RADIATION PROTECTION HANDBOOK

UCSF MEDICAL CENTER
AND
UCSF MOUNT ZION MEDICAL CENTER

University of California San Francisco
Office of Environmental Health and Safety

Revised May 2004

Reviewed and Approved by:

Original signed by:

Table of Contents

Top of page

List of Emergency Phone Numbers

IN CASE OF RADIATION EMERGENCY

1. CALL UNIVERSITY POLICE 9-911
   Follow HazardousMaterials Emergency
   Response Guidelines (See the following page)



2. ALERT PHYSICIANS IN AFFECTED AREA:

   a. RADIATION ONCOLOGY

   Consult Patient Chart or Call (24 hours)

   UCSF Parnassus Campus (24 hours) 353-8900

   UCSF Mt Zion Campus (24 hours) 353-7175

   b. NUCLEAR MEDICINE

   UCSF Campus (24 hours) 476-1521

   UCSF/Mount Zion Campus 885-7280
   (after hours call Page Operator)

Top of page

Hazardous Material Emergency Response

The Office of Environmental Health and Safety's Hazardous Materials Emergency Response Program provides 24-hour emergency support to campus and satellite locations.

The on-call HazMat Responder is available seven days a week, 24 hours a day to provide technical assistance to campus units, CRM, the UCPD and the San Francisco Fire Department. The HazMat Responder will immediately reply by phone to all requests for emergency support. If on-site assistance is required, the HazMat Responder will arrive as soon as possible.

ALL REQUESTS FOR EMERGENCY ASSISTANCE SHOULD BE MADE TO THE UCPD.

HAZARDOUS MATERIALS EMERGENCY REPORTING PROCEDURES:

1. Attend to injured or contaminated persons and remove them from exposure. Avoid unnecessary movement in order to prevent the spread of contamination.



2. Alert persons in the immediate area to evacuate.



3. Call UCPD at 9-911 and provide the following information:
   • Your name
   • Call-back phone number
   • Location of incident
   • Identity of spilled material
   • Quantity of material spilled
   • Any other pertinent information

   UCPD will then contact the EH&S HazMat Responder.

4. Close doors and restrict access to affected area.



5. Have a person knowledgeable of the incident and the affected area assist emergency personnel.

The University of California - San Francisco
OFFICE OF ENVIRONMENTAL HEALTH AND SAFETY
Information Bulletin

Top of page

Preface

The Radiation Protection Handbook is a reference for radiation safety policy, procedures, and general information concerning specific uses of ionizing radiation and radioactivity in the Medical Center environment. It is recognized that many workers may not directly work with radioactive materials or radiation producing machines, but do work from time to time in controlled areas where radioactivity may be present or in areas where ionizing radiation is being used in a diagnostic or therapeutic procedure. This manual addresses matters of radiation safety of a wide audience: medical staff, nursing, technical and ancillary care staff, authorized users of radioactive .materials or licensed radiation producing machine operators. This manual has been formatted in a tabbed binder in order to provide information in a readily accessible, concise manner for the user.

Use of radioactive materials in the Medical Center is done under the license held by the University of California San Francisco from the State of California. The Radiation Safety Committee is charged with the responsibility to establish and maintain a radiation safety program. This handbook is a companion document to the Radiation Safety Manual which outlines the requirements and procedures governing the use of radioactive materials at the University of California San Francisco. All authorized users of radioactive materials are expected to be familiar with the content of the Radiation Safety Manual. The Radiation Safety Committee is responsible for the contents of the Radiation Protection Handbook. Clarifications or requests for additional information on the subject matter of this handbook may be sought from the Radiation Safety Officer (476-1300).

All personnel who work with ionizing radiation in the Medical Center are responsible for knowing and adhering to the guidance of this handbook as well as the specific policies and procedures of their respective departments or sections. The guidance set forth in this manual is in accordance with the California Radiation Control Regulations (Title 17 Health), the University of California San Francisco Radiation Safety Manual, and recommendations of the National Council on Radiation Protection and Measurements reports. The terminology used in this handbook follows NCRP guidelines in using the terms "shall" and "should" with strictly defined meanings.

"Shall" indicates a recommendation that is necessary or essential to meet the currently accepted standards of protection.

"Should" indicates an advisory recommendation that is to be applied when practical. It is equivalent to "is recommended" or "is advisable."

Top of page

Introduction

During the course of your duties, you might be assigned to care for patients who have received radioactive material or you might work near an x-ray machine.

This handbook has been prepared to provide you with the general principles of radiation protection. The intent is to furnish the information that Medical Center employees need to provide quality patient care.

Those who want more information should check the references listed in the Bibliography section following the Appendices or contact the campus Radiation Safety Officer (476-1300).

AS LOW AS REASONABLY ACHIEVABLE (ALARA) PHILOSOPHY

Section 30253 of the California Radiation Control regulations requires each licensee to make every reasonable effort to maintain radiation exposures and releases of radioactive materials in effluents to unrestricted areas As Low As Reasonably Achievable (ALARA), taking into account the state of the technology and the economics of improvements in relation to benefits to the public health and safety. To achieve this goal, the Medical Center addresses dose reduction for both workers and patients.

The success of such a program depends on the cooperation of each employee. Specific radiation safety operating emergency procedures are important elements in any dose reduction program. Recent data throughout the medical community indicates the occupational exposures of less than 10% of the annual maximum permissible dose are readily achievable with proper attention to good practice.

The Medical Center has incorporated into its program those procedures, practices and quality assurance checks that can eliminate unnecessary or extraneous radiation exposure to workers and patients without compromising the quality of medical service.

Such practices and checks include, but are not limited to:

1. Use of appropriate and well-calibrated instruments and equipment;



2. Use of appropriate films and good processing techniques;



3. Use of organ shields in diagnostic radiology;



4. Staying well within the established dosage limits, unless deviation is absolutely essential in the judgment of the responsible physician.

The Medical Center is committed to an efficient medical use of radioactive materials and radiation producing equipment by limiting their use to clinically indicated procedures; utilizing efficient exposure techniques and optimally operating equipment; limiting doses to those recommended by the manufacturer, unless otherwise necessary; using calibrated diagnostic and related instrumentation; and using appropriately trained personnel.

The Medical Center is committed to a program for keeping occupational, individual and collective doses as low as reasonably achievable (ALARA). Toward this commitment, this Handbook describes the written policies, procedures and instructions to foster the ALARA philosophy within our institution.

The Medical Center's Radiation Safety Committee will review this handbook periodically, and all Medical Center practices will be consistent with the Campus Radiation Safety Committee policies and procedures.

Top of page

PART I: PRINCIPLES OF RADIATION PROTECTION

A. THREE CONCEPTS TO REDUCE EXPOSURE TO IONIZING RADIATION

1. Time—The amount of exposure is directly related to the time that one is exposed to ionizing radiation from a source. In order to reduce exposure, plan work in advance in order to reduce the amount of time spent in a procedure that requires the operator to be exposed.



2. Distance—Exposure is related to distance in an inverse square relationship. If one's distance from a source of radiation is doubled, then the exposure rate is reduced to 25% of the original exposure rate. Increase distance from radiation sources when possible.



3. Shielding—Appropriate shielding is generally used where possible in order to reduce exposure to ionizing radiation. The appropriateness of a shield is based upon the character of the radiation that is of interest. For example, alpha radiation may be stopped by a paper or a few centimeters in air. Beta radiation may be stopped by a centimeter or two of Lucite. More penetrating x-ray or gamma radiation usually requires lead or tungsten shielding. Personnel protective equipment may be appropriate for some uses and these may take the form of lead aprons for diagnostic radiographic procedures or some therapeutic procedures, or movable lead shields in other clinical procedures.

B. OCCUPATIONAL RADIATION DOSE LIMITS

An occupational dose is the dose received by an employee in whom the individual's assigned duties involve exposure to radiation and/or radioactive material. The occupational dose does not include dose received from background radiation or from medical procedures administered to the individual or dose received as a member of the general public. There are a variety of sources of exposure to ionizing radiation in the Medical Center setting. These sources include radiation producing machines in the Radiology, Cardiology, and Radiation Oncology Departments or radioactive materials used in Nuclear Medicine diagnostic and therapeutic procedures and sealed sources of radioactive materials that are used in the treatment of cancer by the Radiation Oncology Department. There is an annual limit on the occupational dose that may be received which includes dose that may be received from external sources or internal sources. The annual occupational dose limits are set out in Table 1-1.

The use of ionizing radiation seldom requires that an occupationally exposed worker receives the maximum limit and in order to maintain doses to workers at a minimal level, there are levels of dose that trigger an investigation into the work practice that caused an elevated level of dose. Since the different types of work that are done in the medical center present different situations for exposure, investigational levels have been established that are appropriate for the work being performed (Table 1-1). The purpose of an investigation into an elevated dose is to determine the cause and whether there can be a dose saving by reviewing the work procedure and any relevant engineering or administrative controls. Table 1-1 lists the annual occupational dose limits and the investigational dose levels for Medical Center workers.

Occupational dose is required to be monitored when

• adult employees are likely to receive a dose greater than 10% of the values in Table 1-1 (Annual Occupational Dose Limits).



• minors or declared pregnant employees are likely to receive a dose greater than 1% of the annual occupational dose limit for an adult employee.



• workers enter a high or very high radiation area.

Bioassay - Occupational intake of radioactive material is required to be monitored when

• adult employees are likely to receive in excess of 10% of the annual limits of intake (found in 10 CFR 20 Appendix B).



• minors or declared pregnant workers are likely to receive a committed effective dose equivalent in excess of 50 mrem in a year.

Top of page

C. PREGNANT PERSONNEL POLICY

The dose to an embryo/fetus during the entire pregnancy shall not exceed 500 mrem from occupational dose of a declared pregnant woman. In the event of suspected or known pregnancy, it is the responsibility of the employee to notify her supervisor and the Radiation Safety Officer in writing so that an appraisal of her potential occupational exposure to ionizing radiation can be made. The Appendix to the Nuclear Regulatory Commission Guide 8.12 "Possible Health Risks to Children of Women Who are Exposed to Radiation During Pregnancy" is available upon request (476-1300). The Radiation Safety Officer is available for consultation and advice in evaluating the potential occupational exposure and methods to reduce exposure. The pregnant employee's workload and schedule may be revised to reduce or avoid procedures where the potential exists for radiation exposure. Pregnant staff may not be assigned to work in some areas. However, it is not the policy that pregnant employees be required to stop working in all duties where potential exists for exposure to ionizing radiation.

Pregnant employees (or those suspected to be) who continue to work in fluoroscopic and special procedures should wear wraparound lead aprons that protect all sides of the body. Pregnant employees continuing to work in duties where the potential for exposure to ionizing radiation exists should be issued a film badge which is used to monitor fetal exposure. This dosimeter can be requested from Environmental Health & Safety (476-1300). The fetal dose monitoring allows for a monthly review of the dose level to ensure that the prescribed dose limit is not exceeded. Should the fetal dose approach 500 mrem, then it is mandatory that the worker no longer work in areas where occupational dose to ionizing radiation is present until termination of the pregnancy.

The pregnant employee should immediately inform her supervisor of any unexpected, unusual, or potentially high exposures.

D. RADIATION MEASURING DEVICES

1. Dosimetry

Film badges can measure the exposure to a level as low as 10 mrem per month. These badges are worn on the upper torso of the body in the same position in order to evaluate deep dose equivalent to the employee. The badges must be placed properly in the film holder and protected from nonoccupational exposure including especially any medical or dental exposure the employee may undergo. Ring badges use thermoluminescent detectors to assess exposure to extremities. These detectors are accurate to levels as low as about 5 mrem per month. Both the film badge and ring badges are exchanged on a monthly frequency and the results of the monitoring are made available to each monitored employee.

2. Survey Meters

A useful instrument for measuring radiation levels is the survey meter (an ionization chamber or a Geiger Meter may be used). Other instrumentation may be needed depending upon the type of radiation one is trying to monitor. Background radiation levels must be measured prior to measuring the area where one expects to find an elevated reading. Background radiation rates may be at a level of 20 microrem per hour. See Table 1-2 for background radiation sources.

Top of page

TABLE 1-1

Maximum Dose Limits¹

UCSF & UCSF/Mount Zion External Exposure Investigational Levels

¹California Radiation Control Regulations Title 17 (10 CFR 20.1201)
²NCRP Report No.91, Table 22.1

Top of page

TABLE 1-2

Typical Exposure Levels From Some Common Sources

* References: NCRP Reports 94, 95, 100, 101

Top of page

PART II: DIAGNOSTIC RADIOLOGY (RADIATION PRODUCING EQUIPMENT)

A. POLICIES FOR RADIATION PRODUCING MACHINES AND SURROUNDING AREAS

1. All personnel operating x-ray equipment and personnel in the immediate area (x-ray room or 6 feet from a portable x-ray machine) shall wear a film badge.



2. The structural shielding requirements of any new or renovated installation shall be discussed with EH&S Radiation Safety (476-1300) to insure compliance with State and Federal regulations.



3. An annual scheduled survey of all diagnostic and fluoroscopic equipment for patients shall be made by EH&S Radiation Safety (476-1300). In addition, radiation surveys will be made of all new installations and after every change that might increase the radiation hazard (i.e., replacement of x-ray tube, changes in filtration of beam, etc.).



4. Within any room where fluoroscopic equipment is in use, protective aprons shall be worn by the physician, nurse, technician, and all other persons. The protective aprons should be long enough to cover the thigh and have at least 0.25 mm lead equivalency. If there is a need to turn one's back to the beam, then wrap-around aprons should be worn.



5. In the operation of mobile and dental units:
   1. The operator should stand as far as possible from the tube and patient during exposure, and shall wear a protective apron, or step behind an adequate shield.
   
   
   
   2. An operator, standing at least 6 feet from the tube and patient, should not operate machines to produce more than 5,000 milliampere-seconds of exposure during any one week. Rotation of operators or the use of portable shields is recommended for greater workloads.


6. The hand of the fluoroscopist shall never be placed in the unattenuated useful beam. When the hand is adjacent to the beam, a protective glove of at least 0.25 mm lead equivalent should be worn when possible.



7. In an emergency, a person who needs to hold a patient shall wear protective gloves and a protective apron. No part of this person's body should be in the useful beam. No persons shall be regularly employed to hold patients during exposure, nor shall anyone from the Diagnostic Radiology Department ever be permitted to perform such service.



8. Shutter mechanisms and interlocking devices shall not be tampered with and shall be inspected by EH&S Radiation Safety at regular intervals to insure proper operations.



9. All protective devices that may become defective due to use or abuse, such as protective lead aprons or gloves, should be inspected for radiation leakage at least annually, or whenever the integrity of the equipment is suspect.



10. For fluoroscopy machines, a manually reset, cumulative timing device (5 minutes) shall be used which will either sound an alarm, or turn off the apparatus when the total exposure reaches a certain previously determined limit.



11. In cineradiography (recording of images with a cine-camera, e.g. for cardiac catheterization), tube currents and potentials are higher than those used in fluoroscopy. Thus, special care should be taken to decrease patient exposure.
    The exposure rates on these cineradiography units shall be determined during the annual survey by EH&S Radiation Safety (476-1300).



12. Pregnant staff may work with fluoroscopy equipment only if they use appropriate protective shielding.

Top of page

B. OPERATOR'S RESPONSIBILITY

The operator of any radiation producing equipment is responsible for

1. notifying EH&S Radiation Safety (476-1300) when there is any change in the setup, i.e., new equipment installed, changes in shielding, change in output of radiation, or change in usage of the unit.



2. requesting and wearing appropriate monitoring devices if required by EH&S Radiation Safety. Always wear the assigned monitoring device (e.g., film badge) when working with the unit. Whenever protective lead aprons are worn, the body dosimeter should be worn on the outside of the apron at the collar. In addition, ring badges are to be worn if the unprotected hands and forearms come in close proximity to the beam.



3. keeping exposure as low as possible. The operator shall never expose himself/herself to the direct beam, and must not stand within one meter of the tube or irradiated target while the unit is in operation unless adequately shielded. Make full use of protective lead devices: barriers, lead aprons, gloves, and goggles.



4. clearing the area of all nonessential personnel. The operator shall ensure that all essential personnel are adequately shielded.



5. observing any restrictions on the use of the unit recommended by EH&S Radiation Safety (476-1300).



6. using minimum exposure factors. Fluoroscopic work shall be performed in the minimum time possible using the lowest dose rate and smallest aperture consistent with clinical requirements.



7. ensuring that the C-arm of mobile fluoroscopic C-arm equipment is positioned with the x-ray tube underneath the patient or, when operating in the lateral or other planes, with the x-ray tube on the side of the patient opposite the operator(s).



8. visually monitoring tube current and potential of fluoroscopic equipment with image intensifiers at frequent intervals, because, under automatic brightness control, these variables can rise to high values.



9. notifying the supervisor and calling UC Police (9-911) immediately to report accidental exposures to radiation. UC Police will triage with EH&S Radiation Safety.

Top of page

PART III: NUCLEAR MEDICINE (DIAGNOSTIC USES OF RADIONUCLIDES)

A. GENERAL INFORMATION

1. Sample counting. In these procedures (at a stated time after administration of the radionuclides), specimens such as blood, urine, feces, expired air, etc. are taken for measurement. They are transported from the patient's room to the Nuclear Medicine Division for further processing. In most cases, the amount of radioactivity in the specimen is very low. While there is negligible radiation hazard, care must be taken in handling such materials to prevent loss, spillage or contamination. The tests usually require a knowledge of the total sample volume, so partial loss of the contents could lead to erroneous results.



2. Patient Measurement. Many diagnostic procedures in Nuclear Medicine involve direct measurement of the amount or distribution of a radionuclide tracer within the patient. In such cases, measurements are usually made directly on the patient in the Nuclear Medicine laboratory. Such tests may be called uptakes, scans, imaging procedures, or dynamic function study.

Top of page

B. NURSING CARE

Nuclear Medicine shall inform Nursing Units of patients having received radionuclides for diagnostic procedures by completing the nursing advisory form. The urine of patients who have received millicurie doses of technetium for diagnostic procedures will probably contain a significant amount of radioactive technetium for short periods. Therefore, urine tests of parameters other than radioactivity level should be postponed at least one day. In the event a patient were to be incontinent within the first 24 hours after receiving a radionuclide for a diagnostic procedure:

1. Put on gloves;



2. Use Chux pads to absorb liquid;



3. Wash contamination from skin of the patient and personnel;



4. Restrict access to control the possible spread of contamination;



5. Notify UC Police (9-911) immediately. UC Police will triage with EH&S Radiation Safety. Then call the Nuclear Medicine physician (353-1693 at UCSF Parnassus or 885-7280 at UCSF Mount Zion).

C. SPECIMEN TRANSPORT

Nursing care of patients who have received tracer or diagnostic doses generally presents no radiation hazards. If urine, fecal, or emesis material is to be saved for the laboratory, disposable gloves shall be worn in the collection or placement of the material into containers.

Top of page

D. GUIDELINES FOR THE USE OF RADIONUCLIDES IN THE OPERATING ROOM

Radionuclides are used as tracers in many Nuclear Medicine procedures to examine the function of an organ system. In the operating room such techniques are useful in various applications, from identifying certain lesions that must be removed to monitoring the concentration of a material in systemic circulation. Specialized equipment may be needed in order to detect the radiation from the tracers in the patient, such as a gamma camera or probe devices. Generally, the amount of radioactivity given to a patient in these situations is not great enough to require the use of lead aprons by the operating room staff. Information regarding the amounts of material used in a procedure may be obtained from the Nuclear Medicine physician. Assessment of need for personnel protective equipment or monitoring may be obtained from consulting Environmental Health and Safety. Please contact the clinical section of Environmental Health and Safety at 476-1300. Anyone who may receive an exposure of 100 mrem in a year from procedures done in the operating room should be monitored with assigned personnel dosimetry.

1. The Nuclear Medicine physician supervising the procedure will advise whether personnel protective equipment is needed. Contact Environmental Health and Safety for assistance, if necessary.



2. Water-tight gloves should be worn whenever liquid radioactivity is utilized in a procedure. These gloves should be removed prior to leaving the room to minimize the spread of contamination. Hand-washing is also advised after the gloves have been removed.



3. The radioactive material that is to be administered to the patient must be identified as the proper radionuclide, the intended chemical form and the amount of radioactivity assayed in a dose calibrator that is subject to routine quality control procedures.



4. Administration of the material to the patient shall be performed in such a manner that any spilled radioactivity can be readily absorbed and removed. The potential for contaminating equipment must be considered and adequate monitoring for contamination provided.



5. Monitoring for contamination must be conducted by an individual familiar with performing a survey and with the instrumentation. The Nuclear Medicine personnel assisting with the procedure is the responsible person to perform the survey.



6. Prior to performing any contamination survey
   1. select an appropriate survey instrument;
   
   
   
   2. check the battery or that the device is powered up;
   
   
   
   3. perform constancy test with the designated radioactive source;
   
   
   
   4. examine the instrument for damage.


7. Establish a background reference reading.
   1. With the meter set to its most sensitive response scale, make a measurement of the background radiation in an area of the room where no contamination or radiation is expected to be found. Use this value for determining the presence of contamination.
   
   
   
   2. A rule of thumb is that a reading of greater than two times the background indicates contamination.


8. Monitor all materials that have come into contact with the patient.
   1. Survey the operating table, linen, coverings, instruments and floor.
   
   
   
   2. Survey the surgical team's extremities and the soles of their shoes in case some liquid escaped to the floor.
   
   
   
   3. Survey any fluids and tissues collected from the patient.


9. Place all contaminated items in a container and identify the container with a sign stating the radionuclide, the exposure reading at either the surface or at one meter and the date. The Nuclear Medicine technologist should remove the material for storage until a radioactive waste pick-up from Nuclear Medicine can be arranged with Environmental Health and Safety. Seal all containers of liquids so that fellow workers do not become accidentally contaminated by removing or handling the waste generated by the Operating Room staff or Nuclear Medicine personnel. Remember that all sharps containers should be erect, properly labeled and not overfilled.

Top of page

PART IV. NUCLEAR MEDICINE (THERAPEUTIC USES OF RADIONUCLIDES)

A. THERAPY WITH 1-131

Prior to the release of the patient from the hospital, the patient may receive instructions regarding how to reduce exposure to family members. This may be done by the Nuclear Medicine physician and/or EH&S Radiation Safety. Refer to Appendices 2 and 3 and refer to the "Physician's Orders" sheet in the patient chart.

1. Contamination Control

The room the patient will occupy should be prepared ahead of time by Environmental Health and Safety (EH&S) personnel in order to minimize the spread of contamination. Nuclear Medicine is to arrange ahead of time for the room preparation by EH&S personnel. The floor of the room is covered with a plastic material that is taped down securely. All items that the patient handles regularly are covered with plastic-backed paper. Designated containers for linen and paper products are also placed in the room. Disposable gloves should be worn when working with the patient or with items the patient has handled. All materials should remain in the room until a contamination survey can be conducted and the room is cleared by. EH&S. Please contact the clinical section of EH&S at 476-1300. After 5:00 p.m., please reach EH&S personnel through the UCPD by calling 9-911.

2. Dishes

Disposable dishes, utensils and trays should be used. The dishes, together with other waste, should be placed in the appropriate containers in the room. The materials will be surveyed by EH&S personnel and, if found to be radioactive, removed for storage.

3. Linens

Linens should be held in the room and placed in the designated container until the room is monitored by EH&S personnel. Once cleared, the linen can be sent to the laundry.

Top of page

4. Toilet Instructions

The patient should use the toilet facilities in the room assigned. The toilet should be flushed three times to clear the waste from the lines and dilute the material. The patient should be counseled to avoid splashing urine when voiding and to wipe the toilet seat after use. In some cases, the patient's urine will be pumped via catheter within plastic tubing that is released into a constant flow toilet. For collection of urine, Nuclear Medicine should give instructions for the collection and storage of the specimen. Gloves should be used if personnel are involved with the collection of specimens or in assisting the patient with a bedpan or urinal. The gloves should be washed and then discarded and then the hands should be washed after removing the gloves.

5. Telephone

The telephones and other frequently handled items should be covered with a water-tight barrier to prevent contamination. The items will be surveyed for contamination and either decontaminated if necessary or stored if decontamination efforts are not sufficient.

6. Baths

Unless ordered by a physician, a bath should be postponed for 48 hours. If possible, patients should bathe themselves and should rinse the shower or tub thoroughly afterwards.

7. Environmental Services

Environmental Services shall not be performed until a radiation safety survey has been made at the conclusion of the use of the room. EHS will monitor the room and remove the radioactive materials. When the room has been cleared by EH&S, then the room may be cleaned by Environmental Services.

8. Film Badges

Film badges shall be worn by staff attending an 1-131 patient.

Top of page

9. Restriction of Visiting Time

Nurses and visitors to patients receiving radio-iodine should be limited to the stay times placed on the door of the room by EH&S personnel. The times are calculated based upon monitoring the exposure from the patient. Visitors shall avoid all direct contact with the patient and shall maintain a minimum six foot distance from the patient. Children and pregnant women should not visit a patient receiving radio-iodine therapy.

10. Transporting Patients

Occasionally, patients who have received 1-131 therapy may need to be transported to various clinical services at the Medical Center. Since such patients may contaminate items or irradiate other patients, notify Nuclear Medicine '476-1521 at UCSF or 885-7280 at UCSF/Mount Zion) or EH&S '476-1300) when such patients are to be transported so that proper precautions can be taken.

11. Spills

If there is a spill of radioactive fluid or if a patient who has received radionuclide vomits or is incontinent during the first forty-eight hours, call UC Police '9-911). UC Police will triage with EH&S Radiation Safety for hazardous materials response. Then call the Nuclear Medicine physician listed on the Doctor's Orders Form. Do not attempt to clean up the spill. In such situations, interim steps to help stop the spread of the spill can be taken, as follows:

1. Restrict the area-allow no one to enter, except for urgent patient treatment.



2. Keep people two meters away from the spill.



3. People who may have been contaminated should remain until surveyed and cleared by Nuclear Medicine or EH&S Radiation Safety.



4. Remove contaminated clothing while still in the area. Place contaminated items in a plastic bag and identify the items as radioactive.



5. Cleanse contaminated skin using facilities in the room. Take care not to damage the integrity of the skin while removing contamination from-it.



6. If there is appreciable liquid spilled, cover the area with paper towels.



7. Retain all contaminated or suspected materials in the area until cleared by Nuclear Medicine or EH&S Radiation Safety.

Top of page

12. Emergencies

1. Non-Radiation
   For seizures, cardiac arrest, trauma, etc., follow normal emergency procedures. Call physician listed on Doctor's Orders Form. The physician will determine the need to triage with UC Police '9-911). Nuclear Medicine or EH&S Radiation Safety shall survey potentially contaminated items and personnel. If high radiation levels are present, rotate hospital staff, when possible, to minimize individual exposures.



2. Surgical Procedures
   If surgery is required within twelve days of 1-131 therapy, notify the physician listed on the physician's orders and Nuclear Medicine, if possible before the surgery. (If the surgery involves thyroid tissue, extend the notification period to 45 days.) Monitor tissue specimens prior to Pathology Lab studies. Either Nuclear Medicine or EH&S radiation safety personnel can perform this function.

13. Radiation Patient Death

1. Notify UC Police '9-911) that the patient has died and still contains unsealed radioactive material. UC Police will triage with EH&S Radiation Safety. Then notify Nuclear Medicine and the attending physician on the Doctor's Orders Form. The physician who pronounces the patient dead is responsible for placing a radioactivity precautions tag on the body. The body is not to be released to a funeral director without the approval of the Radiation Safety Officer or his designee. Any handling of the body, autopsy, embalming procedure or treatment of the body must be performed under guidance from Environmental Health and Safety (476-1300). This restriction is for the radiation protection of those who need to handle the remains of the patient



2. If permission has been granted to perform an autopsy, this should be carried out only after consultation with, and under the direction of, Radiation Safety. If the patient dies within the first 24 hours of oral administration of 1-131, the body fluids removed during an autopsy should be removed into closed systems and later flushed into the sewer with adequate water for dilution of the material. When no autopsy is to be performed, the body may be released to the funeral director with the approval of Radiation Safety.
   
   Make sure that the morgue pack form for RADIATION PATIENT DEATH is completely filled out by either Nuclear Medicine or EH&S Radiation Safety. Keep one copy of the form in the chart. Send one copy of the form with the body to the morgue. Retain the third copy in the morgue pack. Place a Radioactive Label on the body bag.



3. Transport of the body: Make sure that all hallways are cleared and elevators are free of other passengers when transporting the body to the morgue. If recommended by either Nuclear Medicine or EH&S Radiation Safety, wear a lead apron when transporting the body.



4. In the morgue, move the body into the cold storage area. Make sure that the Radioactive Label on the bag is clearly visible. Then, flip the sign outside the door of the cold storage unit to indicate a radioactive source is inside. Place the form indicating the level of radioactivity in the holder just below the sign outside the door of the cold storage unit.

14. Nursing Care

Nursing care is to be restricted for the term of treatment to those activities essential to the well-being of the patient. Disposable gloves shall be worn to perform routine patient care. If special nursing care is required, EH&S Radiation Safety (476-1300), Nuclear Medicine 353-1693 at UCSF or 885-7280 at UCSF/Mount Zion) and the Administrative Nursing Manager of the nursing unit will collaborate to identify the specific care requirements. Prior notification of 48 hours is required.

Top of page

B. THERAPY WITH Sm-153 AND Sr-89

Samarium-153 and Strontium-89 are used in the treatment of painful metastatic disease in bone tissue. The material is administered intravenously. Sm-153 is .typically administered in doses of 50-70 mCi while Sr-89 Strontium Chloride is given in doses of 1 to 4 mCi. A patient with metastatic disease may have a 50% uptake of Sm-153 or Sr-89.and the remainder will be excreted through the urinary system and, to a lesser extent, through the GI tract. Other routes of excretion are insignificant for these radionuclides.

Contamination control involves employing universal body fluid precautions when-working with the patient. Personnel dosimetry is not needed when working with a therapy patient containing Sm-153 or Sr-89 as the beta radiation is absorbed within the patient. Some x-rays may be emitted by the patient but the levels of exposure are too low to require the use of lead aprons or shields.

Prior to the release of the patient from the hospital, the patient may receive instructions regarding how to reduce exposure to family members. This may be done by the Nuclear Medicine physician and/or EH&S Radiation Safety. Refer to Appendices 2 & 3 and to the "Physician's Orders" sheet in the patient chart.

1. Contamination Control

The room the patient will occupy should be prepared ahead of time by EH&S personnel in order to minimize the spread of contamination. Nuclear Medicine is to arrange ahead of time for the room preparation by EH&S personnel. The bathroom that is designated for the patient's use should be prepared by covering the floor with a plastic covering and the toilet seat with absorbent paper with a plastic backing so that any needed decontamination can be facilitated. The bathroom facilities shall be surveyed by EH&S Radiation Safety or Nuclear Medicine prior to the release of the room. Please contact the Clinical section of EH&S at 476-1300. After 5:00 p.m., please reach EH&S personnel through the UCPD by calling 9-911.

2. Dishes

No special precautions are necessary.

3. Linens

Bag contaminated linen separately.

4. Toilet Instructions

The patient should use the toilet facilities in the room assigned. The toilet should be flushed three times to clear the waste from the lines and dilute the material. The patient should be counseled to avoid splashing urine when voiding and to wipe the toilet seat after use. For collection of urine, Nuclear Medicine should give instruction for the collection and storage of the specimen. Gloves should be used if personnel are involved with the collection of specimens or in assisting the patient with a bedpan or urinal. The gloves should be washed and then discarded and then the hands should be washed after removing the gloves.

Top of page

5. Telephone

No special precautions are necessary.

6. Baths

Are permitted unless prohibited for any other reason by the physician.

7. Environmental Services

Provide essential service only. Do not remove dressings from the room until monitored and removed by Nuclear Medicine (353-1693 at Parnassus or 885-7280 at UCSF/Mount Zion) or by EH&S Radiation Safety (476-1300).

8. Film Badges

It is not necessary for the nursing staff to wear film badges when working with these patients.

9. Restriction of Visiting Time

There is no need to restrict visitors or routine nursing functions due to the low exposure potential from these patients.

10. Transporting Patient

No special precautions are necessary.

Top of page

11. Spills

Should there be a spill of radioactive fluid, or should the patient who has received Sm-153 or Sr-89 be incontinent during the first 48 hours, call UC Police 9-911). UC Police will triage with EH&S Radiation Safety for hazardous materials response. Then call the Nuclear Medicine physician listed on the Doctor's Orders Form. Do not attempt to clean up the spill. In such situations, interim steps to help stop the spread of the spill can be taken as follows:

1. Restrict the area-allow no one to enter except for urgent patient treatment.



2. Keep people at least 2 meters from the spill.



3. People who may have been contaminated should remain until surveyed.



4. Remove contaminated clothing while still in the area. Place contaminated items in a plastic bag and identify the items as radioactive.



5. Cleanse contaminated skin using facilities in the room. Take care not to damage the integrity of the skin while removing contamination from it.



6. If there is appreciable liquid spilled, cover the area with paper towels.



7. Retain all contaminated or suspected materials in the area until cleared by Nuclear Medicine or EH&S Radiation Safety.

12. Emergencies

1. Non-Radiation
   For seizures, cardiac arrest, trauma, etc., follow normal emergency procedures. Call physician listed on Doctor's Orders Form. The physician will determine the need to triage with UC Police (9-911). Nuclear Medicine or EH&S Radiation Safety shall survey potentially contaminated items and personnel. If high radiation levels are present, rotate hospital staff, when possible, to minimize individual exposures.



2. Surgical Procedures
   If surgery is required within ninety days of Sr-89 therapy, notify the physician listed on the physician's orders and Nuclear Medicine, if possible before the surgery.

Top of page

13. Radiation Patient Death

1. Notify UC Police (9-911) that the patient has died and still contains radioactive material. UC Police will triage with EH&S Radiation Safety. Then notify Nuclear Medicine and the attending physician on the Doctor's Orders Form. Any handling of the body, autopsy, embalming procedure or treatment of the body must be performed under guidance from Environmental Health and Safety '476-1300). This restriction is for the radiation protection of those who need to handle the remains of the patient.



2. Make sure that the morgue pack form for RADIATION PATIENT DEATH is completely filled out by either Nuclear Medicine or EH&S Radiation Safety. Keep one copy of the form in the chart. Send one copy of the form with the body to the morgue. Retain the third copy in the morgue pack. Place a Radioactive Label on the body bag.



3. Transport of the body: make sure that all hallways are cleared and elevators are free of other passengers when transporting the body to the morgue. If recommended by either Nuclear Medicine or EH&S Radiation Safety, wear a lead apron when transporting the body.



4. In the morgue, move the body into the cold storage area. Place the Radioactive Label on the bag so that it Is clearly visible. Then, flip the sign outside the door of the cold storage unit to indicate a radioactive source is inside. Place the form indicating the level of radioactivity in the holder just below the sign outside the door of the cold storage unit.

14. Nursing Care

There is no restriction for routine nursing-care of these patients. If special nursing care is required, EH&S Radiation Safety, Nuclear Medicine and Administrative Nurse Manager of the nursing unit will collaborate to identify the specific care requirements. Prior notification of 72 hours is required.

Top of page

CARE INSTRUCTIONS FOR I-131 THERAPY PATIENTS

Observe all instructions which have been checked below:

Room #: ______   I-131 Activity: ______mCi    Date:______    Time: _______ 

IN EMERGENCY CALL:

External Dose Record for 1-131 mIBG Therapy

Patient Name: __________________

Infusion Date: __________________

Time:   Begin __________________   End __________________

Top of page

NURSE'S CHECK LIST (I-131)

The nurse is responsible for assuring that all precautions and care guidelines for patients receiving radioactive therapy are followed. Nuclear Medicine personnel are responsible for completing and posting the "Radioactive Precautions" sign and care instructions on the door of the patient's room. If there are problems, contact Nuclear Medicine.

1. Does the chart cover have "Radioactive" warning label?



2. Is the room door posted with proper "Radioactive Caution" signs and Care Instructions for I-131 patients?



3. Review Doctor's Orders Form for patients who have received I-131 therapy.
   1. Room assignment and private room.
   
   
   
   2. Patient restriction to room.
   
   
   
   3. Nursing and visiting time restrictions.
   
   
   
   4. Prohibitions against visiting by persons under 18 years and pregnant women (including staff).
   
   
   
   5. Expiration date for precautions.
   
   
   
   6. Film badges, if required.
   
   
   
   7. Note special contamination control procedures required, e.g., disposable dishes, saving linens, special toilet cleaning, etc.
   
   
   
   8. Room must be monitored prior to reassignment.
   
   
   
   9. Forms shall contain the responsible physician's name and 24-hour telephone number.
   
   
   
   10. Review physician instructions and restrictions with patient.

Top of page

PART V: RADIATION ONCOLOGY (BRACHYTHERAPY & TELETHERAPY)

A. BRACHYTHERAPY

1. Operating Room and Post-Operative Care

Many sources are placed in the patient via "afterloading" procedures. This means that the patient receives source holding devices in the Department of Radiation Oncology or in the operating room, but the sources are not installed until later. The installation may be done on the ward. If the patient receives the radioactive sources in the operating room, precautions shall be followed, such as using film badges, placing the patient in a remote corner of the Post Anesthesia Care Unit, and keeping away other patients and pregnant staff. POST-ANESTHESIA CARE PERSONNEL SHALL ALWAYS BE INFORMED PRIOR TO ARRIVAL OF A RADIOACTIVE PATIENT.

Top of page

2. Considerations Relating to the Duration of the Procedure

1. Temporary Interstitial Implants
   In this form of therapy, sealed sources are implanted to irradiate a relatively restricted area for a specified period. The radiation sources) may be afterloaded and controlled by, special programmable "remote afterloader" machines (described below) or the radiation sources may be manually loaded by Radiation Oncology personnel in the form of iridium-192 (Ir-192) seeds contained in a nylon ribbon, iodine-125 '1-125) seeds in catheters or on a plaque sutured to the eye, or palladium-103 (Pd-103) seeds



2. Temporary Intracavitary or Intralumenal Insertions
   In this form of therapy, sealed sources of cesium-137 in the form of tubes or spherical pellets, Ir-192 seeds contained in a nylon ribbon, or a single lr-192 source on a wire are used to irradiate a relatively restricted area for a specified period. The source tubes are placed inside different types of applicators. Rarely, the applicators are loaded with the radioactive sources before insertion into the patient, which means that there is a possibility of radiation exposure from the beginning of the procedure. Usually, the radioactive sources are placed in the applicators later, either manually or using a programmable "remote afterloader" machine (described below).



3. Permanent Interstitial Implants
   This treatment consists of permanently implanting sealed sources in the form of 3-5 mm long seeds into a lesion in a patient to irradiate a relatively restricted area. Radionuclides used for this form of therapy include 1-125 and Pd-103. The activity of the radioactive sources is greatest immediately after implantation and then decays exponentially over a period of weeks or days, depending on which nuclide is used. Apart from the direct radiation, hazards could occur if one of the seeds becomes detached and lost.
   
   The patient shall not be discharged until his/her activity has decreased to permissible levels. This will be determined by the radiation measurements near the patient and also by the ages of the persons living in the patient's household. The requirements are less restrictive if all persons in the household are over 45 years old. The attending physician, fellow, or resident shall be responsible for indicating the expected time of discharge on the "Doctor's Orders Form," and for discussion with the patient and his/her family in advance of the procedure, including the precautions to be taken after discharge. He/she or designee should fill out the form listing "Instructions for Family of Patient With Permanent Implants" 'Appendix 2) (or provide all the relevant information on a customized form), give it to the family, and complete the "Radiation Safety Checklist for Discharge Patients Containing Radionuclides" 'Appendix 3). This checklist and a copy of the completed "Instructions for Family of Patient With Permanent Implants" should be kept with the patient's record.

Top of page

3. Microselectron HDR Remote Afterloader*

The Microselectron High Dose Rate (HDR) machine is a remote afterloader that employs a single high activity Ir-192 source. The source can be programmed for multiple dwell positions within multiple channels (corresponding to multiple discrete sources within multiple catheters or applicators for conventional interstitial brachytherapy). The HDR machine can be used with needles, flexible catheters, bronchial or esophageal tubes, or gynecologic applicators. It is housed in a heavily shielded room in the Mt Zion Department of Radiation Oncology. Radiation treatments with the HDR machine last only 10-15 min.

Because the HDR machine is located in the Department of Radiation Oncology and does not involve radiation exposure to other hospital personnel, HDR Emergency Instructions are located by the HDR suite in the Department of Radiation Oncology and are not included in this manual.

4. Beta-Cath System for Intravascular Brachytherapy

The Beta-Cath system is a manual afterloading device that houses a train of beta-emitting Strontium/Yttrium-90 radiation sources. The sources can be advanced to the distal end of a treatment delivery catheter to irradiate a segment of the coronary artery in selected patients at the time of balloon angioplasty and/or stent placement. The procedure is used to help to decrease the risk of later re-stenosis 'narrowing or blockage) of the coronary artery by reducing or preventing over- proliferation of the lining of the coronary artery. The Beta-Cath system is housed in the source room for the Department of Radiation Oncology, on the 2"d floor of Long Hospital, and is transported as needed to the Cardiac Catheterization Laboratory.

After balloon angioplasty and/or stent replacement by the interventional cardiologist in the Cardiac Catheterization Laboratory, the actual radiation treatment is performed by a Radiation Oncology physician with the assistance of a Radiation Oncology physicist. The duration of the radiation treatment is approximately 2-5 minutes. Because beta radiation is not very penetrating, the only potential risk of radiation exposure is immediately next to the delivery catheter while the radiation sources are being transferred back and forth between the patient and the device. Personnel within the immediate vicinity of the procedure are shielded by the lead aprons and thyroid shields that they routinely wear for protection during fluoroscopy.

Top of page

5. Nurses' Responsibility

1. For patients that have been implanted with 1-125 or Pd-103 seeds, wearing a film badge is not required. Most brain implant patients are required to wear a lead-lined "cap" which will effectively reduce exposure in the room. Exposure from prostate implant patients is significantly reduced due to the thickness of body anatomy surrounding the pelvis. Whenever practical, without harm or discomfort to the patient, encourage the patient to provide for himself/herself. In all cases, avoid excessive hurrying or assuming an awkward position that might hinder efficiency in performing a task or cause undue alarm to the patient.



2. For all radioactive implant patients, apply ALARA principals such as maintaining maximum distance possible from the patient, except when performing tasks necessary for patient care.



3. When appropriate, ensure that the "Radioactive" warning signs, survey form, labels, and wrist bands remain in place as long as the patient is radioactive.



4. After non-remote afterloading patients have had the radioactive sources removed and after Radiation Oncology (353-8900 or 353-7175) or Environmental Health and Safety('476-1300) has monitored the room and released the contents, notify Environmental Services (476-1183) personnel that the patient's room is ready for cleaning.

Top of page

6. Physician's Responsibility

The responsible physician shall:

1. Insure that the nursing staff on the appropriate floor is notified 24 hours or more in advance of a brachytherapy procedure, so that proper radiation safety procedures can be instituted (including the acquisition of portable shields, as required). IF A PATIENT HAS SPECIAL NURSING NEEDS, THE HEAD NURSE FOR THE APPROPRIATE FLOOR MUST BE NOTIFIED AT LEAST THREE (3) WORKING DAYS PRIOR TO THE BRACHYTHERAPY PROCEDURE.



2. Fill out and sign the "Doctor's Orders Form" as soon as the patient is implanted. The form should include names and phone numbers of those to be contacted in case of an emergency. For non-remote after-loading patients, the physician should also ensure that a yellow radioactive-alert-wrist ID band is filled out and placed on the patient.. Warning signs for the patient's chart and door shall be posted. Attending nurse(s) shall be notified.



3. Ensure that radioactive patients are not left unattended in public thoroughfares. The general public shall be excluded from elevators transporting radioactive patients.



4. Verify that no sources remain in the patient or the room after the implant is over. Verification shall be by survey instrument, and may be performed by a brachytherapy technologist or other qualified person. Verification shall be documented in the patient's chart.



5. Notify UC Police (9-911) of any missing sources. UC Police will contact EH&S. Then call Radiation Oncology (353-8900, 353-7175) to report the incident. The site of a radiation accident should never be left unobserved or without warning markers. EH&S and Radiation Oncology will coordinate the search for the missing sources.

Top of page

7. Brachytherapy Technologist Responsibility

The brachytherapy technologist shall:

1. Perform or assist with patient surveys and room surveys when requested.



2. Affix all warning signs, labels, etc., and recover the appropriate ones after therapy is completed.



3. Place an empty shielded container, source handling tools, and a survey meter in the patient's room for non-remote afterloader, temporary implant patients. Also, the technologist shall remove the container, tools, and survey meter when the implant is over.



4. Check all materials in a non-remote afterloader, temporary implant patient's room for radioactivity before anything is removed from the room (residents may share the duty for these tasks).



5. Assist with loading and unloading the radioactive sources.

Top of page

8. Possible Excessive Exposure or Displacement of Source

1. Notify UC Police '9-911) if there is believed to be loss of a source or excessive exposure to any personnel. UC Police will contact EH&S. Then notify the Radiation Oncology at 353-8900 'Parnassus) or 353-7175 (Mt Zion).



2. A lead shielded container, long-handled forceps, and a survey instrument shall be available during all radioactive implant procedures. In the event that sources have to be removed for emergency reasons, or if the sources become displaced, they shall be placed in this container.
   
   CAUTION: NEVER HANDLE SOURCES WITH YOUR HANDS, EVEN IF WEARING GLOVES, SINCE THE DOSE RATE AT THE SURFACE OF THE SOURCES IS EXTREMELY HIGH AND WILL NEEDLESSLY EXPOSE YOUR HANDS.



3. Each sealed source is routinely checked for leakage, and stringent precautions are taken to assure that these sources are not lost or damaged. If, through an unforeseen accident, a source is damaged and possible leaking (i.e., if there is physical evidence of the source being broken, bent, or cracked) immediately notify UC Police (9-911). UC Police will contact EH&S. Then notify Radiation Oncology (353-8900, 353-7175). Place the source in the shielded container if this can be done without further damage to the source. Gently grasp source (needles, ribbons, or apparatus) with long forceps or tongs (10"-12" long) and place the source in the shielded container in the room. Place the container in a remote portion of the room.



4. A nursing supervisor shall be notified in cases where an unusually long period has been spent with a patient who has received a therapeutic dose of radioactive material. This could possibly occur during periods of short staffing or when more than one patient with radioactive material is being attended.

Top of page

9. Death of Patient Who Has a Radioisotope in Place

In the event of the death of the patient, physicians shall:

1. Remove the radioactive sources, if possible; otherwise, survey the body prior to removal to the morgue. Notify UC Police '9-911) that the patient has died and still contains radioactive material. UC Police will contact EH&S.



2. MAKE SURE THAT THE MORGUE PACK FORM FOR "RADIATION PATIENT DEATH" IS COMPLETELY FILLED OUT BY THE APPROPRIATE RADIATION ONCOLOGY ATTENDING PHYSICIAN OR EH&S RADIATION SAFETY. KEEP ONE COPY OF THE FORM IN THE CHART. SEND ONE COPY OF THE FORM WITH THE BODY TO THE MORGUE. RETURN THE THIRD COPY IN THE MORGUE PACK. PLACE A "RADIOACTIVE" LABEL ON THE BODY BAG.



3. If the radioactive source has not been removed,