintillation detector is recommended A standard GM tube has very low efficiency for this energy range and should not be the primary survey instrument of choice Note If two probes are used for the same survey meter calibration with both probes is required Dose rate measurements for x and gamma radiation fields should be taken with ion chambers They have an energy independent response and are therefore recommended for any dose rate measurements Energy compensated probes for survey meters may be
154. n an individual receiving a dose equivalent in excess of 0 005 rem 0 05 millisievert in 1 hour at 30 centimeters from the source of radiation or from any surface that the radiation penetrates Radiation Detector A device which in the presence of radiation provides a signal or other indication suitable for use in measuring one or more quantities of incident radiation Radiation Safety Officer An individual who meets the requirements of the Regulations for the Control of Radiation in Mississippi Radioactive Material Any solid liquid or gas which emits radiation spontaneously Radioactivity The transformation of unstable atomic nuclei by the emission of radiation usually accompanied by the emission of ionizing radiation radiation that displaces electrons from atoms or molecules producing ions Radiograph An image receptor on which the image is created directly or indirectly by an x ray pattern and results in a permanent record Recording Producing a permanent form of an image resulting from x ray photons Registration Registration with MSDH Division of Radiological Health in accordance with the regulations adopted by MSDH DRH Rem A special unit of any of the quantities expressed as dose equivalent The dose equivalent in rem is equal to the absorbed dose in rad multiplied by the quality factor 1 rem 0 01 sievert Restricted Area An area access to which is limited by the licensee or registrant for the purpose of
155. n only be accessed through a cover requiring a tool for access or with electrical interlocks to prevent operation while open The high voltage transformer shall have appropriate safety labels warning personnel of potential electrical shock and or heat related injuries All electrical equipment shall follow Medical Electrical Equipment Standards or their revisions where appropriate particularly l 2 IEC 60601 1 1998 A1 A2 1995 Medical Electrical Equipment Part 1 General Requirements for Safety IEC 60601 1 2 2001 Medical Electrical Equipment General Requirements for Safety Collateral Standard Electromagnetic Compatibility Requirements and tests IEC 60601 2 8 1999 Medical Electrical Equipment Part 2 8 Particular requirements for the safety of therapeutic x ray equipment operating in the range from 10 kV to IMV IEC 60601 2 17 2004 Medical Electrical Equipment Part 2 17 Particular requirements for the safety of automatically controlled brachytherapy afterloading equipment Treatment unit Requirements A The control panel shall provide l 2 4 An indication of whether electrical power is available at the control panel and if activation of the x ray tube is possible An indication of whether x rays are being produced A means for indicating x ray tube potential and current and The means for terminating an exposure at any time A suitable irradiation control device shall be provided to terminate the irrad
156. n therapy the patient s identity shall be verified by more than one method as the patient named in the written directive The person responsible for administering the radiation will complete the verification by at least two of the following methods 169 14 15 University of Mississippi Medical Center a Asking the patient to state his her name b Comparing patient to a recent photograph of same c Asking the patient to state his her birth date d Asking the patient to state his her Social Security Number e Asking the patient to state his her address f Asking the patient for identification such as a driver s license Social Security card or similar g Checking the patient s wrist identification band for name birth date or UMMC ID number or h For patients unable to respond an accompanying relative or friend may attest to the identity Documentation of the verification of the patient s identity shall include the two 2 forms with which the patient was identified the date of the identification and the name of the person making the identification This record will be maintained for three 3 years The determination of which two identifiers to use shall be based on departmental policy that complies with all regulatory entities applicable to the Radiation Oncology treatment program If the information obtained from any two of these methods does not correspond to the information on the written directive the radiati
157. nal dosimeters or pocket dosimeters or detectors must be worn a 7 Tagthe following objects and fill out the tag door O bed O chart O a 8 Gloves must be worn while attending patient a 9 Patient must use disposable utensils a 10 All items must remain in room until approved by the Radiation Safety Office a 11 Smoking is not permitted Page 110 of 185 University of Mississippi Medical Center a 12 Room is not to be released for cleaning until approved by the Radiation Safety Office a 13 Other instructions No need to collect human waste dispose in toilet and flush 2 times No collection of fluid samples until notified by Nuclear Medicine IN CASE OF EMERGENCY CONTACT Nuclear Medicine at 601 952 5413 pager Radiation Safety Office at 601 984 1980 After Hours and Weekends see On Call Scheduling for Radiation Safety or contact Emergency Dispatch at 601 984 142 Page 111 of 185 University of Mississippi Medical Center EMERGENCY PROCEDURES FOR SPILLS INVOLVING RADIOACTIVE MATERIAL Minor Spills 1 2 3 Notify Notify persons in the area that a spill has occurred Prevent the Spread Cover the spill with absorbent paper Clean Up Use disposable gloves and remote handling tongs Carefully fold the absorbent paper and pad Insert into a plastic bag and dispose of in the radioactive waste container Also insert into the plastic bag all other contaminated materials such as disposable gloves Survey
158. nciples of Radiation Protection Employees can maintain ALARA exposures by practicing the basic principles of radiation protection 1 External Radiation Protection a Minimize time of exposure The less time you remain in a radiation field the smaller the dose you receive Perform the procedure or experiment or work with radioactive patients as quickly and as efficiently as possible without increasing the probability of a spill or other accident b Maximize the distance from the source The dose rate for most gamma and x ray radiation varies with the inverse square of the distance from a point source Therefore the farther you position yourself from the source of radiation the smaller the dose you receive For example doubling the distance from a radiation source will result in 1 4 the exposure in the same amount of time Using remote controls on x ray devices remote handling devices such as forceps tongs and tube racks standing across the room from a patient when direct contact is not needed etc will help minimize exposures to radiation Even a small increase in distance can result in a dramatic decrease in dose rate c Shield the source of radiation Place shielding between yourself and a source of penetrating radiation to decrease your dose For Low energy beta emitters such as H C P and 35S shielding is not necessary For high energy beta emitters P Y acrylic is the shielding material of choice For gamm
159. nformation on request NRC s Regulatory Guide 8 29 Instruction Concerning Risks from Occupational Radiation Exposure and NRC s Regulatory Guide 8 13 Instruction Concerning Prenatal Radiation Exposure is on file and can be copied for you Page 130 of 185 University of Mississippi Medical Center APPENDIX B UMMC ALARA Program Page 131 of 185 University of Mississippi Medical Center UMMC ALARA PROGRAM The radiation safety program at UMMC will be conducted in such a manner that exposure to faculty staff students visitors patients not receiving radiation treatments or therapies the public and the environment will be As Low As Reasonably Achievable Our ALARA program depends on the cooperation of the Radiation Safety Committee the Radiation Safety Office Institutional Management and all users of ionizing radiation The ALARA program complies with the requirements of federal and state regulations Duties of Management and Workers The Radiation Safety Manual clearly defines the duties of management and workers The Radiation Safety Manual can be located on the Environmental Health and Safety site on the UMMC Intranet Interdepartmental programs define more job specific duties as necessary Itis the responsibility of departmental supervisors or management to insure this document is available and reviewed by employees Management Commitment l The management and administration of University of Mississippi Medical Center UM
160. ng to isotopes atomic structure radiochemistry radiobiology radiation generating devices x rays or gamma rays etc RADIOACTIVE MATERIALS PREVIOUSLY USED ISOTOPE ACTIVITY LOCATION DATES USED FOR Page 100 of 185 University of Mississippi Medical Center Have you ever been listed as an authorized user on a radioactive materiallicense Yes No If yes provide facility name address ISOTOPES REQUESTED FOR USE AT UMMC ISOTOPE ACTIVITY PURPOSE RADWASTE Radwaste generated is either one or a combination of L non hazardous liquids C chemicals B biological S solids LSV liquid scintillation vials List the locations where radioactive materials will be used building and room number Provide a sketch of these locations indicating areas used for isotope work and storage Number various locations on this sketch to indicate the position of lab survey points in areas where isotopes are used Survey frequency will be established later by UMMC Radiation Safety Office List the survey meter or other counting equipment to be used for lab surveys manufacturer model number and serial number RADIATION DEVICES X RAY OR GAMMA PREVIOUSLY USED DEVICE USED WHERE USED DURATION SUPERVISOR REQUESTED USE OF RADIATION DEVICES X RAY OR GAMMA DEVICE LOCATION PURPOSE OTHERS TO BE Name Model Serial Room Dept SUPERVISED Page 101 of 185 University of Mississippi Me
161. nistration Surveys of the patient s room and surrounding areas will be conducted as soon as practicable after administration of the treatment dose Exposure rates will be measured at the patient s bedside at one 1 meter away and at the entrance to the room The Radiation Safety Office will then record these readings on the form Nursing Instructions for Patients Treated with Iodine 131 Phosphorus 32 or Gold 198 and the form will be posted outside the patient s room immediately after administration of the treatment dose Visitors will not be allowed inside the patient s room after the administration of the radiopharmaceutical without prior approval and supervision of the Radiation Safety Office Radiation levels in unrestricted areas will be monitored to ensure the radiation levels do not exceed the exposure limits set in the regulations for individual members of the public Do not release any patient until either the exposure rate from the patient is less than seven 7 millirem per hour at one 1 meter or the retained radioactivity is less than 33 millicuries Patients may be released with dose rates greater than 7 millirem per hour at 1 meter and activities greater than 33 millicuries following the guidelines for patient release in NUREG 1556 Vol 9 Appendix U Model Procedure for Release of Patients or Human Research Subjects Administered Radioactive Materials Records of releases of patients administered radiopharmaceuticals shal
162. nitor the position of all persons in the treatment room and all persons entering the treatment room to prevent entering persons from unshielded exposure from the treatment beam Page 55 of 185 University of Mississippi Medical Center The electronic brachytherapy unit shall be inoperable either by hardware or password when unattended by qualified staff or service personnel A copy of the current operating and emergency procedures shall be physically located at the electronic brachytherapy unit control console Written procedures shall be developed implemented and maintained for responding to an abnormal situation These procedures shall include 1 Instructions for responding to equipment failures and the names of the individuals responsible for implementing corrective actions and 2 The names and telephone numbers of Authorized Users Authorized Medical Physicists and the Radiation Safety Officer to be contacted if the unit or console operates abnormally If a patient must be held in position during treatment mechanical supporting or restraining devices shall be used The Radiation Safety Office and an Authorized User shall be notified as soon as possible if the patient has a medical emergency suffers injury or dies The Radiation Safety Office or the Authorized Medical Physicist shall inform the manufacturer of the event X ray Source Calibration Measurements A Validation of the electronic brachytherapy x ray source
163. nnel the patient and the patient s referring physician the patient s Social Security Number or medical record number a brief description of the event why it occurred the effect on the patient the actions taken or planned to prevent recurrence whether the authorized user notified the patient or their responsible relative or guardian and if not whether such failure to notify was based on the guidance from the referring physician D ANNUAL REVIEW There shall be an annual review of the Quality Management Program to determine its effectiveness 1 The review will include from the previous 12 months a randomly selected representative sample of patient administrations and all misadministrations a For each patient case reviewed a comparison shall be made between what was prescribed in the written directive and what was actually administered It shall be determined whether the administered radiation dose was in accordance with the written directive in terms of treatment site procedure isotope fractional dose or total dosage b For each patient case reviewed any deviations from the written directive shall be identified along with the cause of each if possible and the action taken to prevent recurrence c When a misadministration is uncovered during the periodic review of the QMP the number of cases included in the review will be expanded The records of each review will be retained for three 3 years These records shall
164. nstalled in a fixed location X Ray System An assemblage of components for the controlled production of x rays It includes minimally an x ray high voltage generator an x ray control a tube housing assembly a beam limiting device and the necessary supporting structures Additional components that function with the system are considered integral parts of the system X Ray Tube Any electron tube that is designed to be used primarily for the production of x rays Page 98 of 185 University of Mississippi Medical Center ATTACHMENTS Page 99 of 185 University of Mississippi Medical Center APPLICATION FOR AUTHORIZATION TO USE RADIOACTIVE MATERIALS OR RADIATION GENERATING DEVICES FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES Name Department Employee ID Campus Email Title Telephone Requesting use of Radioactive Materials Devices Authorization requested Regular or Temporary until experience documented If temporary authorization requested Supervisor Name Department EDUCATIONAL BACKGROUND TYPE OF INSTRUCTION LOCATION DATES HOURS ON THE JOB FORMAL TRAINING INSTRUCTIO mE YES NO YES NO NO Principles practices of radiation safety Radioactivity monitoring YES NO YES l technique and instruments Mathematics basic to the use YES NO YES NO of radiation Biological effects of radiation YEs NO FORMAL TRAINING COURSES List all formal courses pertaini
165. nt to talk to your supervisor or your radiation safety office and ask what a declaration of Page 128 of 185 10 11 12 13 University of Mississippi Medical Center pregnancy would mean specifically for you and your job status In many cases you can continue in your present job with no change and still meet the dose limit for the embryo fetus For example most commercial power reactor workers approximately 93 receive in 12 months occupational radiation doses that are less than 0 5 rem 5 mSv Ref 11 The licensee may also consider the likelihood of increased radiation exposures from accidents and abnormal events before making a decision to allow you to continue in your present job If your current work might cause the dose to your embryo fetus to exceed 0 5 rem 5 mSv the licensee has various options It is possible that the licensee can and will make a reasonable accommodation that will allow you to continue performing your current job for example by having another qualified employee do a small part of the job that accounts for some of your radiation exposure What information must I provide in my written declaration of pregnancy You must provide in writing your name a declaration that you are pregnant the estimated date of conception only the month and year need be given and the date that you give the letter to the licensee A Declaration of Pregnancy form letter that you can use is included in the UMMC Radiatio
166. nt will be located and checked before each HDR afterloader treatment A set of written emergency instructions shall be posted at the HDR afterloader operator console These instructions shall inform the operator of the procedures to be followed if the source fails to return to the shielded position See emergency procedures Training Training on the HDR afterloader will be performed before initiation of treatment and annually thereafter This training will include A key controls Page 43 of 185 j j J K LE QA H Mm U A W University of Mississippi Medical Center console operations catheters and applicators video and intercom systems door interlocks radiation monitors survey meter usage battery backup systems drills of the emergency procedures emergency equipment emergency contacts Plan and Administration of Treatment A A plan of treatment is made for each patient B A separate individual from the individual who performed the calculations checks each plan for accuracy and compliance with the written directive of the Radiation Oncologist C The separate check shall verify that each treatment is in accordance with the written directive of the Radiation Oncologist and shall be done by the Medical Physicist Dosimetrist or a Radiation Therapist D Any deviation from the written directive is identified and appropriate action for correction is taken immediately E A chart review is done weekly to veri
167. nuclides in clinical use C Records of these checks shall include 1l The model and serial number of the dose calibrator Page 27 of 185 D University of Mississippi Medical Center 2 The identity and calibrated activity of the radionuclide contained in the check source The date of the check The activity measured The instrument settings and Daa AP D The initials of the individual who performed the check Records of these checks shall be retained for three 3 years Accuracy Checks A D Testing each dose calibrator for accuracy is required upon installation and at intervals not to exceed 12 months thereafter Checks are completed by assaying at least 2 sealed sources containing different radionuclides the activity of which the manufacturer has determined to be within 5 percent of the stated activity with minimum activity of 50 microcuries and energies representative of the radionuclides in clinical use Records shall include 1l The model and serial number of the dose calibrator The model and serial number of each source used The identity of the radionuclide contained in the source and its activity The date of the test The results of the test The instrument settings and HOO n Bopp OM The signature of the Radiation Safety Officer Records of each accuracy test shall be retained for three 3 years Linearity Checks A Testing of each dose calibrator for linearity is required
168. o declare my pregnancy No The choice whether to declare your pregnancy is completely voluntary If you choose to declare your pregnancy you must do so in writing and a lower radiation dose limit will apply to your embryo fetus If you choose not to declare your pregnancy you and your embryo fetus will continue to be subject to the same radiation dose limits that apply to other occupational workers If I declare my pregnancy in writing what happens If you choose to declare your pregnancy in writing the licensee must take measures to limit the dose to your embryo fetus to 0 5 rem 5 millisievert during the entire pregnancy This is one tenth of the dose that an occupational worker is allowed receive in a year If you have already received a dose exceeding 0 5 rem 5 mSv in the period between conception and the declaration of your pregnancy an additional dose of 0 05 rem 0 5 mSv is allowed during the remainder of the pregnancy In addition 10 CFR 20 1208 Dose to an Embryo Fetus requires licensees to make efforts to avoid substantial variation above a uniform monthly dose rate so that all the 0 5 rem 5 mSv allowed dose does not occur in a short period during the pregnancy This may mean that if you declare your pregnancy the licensee may not permit you to do some of your normal job functions if those functions would have allowed you to receive more than 0 5 rem and you may not be able to have some emergency response responsibilities
169. o reduce exposure C Ifthe sources are present the patient s room will be posted Caution Radioactive Materials D A survey will be performed on the patient with the sources in place to see if additional postings such as Caution Radiation Area are required E Posting requirements will remain in effect until all sources have been removed from the room and a survey has been performed on the patient and the room Patient Surveys A The patient will be surveyed by the Medical Physicist or Radiation Safety Office to ensure a baseline radiation level prior to administration of the brachytherapy treatment Be aware that a nuclear medicine study may have been performed prior to treatment Immediately after implanting sources in a patient the Medical Physicist or Radiation Safety Office shall make a radiation survey of the patient The results of this survey shall be posted outside the patient s room on the form Nursing Instructions for Patients Treated with Brachytherapy Sources Exposure rate measurements will be taken at the patient s bedside one meter from the patient and at the entrance to the room Promptly after implanting the sources the Medical Physicist or Radiation Safety Office will survey the exposure rates in contiguous restricted and unrestricted areas with a radiation measurement survey instrument to demonstrate compliance with the regulations for personnel exposure within the limits for adult occupational workers or in
170. of Authorized User Date of Disposal Radioisotope Estimated Amount mCi Disposal Method Page 117 of 185 University of Mississippi Medical Center ANIMAL DISPOSAL INSTRUCTIONS This notice explains in greater detail the proper method for disposing of animal carcasses contaminated with radioactive material The UMMC Radiation Safety Manual which is part of the UMMC Radioactive Material License issued by the State Department of Health describes this process with greater detail Disposals not complying with these instructions will be tracked to the researcher and returned for proper packaging and tagging Note Only animal carcasses parts and tissue containing radioisotopes are to be placed in the 8 floor freezer units marked Caution Radioactive Material NO BLOOD OR OTHER VIALS SYRINGES NEEDLES GLOVES ETC ARE TO BE PLACED IN THESE UNITS l Double bag all animal carcasses in re biowaste bags and remove any excess air Ensure that the bag is tightly sealed 2 Remove a Caution Radioactive Material tag from the pouch taped to the front of the freezer unit 3 Using a durable marking pen legibly print the following Isotope Amount injected into animal Date isotope was injected Principal Investigator s name Department Note Use mCi for millicuries and uCi for microcuries 4 Attach the tag to the plastic bag by looping the string around the neck of
171. of sources returned to storage 9 The patient s name 10 The room number of use 11 The time and date they were returned to storage 12 The number and activity of sources in storage after the return and 13 The initials of the individual who returned the sources to storage 14 If any discrepancies exist between the inventory record and the number of sources in use and in storage the Radiation Safety Office shall be notified immediately 15 Radiation Oncology shall maintain the inventory records for three 3 years Quarterly inventories Radiation Oncology shall conduct a physical inventory of all brachytherapy sources at intervals not to exceed three 3 months The inventory records shall contain l The model number of each source 2 Serial number if one has been assigned 3 The identity of each source radionuclide and its estimated activity 4 The location of each source 5 Date of the inventory and Page 47 of 185 University of Mississippi Medical Center 6 The signature of the Radiation Safety Officer 7 Radiation Oncology shall retain each inventory record for three 3 years 8 The Medical Physicist shall annotate on the inventory any sealed source that is in storage and not being leak tested Accountability Brachytherapy sources shall be stored in a secure storage area Radiation Oncology shall maintain accountability for all brachytherapy sources at all times whether in storage or use Leak T
172. on Safety Office 3 Put on gloves 4 Swipe the outer surface of the container and measure the swipe activity with a thin window GM tube survey meter If greater than twice background levels take corrective actions as applicable 5 Open the outer package following manufacturer s directions if supplied and remove packing slip Verify the contents using the packing slip and check the integrity of the inner container by inspecting for breakage of seals loss of contents or discoloration of packaging material 6 Swipe the external surface of the inner container and measure the activity of the swipe with a thin window GM tube survey meter If greater than twice background levels stop and take corrective actions as applicable Swipes of packages containing H 3 and C 14 should be analyzed using a liquid scintillation counter LSC Documentation of Package Surveys A record of the results of all package surveys and corrective actions taken if necessary shall be made These records shall be made available for review by the Radiation Safety Office and MSDH DRH for three 3 years SURVEY INSTRUMENTATION All areas where radioactive materials are used or stored must have access to survey instrumentation This instrumentation must be maintained in proper working condition or taken out of service and replaced All survey meters must be registered with the Radiation Safety Office Calibration Survey meters must be calibrated with a r
173. on dose SHALL NOT be administered until conclusive verification of the patient s identity is obtained A Medical Physicist or Medical Dosimetrist and Radiation Therapist shall read the written directive before preparing or administering the radiation dose If any portion of the written directive is unclear he she must contact the specific authorized user who provided the written directive for clarification Any unusual fractionation pattern will precipitate a discussion between all parties involved to assure complete understanding of the written directive and corresponding treatment plans a The radiation dose shall not be administered until the intent of the written directive is thoroughly understood by the Medical Physicist or Medical Dosimetrist and Radiation Therapist If the person reviewing the dose is different from the person administering the dose both shall read and understand the written directive b The Medical Physicist or Medical Dosimetrist and Radiation Therapist shall verify that the specific details of the administration i e isotope treatment site procedure total dose number of fractions are in accordance with the written directive Following the administration of the radiation dose a dated and signed note shall be entered into the patient s treatment chart documenting the administration and dosage Any therapeutic administration must be recorded into the patient s 170 16 17 18 University of Mississip
174. on factors are greater than 1 05 or less than 0 95 or if any data points lie outside the 5 percent error lines it will be necessary to make a correction table or graph that will allow you to convert from indicated activity to true activity If this is necessary be sure to label the table or graph syringe geometry dependence and note the date of the test and the model number and serial number of the calibrator 164 University of Mississippi Medical Center To test the geometry dependence for a 30 cc glass vial draw 1 0 cc of the Tc 99m solution into syringe and then inject it into the vial Assay the vial Record the volume and millicuries indicated Remove the vial from the calibrator and using a clean syringe inject 2 0 cc of non radioactive saline or tap water and assay again Record the volume and millicuries indicated Repeat the process until you have assayed a 19 0 cc volume The entire process must be completed within 10 minutes Select as a standard the volume closest to that normally used for mixing radiopharmaceutical kits For all the other volumes divide the standard millicuries by the millicuries indicated for each volume The quotient is a volume correction factor Alternatively you may graph the data and draw horizontal 5 percent error lines above and below the chosen standard volume If any correction factors are greater than 1 05 or less than 0 95 or if any data points lie outside the 5 percent error line
175. on normally is not necessary when using image intensifiers Extraneous light that interferes with the fluoroscopic examination shall be eliminated Mobile Equipment In addition to the above mentioned general procedures mobile equipment has a few specific guidelines that should be followed any time radiography or fluoroscopy is being performed A Whenever possible the x ray technologist or operator shall stand at least 2 m 6 ft from the patient the x ray tube and the useful beam during radiographic procedures Measurements of mobile fluoroscopic tabletop and or patient entrance air kerma rates shall be made by a qualified expert and documented at least annually Comment Fluoroscopic air kerma rate measurements are especially necessary on apparatus employing imaging devices in which brightness is automatically controlled Such measurements require the use of an attenuation block in the fluoroscopic beam The air kerma rate used in mobile fluoroscopy should be as low as is consistent with the fluoroscopic requirements and should not normally exceed 5 rad min 5 cGy min measured in air at the position where the beam enters the patient Mobile equipment should be used only for examinations when it is not practical to transfer patients to fixed radiographic or fluoroscopic installations The responsible medical supervisor shall assure that operators of mobile equipment understand the proper use and limitations of the equipment to a
176. opharmaceuticals and Doses in Excess of 30 Microcuries of Sodium Iodide NaI I 131 A OBJECTIVE The objective of this Quality Management Program QMP is to provide high confidence that radioactive material or radiation from radioactive material will be administered as directed by the authorized user and thereby eliminate misadministrations AUTHORITY AND RESPONSIBILITY The authority and responsibility to establish and implement this Quality Management Program shall be given to the Nuclear Medicine Nuclear Cardiology and PET CT Departments and the Radiation Safety Office Directives contained herein are added to the existing Department Procedures and the facility ALARA Program POLICY This policy is for the administration of radiopharmaceutical therapies and sodium iodide Nal I 131 in amounts greater than 30 microcuries at UMMC A written directive means an authorized user s written order for the administration of radioactive material or radiation from radioactive material to a specific patient or human research subject l A written directive must be dated and signed by an authorized user prior to administration of I 131 sodium iodide greater than 30 uCi or any therapeutic dosage of radioactive material or any therapeutic dose of radiation from radioactive material 2 The written directive must contain the patient s name the pharmaceutical isotope dosage and route of administration Note The above mentioned information is
177. osimetry devices for departmental employees See Order Terminate Form and Occupational Exposure History Form B Maintaining copies of departmental exposure reports C Posting copies of exposure reports or making them available to all employees within the department D Distributing dosimetry devices to departmental employees as they are provided by the Radiation Safety Office from the vendor E Collecting dosimetry devices from departmental employees to return to the Radiation Safety Office for shipment to the vendor for processing F Keeping control badges in low background areas and assuring the controls are returned to the vendor with the appropriate personnel badges Page 16 of 185 University of Mississippi Medical Center Issuing spare badges to new employees or employees who have reported losing a badge maintaining a record of which employees the spare badges were issued to and when and providing the Radiation Safety Office with this information Notifying the Radiation Safety Office upon termination of employees receiving personal dosimetry devices using the Order Terminate Form and Forwarding any requests for employee radiation exposure histories from employers or employees to the Radiation Safety Office for action Individuals issued personal dosimetry devices must A B Wear the personal dosimetry devices in appropriate locations and conditions Wear only the dosimetry device assigned specif
178. output shall be performed by or under the personal supervision of an Authorized Medical Physicist Calibration validation measurements shall be made for each x ray tube or after any repair affecting the x ray beam generation or when indicated by the spot checks Calibration validation must include as applicable determination of 1 The output within 2 96 of the expected value if applicable or determination of the output if there is no expected value 2 Timer accuracy and linearity over the typical range of use 3 Proper operation of back up exposure control devices 4 Evaluation that the relative dose distribution about the source is within 5 of that expected and 5 Source positioning accuracy to within 1 millimeter within the applicator The validation of the output shall be completed with a calibrated dosimetry system that has been calibrated by the National Institute for Standards and Technology NIST or by an American Association of Physicists in Medicine AAPM Accredited Dosimetry Calibration Laboratory ADCL The calibration shall have been performed within the previous 24 months and after any servicing that may have affected system calibration Page 56 of 185 University of Mississippi Medical Center Required calibration measurements shall be completed in accordance with any current recommendations from a recognized national professional association such as the American Association of Physicists in Medicine fo
179. oxicity H 3 Kr 85 Tc 99m Using the data supplied by the user the Radiation Safety Office will determine the maximum activity of the isotopes that can be used and any special requirements necessary for safe operation Research laboratories actively using radioactive materials will be surveyed no less than once a month An authorized user who is not actively using radioactive materials must enter No Materials Used under surveys in the EHS RAM inventory software interface Procedures for performing area surveys in research laboratories Page 73 of 185 University of Mississippi Medical Center A Frequent surveys are very important when an authorized user is performing a new task or working with a new isotope or compound The more frequent the surveys the better informed the user is of the work environment B Area surveys shall be performed during use when the work is completed prior to break periods and or at the end of the day Documentation of such surveys will be required C Personnel monitoring surveys of individual s working with the radioactive material shall also be performed during use when the work is completed prior to leaving the workstation prior to break periods and or at the end of the day D The weekly and monthly survey shall be performed by the radioactive material user or their designee and depending on the isotope characteristics shall consist of l A measurement of radiation levels with a
180. patient Comment The fluoroscopist should be aware of the air kerma levels associated with the various modes of operation In procedures where spot image cameras are used and where multiple images are easily obtained this operator must be fully aware of the manner in which exposures are made and must exercise great care to assure that only required exposures are made Non intensified fluoroscopy shall not be used Page 62 of 185 I University of Mississippi Medical Center Where fluoroscopy is performed with an undertable image intensifier and overhead tube palpation shall be achieved only with mechanical devices The fluoroscopist s eyes should be sufficiently dark adapted for the visual task required before commencing fluoroscopy Under no circumstances should the fluoroscopist attempt to compensate for inadequate adaptation by increasing the exposure factors employed or by prolonging the fluoroscopic examination Comment The perception of detail under conditions of scotopic vision requires retinal adaptation The adaptation time necessary for the competent performance of a specific visual task depends on the nature of the task itself the per exposure Iuminance level and color the conditions of adaptation and a number of other physiological factors While wearing red goggles for 10 minutes will usually satisfy adaptation requirements in fluoroscopy no specific adaptation period can be recommended for all situations Dark adaptati
181. pi Medical Center permanent medical record These records must be retained for at least three 3 years Department procedures shall contain protocols for all radiopharmaceutical brachytherapy and external beam radiation therapies and be available for review A Medical Physicist or Medical Dosimetrist and Radiation Therapist shall refer to the protocols during any non routine procedure or in any case in which the protocol is not completely familiar to them The Department Chair shall approve any change in protocol before that change is implemented and always before the change is incorporated into the procedure manual Medical Dosimetrist and Radiation Therapists shall be instructed in the change before it is implemented The Medical Physicist shall review and approve the policy and procedure manual on a yearly basis If a deviation from the written directive is identified such as a misadministration or recordable event an investigation of the incident shall be made Documenting and reporting of the unintended deviation shall be in accordance with the reporting requirements of the Regulations for Control of Radiation in Mississippi Recordable Event The Radiation Safety Office shall be contacted immediately upon determination that a recordable event has occurred Within 30 days after discovery of any recordable event the following shall be done a Assemble the relevant facts including the cause of the event b Identifying what if
182. plemented at an uptake level of 1 2 uCi and for I 131 this will be implemented at an uptake level of 1 uCi Exposure Being exposed to ionizing radiation or to radioactive material Exposure rate Exposure per unit of time such as roentgen per minute and milliroentgen per hour External dose That portion of the dose equivalent received from any source of radiation outside the body Extremity Hand elbow arm below the elbow foot knee and leg below the knee Field Emission Equipment Equipment which uses an x ray tube in which electron emission from the cathode is due solely to the action of an electric field Filter Material placed in the useful beam to absorb preferentially selected radiations Gamma Rays High energy short wavelength radiation Gamma radiation frequently accompanies alpha and beta emissions and always accompanies fission Gamma rays are very penetrating and are best stopped or shielded against by dense materials such as lead or depleted uranium Gamma rays are essentially similar to x rays but are usually more energetic and are emitted from the atom s nucleus Geiger Mueller Counter Often referred to as a survey meter it is a radiation detection instrument named for H Geiger and W Mueller When ionizing radiation passes through the gas in the tube a pulse of electrons is created which passes through an external electrical circuit and is counted The dial on the instrument can usually be read in counts pe
183. posure to a known or potential unborn child You should know that the Pregnancy Discrimination Act an amendment of Title VII of the Civil Rights Act of 1964 states that women affected by pregnancy childbirth or related medical conditions shall be treated the same for all employment related purposes including receipt of benefits under fringe benefit programs as other persons not so affected but similar in their ability or inability to work In addition the Equal Employment Opportunity Commission a Federal agency is responsible for examining cases for compliance with this Act Some facts listed below may be helpful in making this decision The first 3 months of pregnancy are the most important so you should make your decision early In most work situations the actual dose received by an unborn child would be less than the dose you would receive yourself because some of the dose would be absorbed by your body The dose to the unborn child can be reduced where possible by Decreasing the amount of time you spend in an area where you will be exposed to radiation Increasing the distance between yourself and the source of radiation and Shielding your abdominal area If you do become pregnant you can ask your employer to reassign you to areas involving less exposure to radiation for the duration of your pregnancy When your occupational exposure is below the 5 rems per year limit the risk to an unborn child is small in r
184. propriate containers were applicable a A sharps container labeled Caution Radioactive Material If necessary two separate containers will be utilized One for isotopes with half lives less than 120 days and one for isotopes with half lives greater than or equal to 120 days Sufficient durable fiber board boxes or other lidded containers with plastic liners and Caution Radioactive Material labels to sort waste as needed for the central collection drum until transfers to these waste drums can be made Radioactive waste containing vials with biological wastes blood and other fluids shall be bagged and taken to central collection drums immediately to reduce odor in laboratories Plastic red biowaste bags for double bagging animal carcasses and tissue If research generates non aqueous hazardous fluids not contained in vials mixed with radioisotopes an appropriate sealable container labeled Caution Radioactive Materials will be required for collection of hazardous radioactive mixtures Since this liquid may be required to be solidified prior to disposal non hazardous solutions suitable for sewage disposals are strongly recommended to reduce disposal costs One fiberboard box or other appropriate container with a plastic liner marked for disposal of uncontaminated broken glassware as ordinary trash Broken glassware Page 83 of 185 University of Mississippi Medical Center or uncontaminated sharps shall not be place
185. protecting individuals against undue risks from exposure to sources of radiation Roentgen A special unit of exposure One roentgen R equals 2 58 x 10 coulomb per kilogram in air see Exposure Page 96 of 185 University of Mississippi Medical Center Scattered Radiation Radiation that during passage through matter has been deviated in direction See Direct Scattered Radiation Shallow Dose Equivalent Hs The external exposure of the skin or an extremity which is defined as the dose equivalent at a tissue depth of 0 007 centimeter 7 mg cm averaged over an area of 1 square centimeter Shutter A device attached to the tube housing assembly which can totally intercept the entire cross sectional area of the useful beam and which has a lead equivalency not less than that of the tube housing assembly SI The abbreviation for the International System of Units Sievert Sv The SI unit of any of the quantities expressed as dose equivalent The dose equivalent in sievert is equal to the absorbed dose in gray multiplied by the quality factor 1 sievert 100 rems Source to Skin Distance SSD means the distance between the source and the skin entrance plane of the patient Survey An evaluation of the radiological conditions and potential hazards incident to the production use transfer release disposal or presence of sources of radiation When appropriate such evaluation includes but is not limited to tests physi
186. providing a reference for comparison against previous and subsequent operational checks The manufacturer an authorized consultant an outside firm or the licensee shall perform calibrations Each calibrated survey meter will possess a calibration certificate on file in the Radiation Safety Office A copy of the calibration certificate will be supplied to the instrument user if requested Choosing Appropriate Instrumentation A All meters will not detect all radioisotopes The following guidelines are designed to assist in selecting meters that are appropriate for detecting various types of radiation For detecting beta emitters with maximum beta energy of greater than or equal to 150 keV such as C 14 S 35 or P 32 use of the following are recommended 1 A portable meter with a GM tube is required for personnel surveys and continuous surveying throughout procedures requiring the use of radiation A Geiger Mueller GM with a maximum window thickness of 1 7 mg cm is required Pancake style GM s are recommended over thin end window GM s because pancake style GM s are generally more efficient for low energy beta emitters such as C 14 or S 35 and the pancake s larger window surface area makes it easier to monitor large areas for contamination 2 Surveys of laboratory surfaces as required monthly can be completed with the use of a liquid scintillation counter The efficiency of a liquid scintillation counter is generally higher tha
187. quires that all commercial and non commercial shippers have documentation indicating that recipients are authorized to possess the type and quantity of radioactive material requested Presently all companies providing radioactive materials to UMMC possess a copy of the facility s broad scope license Copies of this license will be sent to all suppliers upon request UMMC will request a copy of all commercial and non commercial entities radioactive material license s before shipping any radioactive materials to the entity Radioactive materials are classified as hazardous materials and are subject to the federal and state requirements regarding the tracking of hazardous materials This is accomplished by using a computer generated list of all radioactive materials ordered and shipped to UMMC from suppliers In order to maintain this computer receipt list and facility inventory the following procedures must be observed when completing a standard purchase requisition to order radioactive material Procedures for Purchasing Radioactive Materials A Radioactive material purchase order requisitions must identify the isotope i e Tc 99m T1 201 I 131 etc and the activity expressed in millicuries mCi or microcuries uCi If this information is not readily available to the Radiation Safety Office via Lawson a phone call or email will be generated in order to determine the activity and isotope being ordered B Ifthe order is being placed in
188. r electronic brachytherapy when available Equivalent alternative methods are acceptable In the absence of a protocol by a national professional association published protocol included in the device manufacturer s operator s manual should be followed Routine and Day of Use Periodic Spot checks for Electronic Brachytherapy Units A A program to perform spot checks of each electronic brachytherapy facility and on each unit is required 1 At the beginning of each day of use of an electronic brachytherapy unit 2 Each time the unit is moved to a new room or site and 3 After each x ray tube installation The Authorized Medical Physicist will establish written procedures for performing the spot checks 1 The Authorized Medical Physicist need not personally perform the spot check measurements but maintains the responsibility for general supervision of the spot checks 2 f performed by someone else the Authorized Medical Physicist will review the results of each spot check within 2 days 3 Arecord of the results of the spot check shall be retained for three 3 years 4 The Authorized Medical Physicist shall notify the Authorized User as soon as possible in writing of any failures detected during the spot checks If the results of the checks indicate the malfunction of any system clinical use of the system shall be halted until repair A record of each check shall be retained for three 3 years Spot checks of safety devi
189. r minute counts per second or mR per hour Gonad Shield A protective barrier for the testes or ovaries Gray Gy The SI unit of absorbed dose One gray is equal to an absorbed dose of 1 joule per kilogram 100 rads Half life Often referred to as physical half life this is the time required for a radioactive substance to lose 50 of its activity by decay High Radiation Area An area accessible to individuals in which radiation levels from radiation sources external to the body could result in an individual receiving a dose equivalent in excess of 0 1 rem 1 millisievert in 1 hour at 30 centimeters from any source of radiation or 30 centimeters from any surface that the radiation penetrates Page 93 of 185 University of Mississippi Medical Center Image Intensifier A device installed in its housing which instantaneously converts an x ray pattern into a corresponding light image of higher energy density Image Receptor Any device such as a fluorescent screen or radiographic film which transforms incident x ray photons either into a visible image or into another form which can be made into a visible image by further transformations Image Receptor Support For mammographic systems that part of the system designed to support the image receptor during mammography Inspection An official examination or observation including but not limited to tests surveys and monitoring to determine compliance with rules regu
190. radionuclide in a year by the reference man that would result in a committed effective dose equivalent of 5 rems 0 05 sievert or a committed dose equivalent of 50 rems 0 5 sievert to any individual organ or tissue ALI values for intake by ingestion and by inhalation of selected radionuclides are given in the Regulations for Control of Radiation in Mississippi Authorized Medical Physicist An individual who meets the requirements stated in the Regulations for Control of Radiation in Mississippi Authorized User A physician dentist or podiatrist who meets the requirements of the Regulations for Control of Radiation in Mississippi for diagnostic or therapeutic treatment of patients or human research subjects For research programs an Authorized User is an individual who has sufficient training and experience to meet the requirements of the Radiation Safety Committee in order to be approved to use radiation Background Radiation Radiation from cosmic sources naturally occurring radioactive materials including radon except as a decay product of source or special nuclear material and including global fallout as it exists in the environment from the testing of nuclear explosive devices or from past nuclear accidents such as Chernobyl that contribute to background radiation and are not under control of the licensee Background radiation due to cosmic rays and natural radioactivity in rocks and soil varies with location Background rad
191. ranges and facilities at which this material was used 2 List all isotopes requested for use at UMMC including maximum activity to be possessed for each isotope 3 List all laboratory locations where radioactive materials will be used including building and room number 4 Will any procedures increase volatility of labeled compounds Yes No If so which isotopes Page 103 of 185 University of Mississippi Medical Center 5 Describe precautions taken to reduce contamination and personnel exposure levels laboratory preparations shielding waste storage conditions etc 6 If performing iodinations which laboratory hood will be used Has the hood s airflow been checked Yes No If so when By whom Noted cfm Amount of activity mCi per iodination Estimated iodinations per month ds List survey instrumentation to be used include make model and serial number 8 On a separate sheet give a brief description of the purposes for the use of each radionuclide to include A Experimental Procedures Identification of types of labeled compounds Approximate activity per experiment Estimated number of experiments per month m g oa w Specify laboratory animals if applicable and animal husbandry if contamination is a possibility m Which types of waste will be generated 9 Instructions and requirements of UMMC Radiation Safety Office and Committee Use plastic backed absorbent paper for wo
192. rate of 3 7 x 10 transformations per second tps Common sub multiples of the curie are the millicurie and the microcurie One millicurie mCi 0 001 curie 3 7 x 10 tps One microcurie uCi 0 000001 curie 3 7 x 10 tps Decommission To remove from service including decontamination to a level that will permit unrestricted use if necessary Deep Dose Equivalent Hd Applies to external whole body exposure and is defined as the dose equivalent at a tissue depth of 1 centimeter 1000 mg cm Dose A generic term that means absorbed dose dose equivalent effective dose equivalent committed dose equivalent committed effective dose equivalent total organ dose equivalent or total effective dose equivalent Dose Equivalent HT The product of the absorbed dose in tissue quality factor and all other necessary modifying factors at the location of interest The units of dose equivalent are the rem and the sievert Sv Page 92 of 185 University of Mississippi Medical Center Dose Limits The permissible upper bounds of radiation doses established in accordance with the regulations Effective Dose Equivalent HE The sum of the products of the dose equivalent to each organ or tissue HT and the weighting factor WT applicable to each of the body organs or tissues that are irradiated Evaluation Level That level at which an intake shall be evaluated beyond the initial bioassay measurement For I 125 this will be im
193. record of the calibrations on each brachytherapy source for three 3 years after the last use of the source The record must include 1 The date of the calibration 2 The source manufacturer s name 3 Model number 4 Serial number for the source 5 Instruments used to calibrate the source 6 Thesource activity 7 Source position accuracy within applicators and 8 Thesignature of the Authorized Medical Physicist Training A Brief nursing personnel on radiation safety precautions Use the sample form Nursing Instructions for Patients Treated with Brachytherapy Sources as an outline Allow time for questions and answers during the briefing B Radiation safety training will be provided to personnel caring for patients undergoing manual brachytherapy The training will include information on 1 The size and shape of the brachytherapy sources 2 Safe handling and shielding instructions 3 J Patient control 4 Visitor control and 5 Emergency contacts This training will be provided initially before treatments begin and at least annually thereafter Note a vendor or UMMC personnel will provide this training C Training records will be retained for three 3 years The records must include 1 A list of the topics covered 2 The date of the training 3 The names of the attendees and 4 The name of the person providing the training Page 49 of 185 University of Mississippi Medical Center Procedures A
194. recorded on the patient requisition and in the formal report completed by the authorized user caring for this patient 3 Except in emergency situations no radiopharmaceutical shall be administered by any personnel in the absence of a signed written directive containing the above elements 4 A written revision to an existing written directive may be made provided that the revision is dated and signed by an authorized user prior to the administration of the dosage of radiopharmaceutical 5 If because of the emergent nature of the patient s condition a delay in order to provide a written directive would jeopardize the patient s health Page 141 of 185 10 11 University of Mississippi Medical Center an oral directive shall be acceptable provided that the information contained in the oral directive is documented as soon as possible in the patient s record and a written directive is prepared and signed by the authorized user within 48 hours of the oral directive If because of the patient s condition a delay in order to provide a written revision to an existing written directive would jeopardize the patient s health an oral revision to an existing written directive shall be acceptable provided that the oral revision is documented as soon as possible in the patient s record and a revised written directive is signed by the authorized user within 48 hours of the oral revision Specific details of the administration must be in ac
195. reduce exposure to the patient and hospital staff The patients room will be posted Caution Radioactive Materials Area and the foot of the bed will be posted Caution Radiation Area after the patient is administered the radiopharmaceutical Page 153 of 185 10 11 12 University of Mississippi Medical Center Order disposable table service for the duration of the patient s stay Inform housekeeping staff that personnel should stay out of the room until the Radiation Safety Office has released it Supply the nurses with personal dosimetry devices pocket ionization chambers or an electronic alarming dosimeter and instruct them in the use of these monitoring devices Note If personal dosimetry devices are provided they cannot be exchanged between personnel Each device is assigned to one person to be worn by that person only Brief the nurses on radiation safety precautions Use the Instructions to Nurses Assigned to Patients Receiving Therapeutic Radiopharmaceuticals guidelines Allow time for questions and answers during the briefing Leave a written copy of the radiation safety precautions at the nurses station Brief the patient on radiation safety procedures for the dosage administration visitor control radioactive waste and other items as applicable for their stay at the hospital and when they are released Only those persons needed for medical safety or training purposes should be present during the admi
196. rement for two minutes and divide the results by 2 Record results Hold probe in the center of the neck near the Adam s apple for a two minute count and divide the results by 2 Record results Subtract background counts from thyroid counts to obtain net counts Record results Calculate and record the amount of radioactivity in the thyroid by using the following equation Net Counts CPM X 100 ii Efficiency X2 2x10 DPM uci Record the results and compare them to the evaluation and investigational levels Bioassay records shall include the thyroid burden measurement date of measurement the name of the individual whose thyroid burden was measured and the initials of the individual who made the measurements Retain bioassay records for a period of three 3 years Page 159 of 185 University of Mississippi Medical Center Appendix G Dose Calibrator Calibration Procedures Page 160 of 185 B University of Mississippi Medical Center Procedure for Calibrating Dose Calibrator Calibrations Qualified personnel or the radiopharmacy will perform calibration procedures on dose calibrators 1 Repair replacement or arithmetic correction will be considered if the dose calibrator falls outside of suggested tolerances 2 Recommended tolerances for UMMC are more restrictive than those in the Regulations for the purpose of ensuring that corrective actions will be taken before the dose calibrator is outside permissi
197. result in contamination of linen and floor Vomiting can also result in the loss of enough radioactive iodine from the patient to compromise the effectiveness of the entire therapeutic procedure If any such situation occurs or if radioactive urine and or feces is spilled during collection call the Radiation Safety Office Meanwhile handle all contaminated material with disposable gloves and Page 150 of 185 12 13 14 15 16 University of Mississippi Medical Center avoid spreading contamination If contamination of the floor is suspected shoe covers must be worn e Vomitus may be disposed of in the sanitary sewer Feces need not be routinely saved unless ordered on the chart and approved by the Radiation Safety Office The same toilet must be used by the patient at all times and it must be flushed two times after each use Male patients shall be instructed to sit down to urinate Precautions must be taken to see that no urine or vomitus is spilled on the floor or the bed If such a spill occurs notify the Radiation Safety Office If a nurse attendant or anyone else knows or suspects that his or her skin or clothing including shoes is contaminated notify the Radiation Safety Office immediately This person must remain in an area adjacent to the patient s room and must not walk about the hospital If the hands become contaminated wash them immediately with soap and warm water If a therapy patient should need eme
198. rgency surgery or should die notify the Radiation Safety Office and the Nuclear Medicine Department immediately The patient is not to be discharged without first contacting the Radiation Safety Office or the Nuclear Medicine Department The patient s room shall not be released for use by another patient until it is surveyed and decontaminated by the Radiation Safety Office Radiation Safety Office 601 984 1980 After Hours and weekends see On Call Scheduling for Radiation Safety at UMMC Intranet Emergency Dispatch 601 984 1420 Page 151 of 185 University of Mississippi Medical Center APPENDIX E Instructions for Therapeutic Administration of I 131 Page 152 of 185 University of Mississippi Medical Center THERAPEUTIC USE OF IODINE 131 Nal All patients treated with iodine 131 Nal will be treated in a private room specially equipped with a seamless floor and stainless steel sink and toilet Prepare the room as follows a Remove all excess furniture and equipment from the room that will not be needed for the patient Use polycoated craft paper to cover floor surfaces counter tops tables bathroom rails and walls that the patient will be in contact with that are likely to become contaminated Items such as the telephone nurse call TV control door handles faucet handle bed rails tray table and toilet may be covered with plastic bags to prevent their contamination Masking tape may be used to cover light
199. rgies up to 50 MeV Equipment Design Performance and Use NCRP Report No 105 Radiation Protection for Medical and Allied Health Personnel and the Regulations for Control of Radiation in Mississippi Although these procedures were developed for human use of x ray devices their basic safeguards also apply to the non human use of x ray devices for research purposes These procedures are to be followed by all personnel using x ray devices Deliberate exposure of an individual to the x ray device s useful beam for training or demonstration purposes shall not be permitted unless there is a diagnostic need for the exposure and the exposure is prescribed by a dentist or physician As a general rule any technique or procedure that reduces the number of retakes and patient exposure reduces the exposure to radiological personnel Technologists are responsible for knowing and using proper techniques positioning image receptor image intensifier image mode etc appropriate shielding and collimation with each patient It is imperative that the technologist understands the effects of all technique factors on overall image quality It is also important for the technologist to understand the differences among the types of image receptors Page 59 of 185 University of Mississippi Medical Center used in radiology and the effects of these different image receptors on patient and personnel exposure General Guidelines A Each department us
200. rk areas where radiation will be used Mark all radiation workstations with Caution Radioactive Material tape Wear buttoned lab coats Wear gloves Work in fume hoods when volatile compounds are used BB a as B Use beta shields when applicable Page 104 of 185 University of Mississippi Medical Center G Survey radiation work areas after each use and document full surveys at least monthly Assure appropriate calibrated survey instrumentation is available and used for each isotope in use H Keep radioactive waste collection containers in each laboratory where radiation is used and assure proper labeling for clear identification of radiation Page 105 of 185 University of Mississippi Medical Center STATEMENT OF AGREEMENT The individual named below agrees without reservation of any kind to abide by the University of Mississippi Medical Center Radiation Safety Manual and the Mississippi State Department of Health Regulations and hereby waives any right to or recourse against the University of Mississippi for any damage whatsoever resulting from any failure to fully conform to said manual regulation or policies Name printed Date Signature Date Approved Disapproved by RSC RSC Chairman Signature If disapproved explanation or conditions Page 106 of 185 University of Mississippi Medical Center PREVIOUS OCCUPATIONAL EXPOSURE HISTORY FORM You have been identified as a UMMC employee who req
201. room momentarily if the patient must move away from the bed The patient s room will be surveyed twice per day by the Radiation Safety Office Except for essential services to the patient employees shall limit their time around the patient s bed Patients containing radioactive materials are to be confined to their rooms except for special medical or nursing purposes approved by the Radiation Safety Office or in the case of an emergency Visitors or attendants who are pregnant should not be permitted in the room of a patient who has received a therapeutic amount of radioactivity until the patient no longer presents a radiation hazard Female visitors should be asked whether they Page 149 of 185 10 11 University of Mississippi Medical Center are pregnant Declared pregnant nurses should not be assigned to the personal care of these patients Attending personnel must wear disposable rubber or plastic gloves when handling urinals bedpans emesis basins or other containers having any material obtained from the body of the patient Wash gloves before removing and then wash hands The gloves must be left in the patient s room in the designated waste container These gloves need not be sterile or surgical in type Disposable items must be used in the care of these patients whenever possible These items must be placed in the designated waste container after use Contact the Radiation Safety Office for proper disposal of the contents of th
202. rtunity Duties A Keeparecord of the actions taken in approving the use of sources of radiation communications and reports involved in the work of the RSC B Act with the Radiation Safety Office under policies established by the RSC for the Committee between meetings and report such actions taken to the Committee for review at the next RSC meeting RADIATION SAFETY OFFICER The Radiation Safety Officer will be responsible to the Director of the Department of Environmental Health and Safety and will act as a liaison between users of ionizing radiation and the Radiation Safety Committee The Radiation Safety Officer or designee from radiation safety will keep the Radiation Safety Committee informed of matters affecting or involving the use of ionizing radiation at UMMC or any institutions affiliated with UMMC licenses and registrations The primary responsibility of all personnel in the Radiation Safety Office is to advise and assist personnel in matters concerning the use of ionizing radiation and radiation safety Problems concerning the use of radiation will be initially dealt with between radiation safety staff and the individual with whom the problem has arisen If further actions are required the individual s supervisor and the Chairman of the RSC will be asked to assist with a resolution to the problem The Radiation Safety Committee RSC and the Director of the Department of Environmental Health and Safety will be informed and will
203. rvey with a radiation survey instrument all areas where sealed sources are stored at intervals not to exceed three 3 months The record shall include 1 The date of the survey 2 Asketch of each area that was surveyed 3 The measured dose rate at several points in each area expressed in millirems per hour 4 The model number and serial number of the survey instrument used to make the survey and 5 The name of the individual performing the survey Survey records shall be retained for three 3 years Patient Surveys A At the conclusion of each HDR afterloader procedure and after retracting the source from the patient into its shielded position in the HDR afterloader unit a radiation survey shall be made immediately of the patient the HDR afterloader and the area of use A portable radiation detection survey instrument will be used to confirm that the source has been removed from the patient and has returned to the safe shielded position Records of the survey must include 1 Manufacturer model number and serial number of the survey instrument used 2 dose rate expressed as mR hr 3 Time and date of the survey and 4 The name of the individual making the survey Records of surveys shall be maintained for three 3 years Page 40 of 185 University of Mississippi Medical Center Dosimetry Equipment A Radiation Oncology shall have a calibrated dosimetry system available for calibration of the HDR afterlo
204. s 1 Nuclear Medicine Nuclear Cardiology PET restricted area action level is 2000 dpm 100 cm and unrestricted area action level is 1000 dpm 100 cm D Personnel performing wipe surveys shall immediately notify the Radiation Safety Office if contamination exceeds an action level E Decontamination procedures will be followed if the action levels are exceeded Survey Records Records of each survey must be retained for three 3 years These records must include The date of the survey B A sketch of each area surveyed C Action levels established for each area D The measured dose rate at several points in each area expressed in millirems per hour or the removable contamination in each area expressed in disintegrations per minute per 100 2 cm E The serial number and the model number of the instrument used to make the survey or analyze the samples and F The initials of the individual who performed the survey A drawing of the area surveyed keyed to and identifying relevant survey locations such as dose storage areas source storage areas injection areas waste storage areas sinks L block shields treadmills and gamma cameras shall be kept for each area using radioisotopes Storage of Volatiles and Gases Nuclear Medicine Nuclear Cardiology PET personnel shall store volatile radiopharmaceuticals and radioactive gases in the shippers radiation shield and container Personnel shall store and use a multi dose cont
205. s If there is any possibility that the clothes have been contaminated remove this clothing before leaving the lab Eye protection e g goggles face shield is encouraged to prevent contamination of the eyes This is particularly important for individuals wearing contact lenses since some lenses will absorb and concentrate radiochemicals Wear protective gloves at all times when working with radioactive materials Change gloves frequently during the work disposing of the used gloves as radioactive waste Wash hands after using radioactive materials and monitor the hands for contamination prior to leaving the laboratory and especially before eating or smoking Page 138 of 185 University of Mississippi Medical Center Signature of Certifying Officials I hereby certify that UMMC has implemented the ALARA Program described above James E Keeton M D Vice Chancellor for Health Affairs and Dean School of Medicine Signature Date Martin H McMullan M D Radiation Safety Committee Chair Signature Date Robert B Nelson RSO Radiation Safety Officer Signature Date Page 139 of 185 University of Mississippi Medical Center APPENDIX C Nuclear Medicine Quality Management Program Page 140 of 185 University of Mississippi Medical Center University of Mississippi Medical Center Cancer Institute Nuclear Medicine Nuclear Cardiology PET CT QUALITY MANAGEMENT PROGRAM For Administration of Therapeutic Doses of Radi
206. s it will be necessary to make a correction table or graph that will allow you to convert from indicated activity to true activity If this is necessary be sure to label the table or graph vial geometry dependence and note the date of the test and the model number and serial number of the calibrator Accuracy means that for a given calibrated reference source the indicated millicurie value is equal to the millicurie value determined by the National Institute of Standards and Technology NIST or by the supplier who has compared that source to a source that was calibrated by the NIST Certified sources are available from the NIST and from many radioisotope suppliers l To complete an accuracy test at least two sources with different principal photon energies such as Co 57 Ba 133 or Cs 137 shall be used The regulations require that one must have a principle photon energy between 100 keV and 500 keV The regulations also require that sources must be at least 50 microcuries Consider using at least one reference source whose activity is within the range of activities normally assayed Calibration Procedure a Assay a calibrated reference source at the appropriate setting i e use the Co 57 setting to assay Co 57 and then remove the source and measure background Subtract background from the indicated activity to obtain the net activity Record this measurement Repeat for a total of three determinations 165
207. s speculative For example no genetic effects have been documented in any of the Japanese atomic bomb survivors their children or their grandchildren What if I decide that I do not want any radiation exposure at all during my pregnancy You may ask your employer for a job that does not involve any exposure at all to occupational radiation dose but your employer is not obligated to provide you with a job involving no radiation exposure Even if you receive no occupational exposure at all your embryo fetus will receive some radiation dose on average 75 mrem 0 75 mSv during your pregnancy from natural background radiation The NRC has reviewed the available scientific literature and concluded that the 0 5 rem 5 mSv limit provides an adequate margin of protection for the embryo fetus This dose limit reflects the desire to limit the total lifetime risk of leukemia and other cancers If this dose limit is exceeded the total lifetime risk of cancer to the embryo fetus may increase incrementally However the decision on what level of risk to accept is yours What effect will formally declaring my pregnancy have on my job status Only the licensee can tell you what effect a written declaration of pregnancy will have on your job status As part of your radiation safety training the licensee will tell you the company s policies with respect to the job status of declared pregnant women In addition before you declare your pregnancy you may wa
208. s a potentially contaminated area Therefore all workstations shall be clearly identified by all persons entering the area A All workstations where radioactive material is used shall be lined with plastic backed absorbent paper Any and all equipment used during procedures involving radioactive materials shall be tagged with some form of identification of potential contamination whether it is a Caution Internal Contamination tag obtained from the Radiation Safety Office or the application of Caution Radioactive Material tape Page 21 of 185 University of Mississippi Medical Center C Containers for radioactive waste collection will be placed in a location such that employees will not have to leave the workstation to dispose of radioactive wastes during a procedure These temporary waste containers will be identified as radioactive waste with the Caution Radioactive Waste Do Not Empty label if they are placed on the floor Bench top containers will be labeled with waste signs or with tape that states Caution Radioactive Material D Workstations shall if at all possible be set in locations near a sink or in an area where a sink is readily available PROCUREMENT OF RADIOACTIVE MATERIALS Only authorized users are permitted to procure or purchase radioactive materials exceeding exempt quantities Authorized users may order only those radioisotopes and quantities for which they are currently approved The NRC re
209. s and registrations authorizing the use of radioisotopes and radiation generating devices MSDH DRH has Nuclear Regulatory Commission NRC authority to enforce state regulations that comply with federal regulations The Regulations for the Control of Radiation in Mississippi are approved by the Mississippi legislature and are state law Licenses and registrations are issued to facilities and institutions in Mississippi who have submitted applications and corresponding policies and procedures that are followed to assure compliance with state regulations This manual is submitted to MSDH DRH with our application and therefore becomes part of our license The Radiation Safety Committee and MSDH DRH must approve changes to our license and manual Non compliance with our license can result in violations cited by MSDH DRH during inspections of our radiation safety program Serious violations that put patients visitors employees students or our surrounding community at risk of excessive exposures to radiation can result in the loss of licenses and registrations to use radioactive materials or radiation generating devices ALARA CONCEPT The ALARA concept is one involving every individual working around radiation and essentially means that each person must strive to maintain radiation exposures As Low As Reasonably Achievable This is to reduce unnecessary exposure to themselves and or others Those persons authorized by UMMC to make its policies and direc
210. s are contaminated by assessing lab safety procedures i e no spills occurred no pipette problems no radioactive contamination on lab items If there is any possibility that the waste is contaminated with radioactive material it must be disposed of in the appropriate radioactive waste disposal drum in the department Uncontaminated waste must be disposed of in regular trash containers as ordinary waste free of radioactive material Mixing radioactive and non radioactive waste in the disposal drums unnecessarily increases the volume of solid uncompacted radioactive waste for disposal and correspondingly increases disposal costs Non radioactive items contaminated with blood or animal wastes are not to be disposed of in the radioactive waste storage drums Page 87 of 185 University of Mississippi Medical Center Blood contaminated wastes are to be collected for disposal as medical waste under the contract for medical waste disposals Animal carcasses parts bedding and wastes are to be disposed of by the Laboratory Animal Facilities Department as medical waste L Final Waste Disposal Once wastes have been collected by the Radiation Safety Office they must be either held for decay and then disposed of or shipped off site for final disposal via a waste broker Listed below is the method of disposal for each waste category identified in Section A of the Waste Disposal Section of this manual LA LB II III IV V A V B V
211. s per minute dpm If survey results are greater than 200 dpm clean and resurvey a To convert from cpm to dpm use the following formula dpm net cpm efficiency b Typical efficiencies to use for conversion with the use of a pancake probe are as follows 1 P 32 0 20 20 2 S 35 0 03 3 3 P 33 0 03 3 4 Ca 45 0 10 10 5 C 14 0 06 6 6 I 125 0 01 1 7 Tc 99m 0 01 1 c If the survey meter being used reads in counts per second cps multiply by 60 to get counts per minute cpm DOSE CALIBRATORS Nuclear Medicine Nuclear Cardiology PET departments authorized to administer radiopharmaceuticals should possess a dose calibrator and use it to measure the amount of activity administered to each patient Dose calibrator reference and calibration sources traceable to the National Institute of Standards and Technology NIST or other standards recognized as being equivalent by the NIST shall be used for calibrations Qualified UMMC or radiopharmacy personnel shall perform quality control checks and tests on all dose calibrators used for measuring the amount of activity administered to a patient These tests shall include Constancy Checks A Checking each dose calibrator for constancy with a dedicated check source at the beginning of each day of use B Checks shall be done on a frequently used setting with a sealed source of not less than 50 microcuries with energies representative of the radio
212. s used in accordance with all appropriate rules and regulations including the Radiation Safety Manual B Notifying the Radiation Safety Office and Radiation Safety Committee of any proposed changes in protocols procedures equipment licensed materials etc approved by the Radiation Safety Committee and obtaining Radiation Safety Committee approval prior to implementing any proposed changes C Ensuring that the training of personnel working with ionizing radiation is adequate and in accordance with regulatory requirements This includes the requirement for initial and annual training Page 12 of 185 University of Mississippi Medical Center D Ensuring that ALARA principles are practiced and adhered to in all areas where ionizing radiation is being used under the authorized user s supervision E Submitting proposals for new procedures involving the use of ionizing radiation to the Radiation Safety Office for submission to MSDH DRH when necessary and or the Radiation Safety Committee for approval F Notifying the Radiation Safety Office immediately of any incident recordable event or misadministration RESPONSIBILITIES OF INDIVIDUAL USERS An INDIVIDUAL user is classified as any of the physicians scientists and other professional and technical workers engaged in patient care clinical and laboratory research and research support activities which involve actual use and handling of materials and devices producing ionizing radia
213. s using high energy beta emitting isotopes This decision will be based on the isotope activity and procedures used by the individual Ring dosimetry devices must be worn on the hand expected to receive the highest dose if only one is issued and be oriented facing the radiation source The ring s must be returned for analysis along with the whole body dosimetry device Internal Monitoring Thyroid bioassays will be required after the use of radioiodine if certain conditions apply as noted below Thyroid bioassays shall be obtained between 6 and 72 hours following work with radioiodine in excess of the quantities listed below Scheduling of the monitoring will be done through the Radiation Safety Office A Conditions under which thyroid bioassay is necessary 1 Routine bioassay is necessary when individuals handle quantities of radioactive iodine that exceed those listed below a The condition of our license requiring bioassays states that individuals involved in frequent operations less than every two weeks which utilize during any one 1 quarter ten 10 millicuries of Iodine 125 and or Iodine 131 in capsule form or a total of 1 millicurie of liquid Iodine 125 and or Iodine 131 must have a bioassay performed within six 6 to seventy two 72 hours following the use of the licensed material Infrequent use of Iodine 125 and or Iodine 131 greater than every two weeks will necessitate a bioassay within ten 10 days following
214. scan increments shall be provided by the equipment manufacturers A qualified expert shall conduct annual surveys Dental X Ray Equipment The Dental x ray guidelines are taken from the Regulations for Control of Radiation in Mississippi A Deliberate exposure of an individual to the useful beam for training or demonstration purposes shall not be permitted unless there is a diagnostic need for the exposure and a dentist or physician prescribes the exposure The operator or the assistant shall not hold the film in place for the patient during the exposure During each exposure the operator shall stand as far as practical from the patient and outside the path of the useful beam at least six feet from the x ray tube or behind a suitable barrier Only persons required for the radiographic procedure should be in the radiographic room during exposure All persons shall be adequately protected The tube housing shall not be hand held during the exposure Page 65 of 185 University of Mississippi Medical Center Intraoral fluoroscopy shall not be used in dental examinations As a general principle the exposure to the patient shall be kept to the practical minimum consistent with clinical objectives Devices or film holders are available for holding intraoral x ray films in the mouth These devices eliminate the need for the patient to hold the film packet with their hand and aid in positioning and stabilizing the film With
215. scribing physician allied health personnel the patient and the patient s referring physician the patient s Social Security Number or medical record number a brief description of the event why it occurred the effect on the patient the actions taken or planned to prevent recurrence whether the authorized user notified the patient or their responsible relative or guardian and if not whether such failure to notify was based on the guidance from the referring physician D ANNUAL REVIEW There shall be an annual review of the Quality Management Program to determine its effectiveness l The review will include from the previous 12 months a randomly selected representative sample of patient administrations all recordable events and all misadministrations a For each patient case reviewed a comparison shall be made between what was prescribed in the written directive and what was actually administered It shall be determined whether the administered radiation dose was in accordance with the written directive in terms of treatment site procedure isotope fractional dose or total dosage b For each patient case reviewed any deviations from the written directive shall be identified along with the cause of each if possible and the action taken to prevent recurrence c When a recordable event or misadministration is uncovered during the periodic review of the QMP the number of cases included in the review will be expanded 17
216. set by the software for Iodine 131 and Iodine 125 In the case if I 131 the region of interest is in the area of 364 keV For I 125 the region of interest is in the area of 35 5 keV Establish Background Hold probe next to the phantom without a source inserted and initiate a two minute count Divide the results by 2 to get counts per minute cpm Record results Count Standard A known measured amount of radioactivity must be used as the standard When assaying for I 131 an I 131 standard or a standard source of known activity that emits photons of approximately the same energy as I 131 e g Barium 133 must be used I 131 liquid or capsule may be used and must be measured and corrected for decay When assaying for I 125 an I 129 source may be used Sealed sources shall be decayed from the original assay to determine the activity at the time of calibration Place the standard in the Nuclear Associates Victoreen standard thyroid uptake neck phantom model 74 365 Hold probe against the phantom in a geometry similar to one to be used when performing a bioassay on an individual Count the standard for two minutes Divide the counts by 2 to get the counts per minute Record results Repeat the procedure for a total of ten counts Total the sum of the ten counts and divide by 10 to get an average count per minute Ba 133 I 131 Correction Factor 1 299 Ba 133 356 keV gamma ray with 62 05 abundance I 131 364 keV gamma ray with
217. ssssvusssnoossssossonseceussedsessesenesessdsecsenvonsessassnscessesensssonnes 110 EMERGENCY PROCEDURES FOR SPILLS INVOLVING RADIOACTIVE MATERIAL 112 REMINDER OF GOOD RADIOISOTOPE LABORATORY SAFETY PRACTICES 113 RECEIPT OF RADIOACTIVE MATERIALS OUTSIDE OF NORMAL WORK HOURS 114 DAILY INCOMING RADIOACTIVE SHIPMENT INSPECTION e eeeeeee eene ntntne 115 IN HOUSE WASTE DISPOSAL RECORD eere erste eene ee enata enata tasse totae ta spat es enses enses tae 116 RADIOACTIVE WASTE DISPOSAL RECORD 4 eeeee eee ente etta tn sens tn sns ta tuse es enses to sn eae 117 ANIMAL DISPOSAL INSTRUCTIONS eese esee eere ee een sento stes ene ee to sene toten stesse en ep ette toten etn eno 118 GUIDE FOR RADIOLOGICAL PROPERTIES OF ISOTOPES ceres reete tn ntnnnn 119 APPENDIX O ORA E eub du e IN NR TUM etr ute ED te e 121 RADIATION EXPOSURE AND PREGNANCY eeeeeee esses entes eta enata tasa enses tasses sns estu seus 123 APPENDIXB E EE EEEE STORMS SEMIS SERERE OMS ahaa E EH ER peu 131 UMMC ALARA PROGRAM ardet tere t eap RP PER MS EVE OH EER TURA SERERE RUE osei isas aaepe iRGE 132 APPENDIX C aee en RO ate eu eine reu RE E e 140 Nuclear Medicine Quality Management Program eee ee eee ee ee ee ee seen nest en sete eo sette setas sesta ae 140 APPENDIX D ecce ee a RI Un uma Mp E ETE eM eMe 148 Nursing Instructions for 1 131 Therapy
218. switches cabinet handles thermostat controls and to secure the craft paper and plastic bags Patients will be instructed to only touch covered surfaces Disposable gloves should be used when handling the patient contaminated waste linen or any items that may have come in contact with the patient s hands skin or urine Separate plastic bags will be needed for linen disposable waste and non disposable contaminated items No items will be allowed to leave the room until they have been surveyed and cleared by the Radiation Safety Office 1 Alllinens will be placed in a plastic bag and surveyed for contamination before being removed from the patient s room and will be held for decay in storage 2 Disposable plates cups eating utensils food trays tissue and other similar disposable waste items will be placed in a waste can lined with a plastic bag and tagged as Caution Radioactive Material This waste will be surveyed for contamination and held for 10 half lives 3 Non disposable items such as blood pressure machines and tray tables used for these patients will be held in the patient s room and will be checked for contamination by the Radiation Safety Office Items may be returned for normal use held for decay or decontaminated as appropriate Urine will be discarded by release to the sanitary sewer The patient will be instructed to flush twice after using the restroom Urine should not be collected at this time to
219. t for radiation If detected remove the applicator from the patient ensuring that radiation is confined to the applicator Open the lid of the Emergency Container Insert the applicator containing the source into the well using long forceps Guide the transfer tube through the recess at the container edge Close the lid Leave the radiation warning tag hanging outside the container to indicate it contains radioactive material 4 IMMEDIATELY assist the patient from the room 5 Ensure that the applicator and source are safely stored inside the emergency container 6 Leave the room Close the door Mark it NO ENTRY Note The emergency container cannot be considered as a storage container When a radioactive source is in the container the source shielding is insufficient for storage in a treatment room with restricted access 7 Retain the treatment data printout and contact the following Authorized User Srinivasan Vijayakumar Tel 601 815 6868 Authorized Medical Physicist Claus Yang Tel 601 815 7562 Facility RSO Robert Nelson Tel 601 984 1989 On Call Radiation Safety Emergency Dispatch Tel 601 984 1420 180 University of Mississippi Medical Center Nucletron Representatives RSO Debra Bensen Tel 410 913 3162 Technical Support Toll Free Tel 1 855 MYELEKTA 693 5358 The unintended radiation dose to which those present have been subjected should be estimated and recorded by a suitably qualified person See section 2
220. t its activities have the responsibility of seeing that the ALARA concept is applied to employees visitors students and patients This responsibility will be carried out through the following methods Page 6 of 185 University of Mississippi Medical Center A Encouragement of all employees to participate in the establishment implementation and operation of the ALARA program as required by radiation safety policies licenses and registrations and state regulations B Employee safety training in radiation work related activities which includes ALARA concepts C Appropriate planning to ensure that any new facilities or equipment or modifications of old facilities or equipment that may affect radiation protection will be performed in consultation with the Radiation Safety Office D Delegation of sufficient authority to the Radiation Safety Office to enforce regulations and administrative policies regarding radiation safety E Continuing management evaluation of the radiation safety program through appropriate management reviews of personnel requirements budget requirements and operational efforts to maintain exposures ALARA A full copy of the ALARA Program can be viewed in Appendix B at the end of this manual Printed copies are kept on file in the Radiation Safety Office INSTITUTIONAL RADIATION SAFETY COMMITTEE RSC Structure The Radiation Safety Committee membership must include an authorized user of each type of use
221. t to a licensed facility for storage H 3 and C 14 waste is separated from other isotopes for disposal with a licensed broker Do not mix these isotopes with others if at all possible Waste generated with a mixture of radioactive materials and hazardous chemicals should be avoided if at all possible If mixed waste must be generated clear this through the Radiation Safety Office and Hazardous Materials Office prior to beginning the procedures to assure proper collection of the waste Page 120 of 185 University of Mississippi Medical Center APPENDIX A Prenatal Training Information Page 121 of 185 University of Mississippi Medical Center Radiation Safety Office 601 984 1980 Declaration of Pregnancy To Name of your supervisor In accordance with the Regulations for Control of Radiation in Mississippi I am declaring that I am pregnant I believe I became pregnant in Only the month and year need be provided I understand that my occupational radiation dose during my entire pregnancy will not be allowed to exceed 0 5 rem 5 millisieverts unless that dose has already been exceeded between the time of conception and submitting this letter I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy Prior to being issued a fetal monitoring badge a completed copy of this form must be submitted to the Radiation Safety Office In addition please notify
222. th duties regarding licensed material Documentation is maintained to demonstrate that individuals are not likely to receive in one year a radiation dose in excess of 10 of allowable limits or that personnel monitoring devices are provided Ensure that when necessary personnel monitoring devices are used and exchanged at the proper intervals and records of the results of such monitoring are maintained Ensure that licensed material is properly secured Ensure that documentation is maintained to demonstrate by measurement or calculation that the total effective dose equivalent to the individual likely to receive the highest dose from the licensed operation does not exceed the annual limit for members of the public Ensure the notification of proper authorities of incidents such as loss or theft of licensed material damage to or malfunction of sealed sources and fire Ensure recordable events and misadministrations are investigated and reported to the Mississippi Department of Health Division of Radiological Health and cause s and appropriate corrective action s are identified and timely corrective action s are taken Audit the radiation protection program at least annually and document the audit Ensure that if violations of regulations license conditions or program weaknesses are identified effective corrective actions are developed implemented and documented Ensure that licensed material is transported or offered for
223. th the other carcasses AREA SURVEY PROCEDURES Areas in which radioisotopes are used require periodic surveys with appropriate monitoring instruments or wipe tests Survey frequency depends upon toxicity activity and use with the frequency of survey ranging from daily to monthly The Radiation Safety Office will review isotope use in existing and proposed radioisotope laboratories performing research and determine the appropriate survey frequency based on hazards present A Research laboratory hazard classifications are based on the radiotoxicity of the isotope in use the maximum amounts of activity stored or used in the area and type of use in terms of the relative hazard of the handling and experimental procedures Radiotoxicity is used to indicate the relative hazard of the various radionuclides if deposited internally The radiotoxicity depends on the energy of the emitted radiation the chemical and physical form of the material and the organ in which the material concentrates Based on these considerations the relative radiotoxicity of typical radioisotopes is given below 1 Class I Very High radiotoxicity Sr 90 Pb 210 Ra 226 Th 227 Pa 231 U 233 Pu 238 Am 243 Po 210 Ra 228 2 Class II High radiotoxicity Ca 45 Na 22 Co 56 I 131 Bi 207 C1 36 Co 60 I 125 Ir 192 3 Class III Moderate radiotoxicity P 32 S 35 Co 60 Rb 86 Cs 137 Cr 51 Sc 46 Zn 65 Gd 153 C 14 Y 90 4 Class IV Low radiot
224. the package survey shall be performed no later than three 3 hours from the beginning of the next working day A Package Survey Procedures 1 Visually inspect the package for any sign of damage e g wetness crushed a If damage is noted the survey procedure will be halted and the following steps taken 1 Restrict further access to the package 2 Using gloves swipe the exterior of the package and measure the swipe activity with a thin window GM tube survey meter for radiation levels above twice background levels 3 If negative proceed with package survey 4 If positive a Place the package in a plastic bag and relocate to a shielded area for examination and eventual return to the radiopharmacy b Survey all areas and workers including clothing that came into contact with the package Decontaminate if necessary to background levels c Contact the Radiation Safety Office the radiopharmacy and the carrier as soon as possible and provide contamination details b Ifthe package appears to be undamaged upon visual inspection 1 Measure the radiation exposure rate at one 1 meter from the package surface and record If greater than 10 mR hr stop the procedure and notify the Radiation Safety Office Page 23 of 185 University of Mississippi Medical Center 2 Measure the exposure rate at the surface and record If greater than 200 mR hr stop the procedure place in a shielded area and notify the Radiati
225. tify the patient without first consulting with the referring physician If the referring physician or the patient cannot be reached within 24 hours they shall notify the patient as soon as possible thereafter Nuclear Medicine Nuclear Cardiology PET CT Departments may not delay any appropriate medical care for the patient including any necessary remedial care as a result of the misadministration because of any delay in notification If the patient was notified a written report will be furnished to the patient within 15 days after discovery of the misadministration The report will either be a copy of the report that was submitted to MSDH or a brief description of both the event and the consequences as they may affect the patient If a letter describing the event and the consequences not the report submitted to MSDH is sent to the patient it will include a statement to the effect that a copy of the report submitted to MSDH will Page 144 of 185 University of Mississippi Medical Center be made available to the patient if requested A copy of this report shall be provided to the referring physician within 15 days after discovery of the misadministration The Nuclear Medicine Nuclear Cardiology PET CT Departments shall retain a record of each misadministration for three 3 years The record must contain the university s name and department the names of all individuals involved including the prescribing physician allied health perso
226. tion These personnel usually work under the supervision of the authorized user The success of the radiation safety program depends on the individual s thoughtfulness and care in handling radioisotopes and devices producing ionizing radiation The individual user is responsible for the following A Complying with the Radiation Safety Manual applicable regulations license conditions and safety procedures of the authorized user protocols and any administrative control that may apply to the work being done B Using all appropriate protection and security measures for the safe use storage transfer and disposal of the material machine or device Reporting any defective equipment to the supervisor or the Radiation Safety Office Immediate notification of the Radiation Safety Office in the event of an emergency or of a situation that may create a radiological safety hazard and carrying out recommended action and or corrective measures E If required wearing of an applicable dosimeter in a location on the body that will give the most accurate measurement of radiation exposure and wearing it at all times while working in the presence of ionizing radiation Keep exposures as low as possible F Reporting immediately to the supervisor and to the Radiation Safety Office any lost or stolen materials or equipment that produce or generate ionizing radiation G Wearing appropriate protective equipment such as lead aprons to assure exposure
227. tions Licensees who use generators and radiopharmaceutical kits should also do the test using a vial similar in size shape and construction to the radiopharmaceutical kit vials normally used The following test assumes injections are done with 3 cc plastic syringes and that radiopharmaceutical kits are made in 30 cc glass vials If you do not use these change the procedure so that your syringes and vials are tested throughout the range of volumes commonly used a In a small beaker or vial mix 2 cc of a solution of Tc 99m with an activity concentration between 1 and 10 mCi ml Set out a second small beaker or vial with non radioactive saline You may also use tap water b Draw 0 5 cc of the Tc 99m solution into the syringe and assay it Record the volume and millicuries indicated on Form 109 Dose Calibrator Geometrical Variation Test c Remove the syringe from the calibrator draw an additional 0 5 cc of non radioactive saline or tape water and assay again Record the volume and millicuries indicated d Repeat the process until you have assayed a 2 0 cc volume e Select as a standard the volume closest to that normally used for injections For all the other volumes divide the standard millicuries by the millicuries indicated for each volume The quotient is a volume correction factor Alternatively you may graph the data and draw horizontal 5 percent error lines above and below the chosen standard volume f Ifanycorrecti
228. tive of the examination Radiographic films should not be used beyond the expiration date included in the manufacturer s recommendations and appropriate shielding shall be used to adequately protect unprocessed film Radiographic image receptors should be cleaned according to the instructions of the manufacturer and should be evaluated periodically for adequate function at intervals not exceeding six months Individuals operating radiographic or fluoroscopy equipment must wear personal dosimetry devices provided by the facility When wearing protective clothing lead aprons etc the dosimetry device must be worn on the outside of protective clothing on the front portion of the body and at or near collar level The tube potential kilovoltage filtration and source skin distance SSD employed in fluoroscopic examinations should be as large as practical consistent with the objectives of the study The x ray technologist or operator should use the maximum SSD consistent with medical requirements of the procedure For radiographic or fluoroscopic procedures distances of less than 30 cm 12 in shall not be used and distances of less than 38 cm 15 in should not be used The smallest practical field sizes and the shortest irradiation time should be employed Each person except the patient shall wear protective aprons of at least 0 5 mm lead equivalent material in the radiography or fluoroscopy room if they may be exposed to the useful
229. tment site Establishing the quality assurance spot checks and reviewing the data from those checks as required Consultation with the authorized user in treatment planning as needed and Perform calculations assessments regarding patient treatments that may constitute medical events Operating Procedures A Only individuals approved by the Authorized User Radiation Safety Officer or Authorized Medical Physicist shall be present in the treatment room during treatment Protective shielding barriers shall be available for persons in the treatment room when the beam is energized Personnel unable to remain behind the shielding should wear fluoroscopic aprons and thyroid shields when compatible with patient safety and necessary for the radiation exposure levels possibly encountered The Authorized Medical Physicist will determine which persons in the treatment room require monitoring when the beam is energized When the unit and or shielding is portable the operator shall use a survey meter to verify proper placement of the shielding immediately upon initiation of treatment or alternatively the Authorized Medical Physicist may define areas within the room and appropriate shield locations necessary to maintain safe radiation levels to the operator An Authorized Medical Physicist shall be physically present from the initiation through the duration of all patient treatments involving the unit During operation the operator shall mo
230. to radiation is as low as possible Applying for Authorization to Use Radioactive Material Under a broad scope license the authority to control the use of radioactive materials or sources and equipment that generate radiation within this institution is vested in the institutional Radiation Safety Committee RSC Persons requiring information concerning the use of radioactive materials should call the Radiation Safety Office for guidance Page 13 of 185 University of Mississippi Medical Center A Personnel with prior approval Those desiring to modify their approval must either submit a memo to the Radiation Safety Office indicating the change requested and a brief description of how the radioactive material will be used or obtain an Application for Authorization to Use Radioactive Materials from the Radiation Safety Office download it from the EHS web page or copy it from this manual The completed form must be returned to the Radiation Safety Office for submission to the Radiation Safety Committee B New Personnel Persons applying for approval to use radioactive material or radiation sources for the first time must obtain an Application for Authorization to Use Radioactive Materials for diagnostic or therapeutic uses or an Application for Authorization to Use Radioactive Materials for Research Purposes from the Radiation Safety Office or download it from the EHS web page or copy it from this manual When completed this form must b
231. to assert authority If the RSC has overruled the RSO it will record the basis for its action in the minutes of the next RSC meeting Review of ALARA Program a The RSC will encourage all users to review current procedures and develop new procedures as appropriate to implement the ALARA concept The RSC will perform a review of occupational radiation exposure with particular attention to instances in which the investigational levels are exceeded The principal purpose of this review is to assess trends in occupational exposure as an index of the ALARA program quality and to decide if action is warranted when investigational levels are exceeded Refer to the Personnel Monitoring section of this document for clarification of investigational levels The RSC will evaluate our institution s overall efforts for maintaining doses ALARA on an annual basis This review will include the efforts of the Radiation Safety Office authorized users and workers as well as those of management Page 133 of 185 University of Mississippi Medical Center Radiation Safety Office l Periodic Review of ALARA Program a The Radiation Safety Office will perform an annual review of the radiation safety program for adherence to ALARA concepts Review of specific methods of use may be conducted on a more frequent basis b Occupational exposures will be reviewed as the reports are received from the vendor The Radiation Safety Office will review the ext
232. to individuals as far below the limits as is reasonably achievable the sum of the doses received by all exposed individuals will also be maintained at the lowest practicable level Due to the nature of the specialties within which UMMC personnel are branched into certain groups are Page 132 of 185 University of Mississippi Medical Center expected to receive higher exposures than other groups Efforts will be made to keep exposures to these specialty areas to the lowest possible level Radiation Safety Committee 1 Review of Proposed Users and Uses a The RSC will thoroughly review the qualifications of each applicant with respect to the types and quantities of materials and methods of use for which application has been made to ensure that the applicant will be able to take appropriate measures to maintain exposure ALARA When considering a new use of radioactive material the RSC will review the efforts of the applicant to maintain exposure ALARA The RSC will ensure that the users justify their procedures and that individual and collective doses will be ALARA Delegation of Authority The judicious delegation of RSC authority is essential to the enforcement of an ALARA program This authority is assigned by the Vice Chancellor and will be re enforced by the Vice Chancellor a The RSC will delegate authority to the RSO for enforcement of the ALARA concept The RSC will support the RSO when it is necessary for the RSO
233. transport in accordance with all applicable DOT requirements Ensure licensed material is disposed of properly Ensure appropriate records are maintained Ensure an up to date license is maintained and amendment and renewal requests are submitted in a timely manner RESPONSIBILITIES OF DEPARTMENT CHAIRMEN DEANS AND ADMINISTRATORS Department Chairmen Deans Directors of Research Institutes or Centers as Administrators are responsible for the general safety of faculty staff and students working with radiation in their overall area of jurisdiction It shall be emphasized that this responsibility is reduced in no way by activities of the Radiation Safety Committee or the Radiation Safety Office Page 11 of 185 University of Mississippi Medical Center Administrators shall ensure that the principal investigators in their areas of jurisdiction are provided with appropriate safety policies and procedures and shall stress the importance of compliance with the guidelines described therein Administrators are mutually responsible with the principal investigators or authorized users for informing the Radiation Safety Office of work involving radiation and reporting accidents or incidents involving radiation to the Radiation Safety Office The Department Chairmen and the faculty members who supervise teaching laboratories are mutually responsible for informing students of proper precautions to be taken when working with radiation RESPON
234. tritium in a non contained form other than metallic foil within a Page 19 of 185 University of Mississippi Medical Center 30 day period shall have bioassays performed within one week following a single operation Individuals believed to have ingested or inhaled significant amounts of a tritium compound from an accident or incident will be required to provide a urine sample for determination of exposure LABELING AND POSTING The Radiation Safety Office provides all required signs and labels Notices A In areas where employees are working around x ray generating devices the following items must be posted 1 2 Notice to Employees sign RH 5 must be posted in a conspicuous location contact the Radiation Safety Office to obtain a copy Appropriate operating procedures must be posted In areas where employees are working around radioactive material the following items must be posted contact the Radiation Safety Office to obtain any of these signs 1 2 3 4 Notice to Employees sign RH 5 must be posted in a conspicuous location Emergency Procedures for Spills Involving Radioactive Materials Reminder of Good Radioisotope Laboratory Safety Practices Sign specifying No Eating Drinking or Smoking in This Area Caution Signs The conventional magenta or black and yellow three blade design caution sign must be posted in areas described below contact the Radiation Safety Office
235. turer 185
236. uch barriers In addition to the requirement for primary and or secondary barriers the following design requirements are made A Each treatment room shall have provisions to permit continuous aural communication and visual observation of the patient from the treatment control panel during irradiation The electronic brachytherapy unit shall not be used for patient irradiation unless the patient can be observed B If applicable provision shall be made to prevent simultaneous operation of more than one radiation producing therapeutic device in a treatment room C For electronic brachytherapy units operated at accelerating potentials lower than 60 kV 1 Access to the treatment room shall be controlled by a door at each entrance 2 Radiation shielding for the staff in the treatment room shall be available either as a portable shield and or as localized shielded material around the treatment site The shielding shall be designed in terms of width height thickness and distance from the source to limit the radiation exposure to all personnel within permissible limits Electrical Safety A The high voltage transformer shall be electrically isolated to prevent electrical and magnetic interference with the surrounding environment and ancillary equipment Page 53 of 185 University of Mississippi Medical Center The high voltage transformer shall be isolated from personnel e g operator and the environment by protective housing that ca
237. uires a radiation badge As a requirement of this facility s radioactive material licenses and x ray device registrations issued by the Mississippi State Dept Of Health the UMMC Radiation Safety Office must obtain any past occupational exposure that you may have received while wearing a radiation badge issued by a previous employer Complete this form by supplying the name address and dates of previous employment where you were issued a radiation badge You must also provide your social security number and birthday for this office to track your occupational exposure to radiation while employed at UMMC CHECK ONE I was not issued a radiation badge at any of my previous places of employment I was issued a radiation badge by these previous employers addresses included on the following dates and I authorize the release of my exposure histories to the UMMC Radiation Safety Office EMPLOYER DATE ADDRESS Social Security No Date of Birth Title Employee ID No Name Printed Signature STATEMENT OF EMPLOYEE TRAINING FORM INSTRUCTIONS Before a radiation badge can be issued and before you can perform duties involving sources of radiation you must complete the training as indicated below a If using radioactive material Contact Radiation Safety to be enrolled in the appropriate course on Blackboard or Health Stream b If working around x rays Contact Radiation Safety to be enrolled in a course on Blackbo
238. upon installation and at intervals not to exceed 3 months thereafter Testing shall be completed over the range of use between 30 microcuries and the highest dosage that will be assayed Records shall include 1 The model and serial number of the dose calibrator Page 28 of 185 D University of Mississippi Medical Center The calculated activities The measured activities The date of the test and we we ug The signature of the Radiation Safety Officer Records of each linearity test shall be retained for three 3 years Geometry Dependence Testing A Testing each dose calibrator for geometry dependence is required upon installation to include the range of volumes and volume configurations for which it will be used A record of this test shall be retained for the duration of the use of the dose calibrator Records shall include 1 The model and serial number of the dose calibrator 2 The configuration and calibrated activity of the source measured 3 The activity of the source 4 The activity measured and the instrument setting for each volume measured 5 The date of the test and 6 The signature of the Radiation Safety Officer Personnel shall mathematically correct dosage readings for any geometry or linearity error that exceeds 10 percent if the dosage is greater than 10 microcuries and shall repair or replace the dose calibrator if the accuracy or constancy error exceeds 10 percent Checks an
239. ve adopted are listed below in the Personnel Monitoring section of this document Personnel Monitoring Personnel will be issued radiation monitoring badges if exposure to radiation is likely to exceed 1046 of the maximum permissible dose as stated in state and federal regulations Annual limits of exposure to radiation are stated in the Regulations for the Control of Radiation in Mississippi and are listed below 1 Occupational Dose Limits for Adults a Annual limit shall not exceed which is the more limiting of 1 The total effective dose equivalent TEDE being equal to 5 rems 5000 mrem or 0 05 sievert or 2 The sum of the deep dose equivalent DDE and the committed dose equivalent CDE to any individual organ or tissue other than the lens of the eye being equal to 50 rems 50000 mrem or 0 5 sievert b Annual limits to the lens of the eye to the skin and to the extremities which are Page 135 of 185 University of Mississippi Medical Center 1 Alens dose equivalent LDE of 15 rems 15000 mrem or 0 15 sievert and 2 Ashallow dose equivalent SDE of 50 rems 50000 mrem or 0 5 sievert to the skin or to any extremity 2 Occupational Dose Limits for Minors Occupational dose limits for minors are 10 percent of the annual occupational dose limits specified for adult workers 3 Dose to an Embryo Fetus The dose equivalent to an embryo fetus during the entire pregnancy due to occupational exposure o
240. ved a m p m EXPOSURE RATES IN mR hr Bedside 1 meter from bed Entrance to room COMPLY WITH ALL CHECKED ITEMS 1 Wear film badge or pocket dosimeter 2 Wear disposable gloves 3 Place laundry in linen bag and save 4 Housekeeping must not enter the room 5 Patient must not have visitors 6 Patient must not have pregnant visitors 7 Patient must not have visitors under 18 years of age 8 A dismissal survey must be performed before patient is discharged 9 Patient must have a private room 10 Other instructions Attached as needed IN CASE OF EMERGENCY CONTACT The Radiation Oncology Department at 601 984 2550 Radiation Safety Office at 601 984 1980 After Hours and Weekends see On Call Scheduling for Radiation Safety or contact Emergency Dispatch at 601 984 1420 Page 109 of 185 University of Mississippi Medical Center Date INSTRUCTIONS FOR PATIENTS TREATED WITH THERAPEUTIC DOSES OF IODINE 131 PHOSPHORUS 32 OR GOLD 198 Patient s Name Room No Physician s Name Radioisotope Administered Date and Time of Administration Dose Received Method of Administration Exposure Rates in mR hr Date Time Bedside 3 Feet 6 Feet Door Comply with all checked items a 1 Visiting time permitted a 2 Visitors must remain from patient a 3 Patient may not leave room a 4 Visitors under 18 are not permitted a 5 Pregnant visitors are not permitted Q 6 Perso
241. ved as long as a complete copy of said record can be retrieved until such time as is authorized by MSDH DRH for final disposal The following information shall be maintained in a separate file or package for each therapeutic radiation machine A Report of acceptance testing B Records of surveys calibrations and periodic quality assurance checks of the therapeutic radiation machine required by the Regulations for Control of Radiation in Mississippi as well as the name s of person s who performed such activities C Records of major maintenance and modifications performed on the therapeutic radiation machine as well as the name s of person s who performed such services and D Signature of person authorizing the return of the therapeutic radiation machine to clinical use after service repairs or upgrade Page 69 of 185 University of Mississippi Medical Center INSTRUMENT QUALITY CONTROL Diagnostic X Ray Devices A Devices should be evaluated annually by a qualified expert and calibrated as necessary B Thecalibrated dosimetry system for diagnostic x ray devices shall be traceable to a national standard Computed Tomography Devices A Devices should be evaluated annually by a qualified expert and calibrated as necessary B The calibrated dosimetry system for CT devices shall be traceable to a national standard Fluoroscopic X Ray Devices A Devices should be evaluated annually by a qualified expert and calibrate
242. ventoried Page 42 of 185 University of Mississippi Medical Center 5 Radiation monitors will be checked for proper operation 6 Timer accuracy will be checked 7 The date and time will be checked in the unit s computer 8 The sources decayed activity will be checked in the unit s computer B If the results of the above checks indicate a malfunction of any system Radiation Oncology personnel shall lock the HDR afterloader control console in the off position and not use the unit except as is necessary to repair replace or check the malfunctioning system Spot check records shall include 1 The date 2 The manufacturer s name model number and serial number for the HDR afterloader unit and source 3 An assessment of timer accuracy 4 Notations indicating the operability of each entrance door electrical interlock 5 Operability of radiation monitors source exposure indicator lights viewing and intercom systems and clock 6 Decayed source activity in the unit s computer and 7 The name of the individual who performed the spot check and the signature of the Authorized Medical Physicist who reviewed the record of the spot check C A record of the daily spot checks shall be retained for three 3 years Emergency Procedures The emergency source recovery equipment is located adjacent to HDR unit and consists of remote handling tools forceps shielded storage container Pig and a cable cutter This equipme
243. verse effects The range of potential adverse outcomes depends on at least three key factors Page 123 of 185 University of Mississippi Medical Center The chemical and or physical properties of the agent of concern The dose to which an individual is exposed and The timing of the exposure relative to the development of the fetus The potential risks posed by workplace exposures are difficult to assess because of the complexity of human reproductive and developmental processes the difficulty in differentiating from other contributing factors difficulties associated with interpreting laboratory tests and the lack of available human data Prenatal Radiation Exposure Policy for Employees It is the responsibility of all women of childbearing age who wish to declare their pregnancy to notify their supervisor or the Radiation Safety Office as soon as they know or even suspect that they may be pregnant if their duties involve working in areas where radiation sources are used or stored A woman who wishes to declare her pregnancy must complete the Declaration of Pregnancy Form Attachment A to the Radiation Safety Manual and return it to the Radiation Safety Office It is the institutional policy to transfer the employee to a working environment where occupational radiation exposure is negligible However it is important to note that an employer cannot force an employee to transfer jobs resign or take unpaid leave A pregnant employee
244. void needless exposure of the patient and other persons in the vicinity during equipment use The x ray technologist or operator shall determine that no person other than the patient will be exposed to the useful beam The radiographer shall ensure that all persons other than the patient are as far from the mobile unit as their duties and condition will allow Page 63 of 185 University of Mississippi Medical Center Human patients who cannot be removed from the room shall be protected from the direct scatter radiation by whole body protective barriers of not less than 0 25 millimeters lead equivalent material or shall be so positioned that the nearest portion of the body is at least 2 meters from both the tube head and the nearest edge of the image receptor Mammography X Ray Equipment In addition to the above mentioned general procedures mammography equipment has a few specific guidelines that should be followed any time radiography is being performed A B Compression shall be used in all mammographic procedures Imaging techniques should minimize exposure times by use of sufficiently high mA values in order to avoid unnecessary dose increase due to reciprocity law failure A mammographic unit that is designed for a specific purpose should only be used for that purpose Cardiac and Special Procedures Radiographic Equipment In addition to the above mentioned general procedures cardiac and special procedures equipment has a f
245. who made the survey Trash and linen removed from the patient s room shall be monitored with a radiation detection survey instrument and held for decay in storage when necessary before being released Tray tables blood pressure cuffs pillows and other items removed from the room must be surveyed before being released If contaminated with radioactive material the items will be decontaminated before being released or held for decay in storage by the Radiation Safety Office A survey of the patient s room and bathroom for removable contamination will be made with a radiation detection survey instrument before assigning another patient to the room The room must not be reassigned until removable contamination is less than 200 disintegrations per minute per 100 square centimeters A measurement of the thyroid burden of each individual who helped prepare or administer a dosage of iodine 131 will be made within 6 72 hours after administering the dosage Bioassay records will be retained for a period of three 3 years Bioassay records shall include 1 The thyroid burden measurement Date of the measurement The name of the individual whose thyroid burden was measured and Tw 9 Bb The initials of the individual who made the measurements Syringe Shields and Vial Shields A Nuclear Medicine Nuclear Cardiology PET personnel shall keep syringes that contain radioactive material to be administered in a radiation shield Personn
246. wn the Radiation Safety Office will implement changes in the program to maintain doses ALARA Authorized Users l New Methods of Use Involving Potential Radiation Doses Page 134 of 185 University of Mississippi Medical Center a The authorized user will consult with the Radiation Safety Office and or RSC during the planning stage before using radioactive materials for new uses b Theauthorized user will review each planned use of radioactive materials to ensure that doses will be kept ALARA 2 Authorized User s Responsibility to Supervised Individuals a The authorized user will explain the ALARA concept and the need to maintain exposures ALARA to all supervised individuals b Theauthorized user will ensure that supervised individuals who are subject to occupational radiation exposure are trained and educated in good health physics practices and in maintaining exposures ALARA Individuals Who Receive Occupational Radiation Doses l Workers will be instructed in the ALARA concept and its relationship to work procedures and work conditions 2 Workers will be instructed in recourses available if they feel that ALARA is not being promoted on the job Establishment of Investigational Levels This institution hereby establishes investigational levels for occupational radiation doses which when exceeded will initiate review or investigation by the RSC and or the Radiation Safety Office The investigational levels that we ha
247. xposure The deep dose reading which results from the penetrating component of a radiation field is the most important measurement The shallow dose component reading is essentially a determination of the amount of exposure received by the skin of the whole body If a monitor is worn close to the head of the body the lens dose reading is a determination of the exposure received by the lens of the eye Exposures due to uptakes of radioisotopes into the body will be determined from measurement of biological samples and or partial body counting of radiation emitted from within the body The Page 14 of 185 University of Mississippi Medical Center Radiation Safety Office through a review of the situation and the applicable regulatory requirements will determine the need for the various types of monitoring The method of monitoring in each group whether internal or external will be determined at the time applications for radiation use are reviewed however the monitoring requirements for an individual will be reviewed and if necessary changed at any time by the Radiation Safety Office If an authorized user or individual user believes that monitoring is necessary then such monitoring will be provided initially and the results as to the need for further monitoring evaluated by the Radiation Safety Office If such monitoring is completely unnecessary it will be brought to the Authorized User s attention and monitoring may be discontinued It
248. y are pregnant 2 No visitors less than 18 years of age 3 Visitors must maintain a distance of 3 feet or greater from the patient and limit visitation time as specified in the order provided to the nurses by the Medical Physicist for each individual patient Whenever in doubt as to a correct radiation procedure ask before you act Contact the Radiation Oncology Department at 984 2550 and speak with the Medical Physicist or contact the Radiation Safety Office at 984 1980 and speak with the Radiation Safety Personnel 178 University of Mississippi Medical Center APPENDIX J HDR Emergency Procedures 179 University of Mississippi Medical Center EMERGENCY PROCEDURES FOR microSelectron HDR GENIE IF THE SOURCE FAILS TO RETURN TO THE SAFE 1 Press the RED EMERGENCY STOP BUTTON on the treatment control panel If the source retracts and the radiation indicator light is off go to step 7 otherwise step 2 2 Enter the treatment room e Lift the ACCESS PANEL on top of the treatment unit to access the GOLD HAND CRANK Turn it in the direction of the arrows on the hand crank until it blocks e If the source retracts go to step 7 otherwise step 3 GOLD HAND CRANK Black Hand Crank Well Recess ACCESS PANEL lift here NE Radiation Tag Safe Indicator Emergency Stop Button ce Radiation Indicator L1 Gold Hand Crank Location Access Panel Location Emergency Container 3 Check the patien
249. y is less than 30 microcuries For dose calibrators on which you select a range with a switch select the range you would normally use for the measurement Convert the time and date information you recorded to hours elapsed since the first assay On a sheet of log log graph paper label the vertical axis in actual millicuries as recorded on the dose calibrator Label the logarithmic horizontal axis in millicuries as calculated for decay Plot the actual readings in millicuries against the calculated readings in millicuries The actual readings versus the calculated activity must be within 5 At the top of the graph note the date manufacturer model number and serial number of the dose calibrator Then plot the data Draw a best fit straight line through the data points For the point farthest from the line calculate its deviation from the value on the line Deviation activity observed activity value from best fit line activity value from best fit line If the worst deviation is more than 0 05 the dose calibrator should be repaired or adjusted If this cannot be done it will be necessary to make a correction table or graph that will allow you to convert from activity indicated by the dose calibrator to true activity Put a sticker on the dose calibrator that states when the next linearity test is due b Shield Method 162 University of Mississippi Medical Center If you decide to use a set of sleeves of var
250. ze the patient s health an oral directive shall be acceptable provided that the information contained in the oral directive is documented as soon as possible in the patient s record and a written directive is prepared and signed by the authorized user within 24 hours of the oral directive If because of the patient s condition a delay in order to provide a written revision to an existing written directive would jeopardize the patient s health an oral revision to an existing written directive shall be acceptable provided that the oral revision is documented as soon as possible in the patient s record and a revised written directive is signed by the authorized user within 48 hours of the oral revision Each administration must be in accordance with the written directive Specific details of the administration and related calculations of the final treatment plan must be in accordance with the written directive Both manual and computer generated dose calculations must be checked for accuracy Computer generated dose calculations must be correctly transferred into the consoles on the therapeutic medical units HDR or accelerator Any unintended deviation from the written directive shall be identified and evaluated so that appropriate action can be taken The Radiation Safety Office will be notified of the deviation Records of the written directives shall be retained for a period of three 3 years Prior to administration of a radiatio

Radiation Safety Manual - University of Mississippi Medical Center

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