Radiation protection review for credentialed fluoroscopy operators at BWH

1. Radiation protection review for credentialed fluoroscopy operators at BWH AY 2012-2013 Dept. of Health Physics and Radiopharmacology Brigham and Women’s Hospital

2. Radiation protection review for credentialed fluoroscopy operators Why is there a recertification requirement? • Recent JCAHO and FDA initiatives to reduce patient radiation dose associated with fluoroscopy, CT, and nuclear medicine procedures • Updated Massachusetts regulations • To review safe practices of fluoroscopy; and recent trends in BWH radiation dosimetry

3. Who provides fluoroscopy oversight? • Government - US FDA - Massachusetts Dept. of Public Health: inspects and enforces regulationsin Massachusetts • Accreditation organizations - JCAHO, ACR, CMS • BWH Radiation Safety Committee • Medical Directors-Radiology, Cardiology, Endoscopy, etc.

4. Radiation protection regulations Code of Massachusetts Regulations (CMR) 105 CMR 120: Regulations for the Control of Radiation 120.400: X‑RAYS IN THE HEALING ARTS 120.405: Fluoroscopy (updated, March 2012) All available on-line at the Mass. DPH website

5. Radiation protection regulations Who can actually operate fluoroscopic equipment? • Board-certified radiologists • Mass. licensed physicians who have undergone fluoroscopy safety training/credentialing • Mass.-licensed radiologic technologists trained in the safe use of fluoroscopic x-ray systems

6. Radiation protection regulations As of March 2012: • Licensed physician assistants and nurse practitioners who have met the fluoroscopy safety training requirements and are supervised by licensed physicians whom have met fluoroscopy safety training and continuing education requirements* * not yet formalized by BWH Radiation Safety Committee

7. Fluoroscopy credentialing @ BWH Since 1990: • All new fellows, residents, and attending physicians undergo a training course with take-home reading materials, exam, and fluoroscopy competency assessment. • Upon successful completion, are issued a certificate and entered into BICS as holding Fluoroscopy privileges • Ad hoc retraining/radiation safety in-services presented

8. Fluoroscopy credentialing @ BWH As of 2008 (non-radiologist physicians): • BICS Fluoroscopy privileges will expire annually • Recertification takes place by viewing on-line study materials and returning quiz to Health Physics • Ad hoc retraining/radiation safety in-services presented

9. Recredentialing process @ for BWH Fluoroscopy operators Process 1. MD participant receives notification from Health Physics that fluoroscopy credential will be expiring 2. Participant reviews slide show. Contacts RSO with any questions 3. Participant completes and returns quiz 4. BWH Fluoroscopy credentials renewed for the next 12 months

10. Fluoroscopy: safety concerns? Deterministic effects threshold-related worsen with dose Lead to: skin damage adverse birth outcomes Stochastic risks non-threshold probabilistic Lead to: genetic mutation genomic instability radiogenic cancer Indeterminate risks changing dose thresholds Lead to: lens opacities cataract formation

11. What if the patient is pregnant? • Consult Pregnancy Policy of the proposed imaging service • Consider alternative imaging procedures (Ultrasound, MRI) • Consider limiting projections, exposure times, cine runs (in consultation with Radiology or attending cardiologist) • With technical staff, apply additional Pb shielding if possible See also: A Health Care Personnel Guide For Assessing Radiation Risk And Selecting Imaging Procedures In Pregnant Women http://brighamrad.harvard.edu/education/fetaldose/

12. What if the fluoroscopist is pregnant? • Consult Pregnancy Policy of the proposed imaging service • Suggest (i.e., not mandatory) confidentially declaring pregnancy status to Health Physics Department which then initiates: 1. Joint review of dosimetry history 2. Joint review of regulations and dose limits 3. Determination if workload or lab environment needs to be modified during pregnancy 4. Issuance of additional fetal radiation dosimeters 5. Receipt of regular dose surveillance reports.

13. Fluoroscopy; patient dose-limiting protocols Whenever and wherever possible: • Maintain adequate x-ray source-skin distance • Keep image intensifier as close as possible to patient • Apply positive beam limitation (collimators) • Limit magnification and beam-time Note: these measures also reduce staff dose

14. 105 CMR 120.405 Summary of changes, as of March 2012 (fluoroscopydose reporting) Each facility performing traditional fluoroscopy or interventional CT shall: • conduct patient dose evaluation for any procedure that has a reasonable probability of resulting in a deterministic injury • have patient dose monitoring procedures in place. • document in the patient’s medical record an estimate of the absorbed dose to the skin.

15. Fluoroscopy dose reporting105 CMR 120.405 Summary of changes, as of March 2012 • Any cumulative absorbed dose to the skin equal to or greater than 2.0 Gy (200 rads) shall be noted in the patient’s medical record and reviewed by the Radiation Safety Committee. • Each facility shall maintain a record for five years of the cumulative fluoroscopic exposure time used and the number of spot films for each examination. This record shall indicate patient identification, type of examination, date of examination, and operator’s name.

16. Sample, Dose tracking database from CDIC

17. RT notes dose cumulative doses > 2 Gy tracked by RSO Current BWH dose tracking scheme RSO reports to RSC If cumulative doses > 5 Gy, RSC prompts fluoroscopist follow-up RSC documents dose/follow-up Fluoroscopist contacts referring MD referring MD follows patient

18. - a single collar badge, with red icon (worn above Pb) a single whole body badge, with black icon(worn below Pb apron) - both badges, if you regularly operate the fluoroscope during interventional studies. a fetal dose monitor, if pregnancy declared Occupational dose: staff and trainees working with ionizing radiation are issued monthly radiation dosimeters. Options include:

19. Radiation – dose limits for staff Maximum permissible dose (MPD) • Whole body, deep dose equivalent (DDE) = 5,000 mrem/yr (= 50 mSv) • lens = 15,000 mrem/yr (= 150 mSv) • shallow/extremities = 50,000 mrem/yr (= 500 mSv) Note: Keep in mind that annual per capita dose from natural sources of radiation (background) = ~311 mrem (3.1 mSv) in U.S.

20. Radiation – dose limits for staff If declared pregnant worker, fetal dose limits are: = 500 mrem/gestational period (= 5.0 mSv) = not to exceed 50 mrem/month (= 0.5 mSv)

21. Occupational radiation dose trends Note, N = 1873 badged - 237 unknown results = 1636 98.5 % (1612/1636) < “bgd” 99 % (1625//1636) < 10% of maximum permissible dose

22. BWH Occupational Exposures EP LAB 98.5% of badged staff received < 10% MPD 97% of badged staff received < annual bgd. value unknown dose for 10% (7/67) of staff CATH LAB 93% of badged staff received < 10% MPD 87% of badged staff received < annual bgd. value unknown dose for 7% (6/91) of staff

23. Radiation safety maxims for staff • Decrease time around source (if possible, move to shielded area for cine runs) • Increase distance from source (inverse square relationship) • Use appropriate shielding/PPE (0.5 mm Pb equivalent aprons and thyroid collars)

24. Intensity of the radiation dramatically drops off with distance, due to the inverse square law: Exposure rate @ 0.5 m = 100 mR/hr What is the exposure rate @ 1.5 m Original intensity = (New distance)2 New intensity (Old distance)2 (100 mR/hr)/( ? mR/hr) = (1.5 m)2 /(0.5 m)2 100/x = 2.25/0.25 100/x = 9.0 100 = 9x x = 100/9 11.1 mR/hr @ 1.5 m

25. Personal shielding requirements • Mass. regulations require hospitals to provide sufficient number and availability of protective lead aprons • BWH Radiology Policy requires use of lead aprons, thyroid shields, and gloves (as necessary) • Thickness should be at least equal to 0.5 mm Pb equivalent • Pb eyeglasses recommended for many procedures

26. Radiation Safety Liaisons have been established for each area to assist you with badges, lead PPE, etc. CDIC = Kelley Grassi, RT EP Lab = Jim McConville, RT, CNMT, Jack West, RT Endoscopy = Sandra Cialfi, RN Pain Management = Diane Palombi, RN Interventional Radiology = Carol Upson, RT, Patrice Embree, RT Diagnostic (L1) Radiology = Charles David Healy, RT Emergency Dept. = Angela McLaughlin, RT Nuclear Medicine/AMIGO = Victor Gerbaudo, PhD O.R. Nursing = Susan Lovell, RN O.R. Radiology equipment = Tiffany King, RT

27. BWH Radiation Safety Contacts Health Physics Main # = 617 732 6056; fax# = 617 566 9574 Director & Radiation Safety Officer Christopher Martel, MS, CHP = 617 732 6057 Dosimeters Erin Poitras, MS = 617 525 7042 IRB, Training A. Robert Schleipman, RT, CNMT, MSc = 617 732 5963 Emergency on-call pager = 33330 Patient dose calculations, equipment testing, training Richard Nawfel, MS Medical Physics, Radiology = 617 732 7201