1 | P a g e POLISI JABATAN RADIOLOGI POLISI
2 | P a g e POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
3 | P a g e POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
4 | P a g e AMENDMENT PAGE DOKUMEN KEMASKINI POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
5 | P a g e KANDUNGAN Bil. Perkara Muka Surat 1. Ionizing Radiations Health & Safety General Policy 7 2. Procedures and Work Instructions - General Radiography - Mobile Radiography - CT. Scan - Mammography 8 9 – 11 12 – 13 14 - 15 3. Controlled Area - Scattered Radiation - Shielding Design for An Exposure Room 16 16 17 - 18 4. Local Rules : Act & Regulation Governing Usage of Radiation - Atomic Energy Licensing Act (Act 304) - Radiation Protection Regulations (Basic Safety Standard) 1988 - Malaysia Standard (MS) 838, 1985 Code of Practice for Radiation Protection (Medical X-Ray Diagnosis) 19 19 19 5. Exposure - System of Dose Limitation - Occupational Exposure - Exposure of Members of the Public - Medical Exposure 20 20 – 21 22 22 - 23 6. Radiation Protection Committee - Member of Radiation Protection Committee - Responsibilities of Licence Holder - Responsibilities of Person Responsible for The License - Responsibilities of Radiation Protection Officer - Responsibilities of Radiation Protection Supervisor - Responsibilities of Radiation Workers - Radiation Protection Programme 24 – 25 25 – 26 27 27 28 – 29 30 31 32 POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
6 | P a g e 7. Personal Dose Monitoring 33 8. Information of Dose Reports 34 - 35 9. Dose Reduction Policy 36 - 38 10. Radiological Safety 39 - 45 11. Pregnancy Patient In Diagnostic Procedure 46 - 47 12. Appendix A & B 48 13. Appendix C 49 14. Appendix D 50 15. Pelan Tindakan Kemalangan Radiasi Hospital Slim River 51 16. Bacaan Melebihi Dos Dibenarkan 52 POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
7 | P a g e IONIZING RADIATIONS HEALTH & SAFETY GENERAL POLICY i) Introduction - Inspite of the presence of various Acts, Regulations, Codes, Standards, and guidelines, there is a variation inthe interpretation and subsequent implementation of these rules. It was felt that the time was right for standardization of practices, at least among the public sector health facilities. In view of this, a committee was formed to prepare this guidance document, for use by all public sector health facilities. • Ionizing radiation is used widely in modern health care, both for diagnosis and treatment. Whilst being tremendously useful, they can be hazardous to patient, staff and members of the public, especially if not well managed. • This document aims to outline the actions to be taken by the Diagnostic Imaging Departments to ensure the safe use of ionizing radiations for patients as well as staff and public. ii) General Policy • The KKM,as the employer is responsible for ensuring that compliance is met with Regulations governing the use of ionizing radiation. Every hospital and health facility with two or more x-ray producing equipment shall have a Radiation Protection Committee, to oversee the adherence to and implementation of, the existing rules and regulation. iii) Legislation 1. Atomic Energy Licensing Act (Act 304), 1984. 2. Radiation Protection Regulations (Basic Safety Standard) 1988 3. Licensing Regulations 4. Malaysia Standard (MS) 838 : 1985 POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
8 | P a g e PROCEDURES AND WORK INSTRUCTIONS 1. GENERAL RADIOGRAPHY a. Radiographic examination(s) are requested by Specialist or Medical Officer by filling up Borang Permohonan X-Ray PER.SS.RA 301 (Pind 1/2018) b. All radiographic examinations shall be completed on the same day unless the radiology request has been accepted as a future order. c. The task description of performing general radiographic examination is as follows: i. The radiographer inthe examination room shall view the examination request. ii. Priority shall be given to critical cases that will be called by name or queue number according to system. iii. As for non critical cases with queue number, the patient shall be called in sequence according to the queue number given at reception counter. iv. When the patient arrives at the examination room, the Radiographer shall check the patient's identity, identify possibility of pregnancy and verify the request form. · v. If there is a mismatch between the request order and the patient further verification with the wards/clinics isto be done.Based on the final outcome patient would be advised accordingly. The patient shall be requested to wait for their turn. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
9 | P a g e Radiation Protection Requirement • Use of lead gowns, gonad shields, thyroid shields are advised where necessary and when not interfering with region of interest 2. MOBILE RADIOGRAPHY Mobile units can be utilized for Mobile Radiography at wards, Emergency Department, Intensive Care Unit (ICU), Mortuary and Operation Theatre. There are also units of Mobile C-Arm.Fluoroscopy to be utilized in Operation Theatre . a. Bedside I ward radiography shall only be requested and be performed when the patient is too ill to be transported to the Radiology Department. b. The imaging department personnel on duty should verify the request for the examinations as appeared on Borang Permohonan X-Ray PER.SS.RA 301 (Pind 1/2018) c. The task description of performing Mobile Radiographic examination is as follows: i. During Ward Radiography, the minimum distance of the operator from the tube and patient shall be 2 (two) meters. The distance of the other patients from the patient being radiographed and the tube should be as far as allowable by the bed arrangement. Ideally, if space constraint is not a hindrance, a specific area away from nursing station and beds cubicle should be identified for the purpose of mobile radiography provided patient's bed could be wheeled to the area. ii. On arrival at the location, the team shall inform the ward staff to identify the patient. The ward staff may be required to assist in patient positioning if needed. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
10 | P a g e iii. Radiographer shall ensure adequate radiation safety precaution is Implemented before performing the examination. This may vary from case to case and environment. Inform ward staff, ambulatory patient and visitors in the near vicinity before making exposure. Patient immobiliser andcassette holderto be used when necessary Only those persons who are required to assist shall be present during the performance of an X-Ray examination. No person shall hold a patient, XRay or film cassette during exposure unless it is absolutely necessary. When a patient or film must be held by an individual : a) the holder shall be selected from a number of individuals who may be rotated through assignment. b) the holder shall beinorder of preference : i) Next of kin ii) Relative or friend attending to the patient iii) Medical Staff accompanying the patient c) the holder shall not be a radiation worker at the facility, unless in an emergency where noother person/ persons are available. No pregnant women or young persons under the age of 18 shall do any holding. Any person holding the patient or film cassettes in position during an x- ray examination shall wear a lead apron (minimum 0.25Pb equivalent). No part of the holder's body shall be in the primary beam, even if covered with protective clothing. i. For mobile services at the special unit or isolation unit, all imaging department personnel shallpractice universal precaution. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
11 | P a g e ii. The image shall be checked and verified. If the image is not of diagnostic quality, the image is rejected and a repeat is done. The reason for rejection shall be captured. On completion of examination the performing Radiographer shall document the number of projection done, number / sizes of films use and exposure factors on the form. iii. Radiography of dead body shall be performed by a Mobile X-Ray Machine inthe Mortuary Radiation Protection Requirement • Due to technical limitations (low power rating) of Mobile X-Ray units, optimum exposure factors, beam collimation to area of interest and optimum FFD (focus film distance lOOcm) should be used to reduce probability of repeats and consequently reduce dose to patient. d. Detailed guidelines on the use of Mobile X-Ray Machines is as follows: isprovided inAppendix I.(Pekeliling MOHGuidelines onthe use of Mobile XRay Machines). POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
12 | P a g e 3. CT SCAN Radiation Protection Requirements The following precautions should be observed: • Adherence to the 10days ruleto avoid unrecognized pregnancies. • Collimation of beam to area of interest only. • Intermittent screening is recommended to reduced unnecessary prolonged exposure to radiation. Secondly to protect the life spend of the X-Ray tube a) General Requirement Of an X-Ray Examination Room Warning Lights • There shall be prominent light on the control panel which will illuminate when the x-ray exposure ismade • Warning sign and lights should be installed at entrances to the X-Ray room. These lights shall illuminate prior to an exposure. The warning light should be red in colour but yellow or amber may be used. Warning Sign • All entrances to the X-Ray room shall be marked with a "Radiation Warning" sign to warn the presence of X-Ray. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
13 | P a g e b) Structural shielding Room Size • The dimension of the x ray room must have a minimum size of 5.0m x 4.0m. Wall Thickness • The doors and windows shall have the same lead equivalent as the requirement of the wall. The wall thickness of an X-Ray room must be of 2.0mm lead equivalent at 120kV. Lead Glass • The size of the lead glass (for viewing of patient during X-Ray exposure) must be, 2.0mm lead equivalent at 120kV. Personal Protection / Monitoring All persons operating the CT Scan shall be provided with a monitoring device such as film badge or thermo-luminescent detector. This will allow proper record for the doses received by the worker involved. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
14 | P a g e 4. MAMMOGRAPHY a. Screening mammography shall not be done for women ress than 35 years old. Exceptional cases should be discussed with the Radiologist. b. Requests shall be made by Specialists or Medical Officers on behalf of the specialists with relevant information captured appropriately. c. Requests for elective mammogram examinations shall be placed on the next available time/date or on preferred date. d. Requests for urgent examination of Mammography should go through department authorisation (Radiologist / MO). The Radiologist on duty reserves the right in accepting / replacing / rejecting the case based on the merit of the request. e. The requesting Specialist or Medical Officer shall screen and prepare patient adequately for mammogram-guided procedures. f. Since the galactography procedures require the administration of water soluble contrast agent, appropriate checklist shall be completed and informed consent obtained by the requesting Specialist or Medical Officer. g. The imaging department personnel shall advice and give a printed instruction to the outpatient on the necessary preparation required for the examination. h. The images and reports will be available to the Specialist and Medical Officer within 2 working days for non-urgent cases and within 1hour for urgent cases after completion the examination. i. The patient needs to be recalled before finalizing the report if the image has to be repeated. j: The task description of performing Mammography is as follows: POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
15 | P a g e Radiation Protection Requirement a) Staff safety Although the Mammography complies with the manufacturing standards for medical X-Ray equipment, radiation protection is largely dependent on the behaviour of the operating personnel. The following regulations should therefore be observed: • During exposure,the operator shall stand behind the radiation protection shield. If exposure is to be released via a separate wall-mounted or table-mounted control console, or via an exposure handle on extension cord (optional), adequate radiation protection in form of additional radiation shields or radiation-proof window in adjacent room must be provided. • If the radiation protection shield is not used, the operator shall wear protective clothing of 0.25mm lead equivalent or stand in the low radiation area behind the patient, at a distance of at least 1m from the object under examination. • Wear a film badge or pen dosimeter for monitoring of the personal radiation exposure. b) Patient safety • Before exposure is released, it is the operator's duty to check that the exposure parameter set on the control panel are the ones intended and that they have not changed, while attending to the patient. Failure to do so might expose the patient to unnecessary radiation. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
16 | P a g e Controlled Area According to MS 838 with regards to Public Health & Safety this code provides criteria for the safe use of X-Rays in Medical Diagnosis. It applies to administrative and working procedures, shielding requirements for X-Rays rooms and technical specifications for X-Ray systems with respect to safety and performance. Scattered Radiation Definition: MS-838: Radiation which is produced due to change of direction and every of X-Ray photons after interaction mainly with electrons of atoms intheir path. • The materials of construction of every diagnostic X-Ray room shall be such that the exposure rate at every occupied position outside the room and at the position normally occupied by the operator at the X-Ray controls, is as low as reasonably achievable, social and economic consideration being taken into account and the materials shall be such that the exposure rate at every such position does not exceed l0 mR per week. • In most circumstances as low is reasonably achievable, economic and social considerations being taken into account means of the order 1 mR per week. • Secondary or scatter radiation must often be taken into consideration when producing a radiograph. The scattered photons create a loss of contrast and definition. Often secondary radiation is thought of as radiation striking the film reflected from an object in the immediate area, such as a wall, or from the table or floor where the part is resting. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
17 | P a g e • Side scatter originates from walls, or objects on the source side of the film. Control of side scatter can be achieved by moving objects in the room away from the film, moving the X-Ray tube to the center of the vault, or placing a collimator at the exit port, thus reducing the diverging radiation surrounding the central beam. Shielding Design For An Exposure Room • An exposure room isan enclosed space engineered to provide adequate shieldingfrom ionizing radiation for persons in the vicinity • The use of an enclosure also allows other work in the vicinity to continue without interruption. • The general design principles are similar for all enclosures although different characteristics are incorporated depending on whether the enclosure is to be suitable for X-Ray. • It is important to plan the design of the exposure room for immediate and foreseeable future needs beforecommencingthe construction. • Detailed drawing or sketches are prepared of the installation and its surrounding, including dimensions of each enclosed area, thickness, density and type of shielding material on all sides including above and below the exposure area. • Entrances are identified and distances to potentially occupied areas adjacent to,above and the below the exposure area are indicated. • The design principles are similar for all exposure rooms although different shielding characteristic are incorporated depending on whether the shielded enclosure will be used for X-Ray. • The shielding design should also consider both the primary and scattered radiation.The amount of shielding should be calculated with reference to the dose rate, use factor and occupancy factor. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
18 | P a g e Documentation should be kept showing the results of calculation, radiation level measurement and maximum expected radiation levels inside the shielded enclosure and in all areas adjacent to it. • When the design of the exposure room has been established, no subsequent changes that effect radiation safety are made unless they are more effective and are authorized or approved by the appropriate authority. • Secondary protective barriers shall be provided in all walls,ceilings and floor areas not having primary barriers. All barriers shall have a minimum height of 2m above the floor. • Doors and windows shall have the same lead equivalence as that required for the wall. If the X-Ray room is located above the ground floor, a protective barrier of 1.5mm lead equivalence in thickness and 1.2m by 2.5m in area shall be provided in the floor area beneath the X-Ray examinationtable. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
19 | P a g e LOCAL RULES : ACT & REGULATION GOVERNING USAGE OF RADIATION a) Atomic Energy Licensing Act (Act 304) 1984 Act 304 has made it compulsory for licensee holders to take measures to ensure that their radiation-related activities are not dangerous to their workers and public (Section V: Health and Safety).This is done by fully abiding to all Atomic Energy Licensing Board's (AELB) instructions. To this effect, AELB has introduced Basic Safety Standard for radiation workers and those persons who might be exposed to radiation. This Basic Safety Standard is clearly explained in Radiation Protection Regulations (BasicSafetyStandard) 1988. b) Radiation Protection Regulations (Basic Safety Standard) 1988 This set of regulations is enacted to give a technical perspective of the ways to control safety & health of radiation workers the public and the surrounding from the hazards of ionizing radiation. This 1988 regulation was published to further compliment Section 68 and subsection (6) from section 25 of Act 304. c) Malaysia Standard (MS) 838, 1985 Code of Practice for Radiation Protection (Medical X-Ray Diagnosis) This Malaysian standard Code of Practice was prepared by Radiation Protection Unit of the Ministry of Health, Malaysia with the assistance of a panel of representatives from academic organizations in Malaysia. This code provides criteria for the safe use of X-Rays in medical diagnosis. It applies to administrative and working procedures, shielding requirements for X- Rays rooms and technical specifications for x-ray systems with respect to safety and performance. The requirement listed in this code are subject to amendments as are deemed necessary for the protection of public health and safety. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
20 | P a g e All radiographers working in Diagnostic Imaging Department are qualified either through DCR- Diploma College of Radiographers, London or Diploma Radiography, Ministry of Health. Copies of the certificates are kept in their Respective Personal Files. Further Post Basic Courses e.g Post Basic CT, Trauma are also offered to selected Radiographers. MRI training is carried out at department level where privileging is awarded by the resident Radiologists. EXPOSURE i) System of Dose Limitation a) The Hospital Radiation Protection Committee shall take steps to restrict the necessary exposure to any person and such exposure shall be as low as is reasonably achievable, economic and social factors being taken into account. b) The Hospital Radiation Protection Committee shall ensure that no worker or member of the public receives exposure exceeding the annual dose limits. c) The annual dose limits shall not apply to medical exposure or exposure due to natural background radiation. ii) Occupational Exposure a) No person shall allow any person under age of eighteen years to work in a controlled area but a person who has attained the age of sixteen years may be allowed to work in supervised area for training purposes only notwithstanding that he has not attained the ageof eighteenyears. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
21 | P a g e b) No person shall allow any person under the age of sixteen years towork ina supervised or a controlled area. c) No person shall allow a female worker to work in a controlled area if she is or is suspected to be pregnant. d) No person shall employ a nursing mother in any work involving a high risk of radioactive contamination unless she is placed under special surveillance to detect any possible radioactive contamination. e) The annual dose limit for the whole body exposure of a worker shall be 50milisieverts (mSv). f) Where a female worker is pregnant, the dose to the fetus accumulated over the period of time between confirmation of pregnancy and the date delivery shall not exceed 10mSv. g) In the case of partial body exposure of a worker- • The limit for the effective dose equivalent evaluated by the method set out in Section 2 of the Second Schedule shall be 50mSv in a year and the average dose in each organ or tissue shall not exceed 500mSv in a year except for the lens of the eyes where the annual dose limit shall be 150mSv. h) If any radiation worker is found to have exceeded the yearly dose limit, Radiation Protection Officer-Physicist should initiate investigation to find out the caused of the exceeded dose. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
22 | P a g e iii). Exposure of Members of the Public a) For whole body exposure-the annual dose limit for a member of the public shall be 1mSv; and b) Who is likely to be exposed to ionizing radiation at or near the annual dose limit for prolonged periods (many years) shall be 5mSv in a year, provided that the average annual dose over a lifetime does not exceed 1mSv. c) In the case of partial body exposure-the limit for the effective dose -equivalent by the method set out in Section 2 of the Second Schedule shall be 1mSv in a year and the average dose for the skin and lens of the eyes shall not exceed 50mSv ina year. iv). Medical Exposure •Medical Diagnosis And Treatment a) Before any exposure is administered to the patient, the medical practitioner shall ascertain whether the desired information is already available or is not available from previous examinations or whether the same information can be obtained using any other procedure which does not involve the use of any radioactive material, nuclear material,prescribed substance orirradiatingapparatus. b) The medical practitioner shall always pay attention to details of radiological techniques that would ensure minimization of exposure to any embryo or fetus that might be present, whether or not the women is known to be pregnant. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
23 | P a g e c) No person shall carry out any systematic radiological examination on any person unless there are clear clinical needs and unless such examination is justified, taking into consideration the useful information expected to be obtained and the importance of this information to the person's health. • Radiological examination for occupational purposes d) No person shall carry out any radiological examination for occupational purposes unless such examination is necessary for the purpose of evaluating the health of the person examined and the fitness for the work. e) Radiological examinations for occupational purposes shall be performed in a manner consistent with optimization of radiation protection. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
24 | P a g e RADIATION PROTECTION COMMITTEE The administration of Hospital shall establish a Radiation Protection Committee to oversee the use of ionizing radiation in medicine. The Committee shall meet the following administrative requirements: a. membership shall consist of not less than three individuals and shall include an authorized user of each type of use permitted by the Hospital, the Radiation Protection Officer, a representative of management who is neither an authorized user nor a Radiation Protection Officer. b. The Committee shall meet at least once every 6 months. c. the minutes of each Radiation Protection Committee meeting shall include: i. the date of the meeting; ii. members in attendance; iii. members absent; iv. summary of deliberations and discussions; v. recommended actions and the results of all votes; and vi. documentation of the radiation protection programme review required by the ALARA programme in Local Rules and Regulations. d. The Committee shall provide each member with a copy of the meeting minutes before the next meeting and retain one copy for 5 years from the meeting date. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
25 | P a g e e. Function of committee: i. Assist the management to establish the policy on radiation protection consistent with the Local Rules and Regulations / Standards . ii. Review and approve emergency plans and procedures. iii. Review and approved routine and standard procedures. iv. Review and approved safety assessment for new operations and new or modified installations that have safety implications. v. Review reports of incidents, accident and overexposures and make recommendations on improvement to the management. i) MEMBER OF RADIATION PROTECTION COMMITTEE Chairman Director of Hospital Co-Chairman - Consultant Radiologist & HOD, Diagnostic Imaging Department Secretary Committee - Physicist, Diagnostic Imaging Department Committee - Radiologist, Diagnostic Imaging Department - Head of Department, Orthopedics Department - Head of Department, Dental Department POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
26 | P a g e - Head of Department, Peads Dental Department - Head of Department, Obstetric andGynaecology - Head of Department, Accident And Emergency Department - Head of Department, General OT Department - Chief Radiographer, Diagnostic Imaging Department ___________________________________________________________________ License Holder - Director of Hospital Person Responsible for the License / Co-Chairman - Consultant Radiologist & HOD, Diagnostic Imaging Department Radiation Protection Officer - Consultant Radiologist & HOD, Diagnostic Imaging Department Radiation Protection Supervisor - Chief Radiographer, Diagnostic Imaging Department POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
27 | P a g e ii) RESPONSIBILITIES OF LICENSE HOLDER 1. To appoint a person responsible for the license among the committee members. 2. To ensure only the person responsible for license (Consultant Radiologist & Head Diagnostic Imaging Department ) and Radiation Protection Officer (Head of Department) communicate with Atomic Energy Licensing Board (AELB). 3. To ensure all activities involving ionizing radiation comply with Akta Perlesenan Tenaga Atom 1984 (Akta 304) and appendices underneath. iii) RESPONSIBILITIES OF PERSON RESPONSIBLE FOR THE LICENSE 1. Performs all activities related to Atomic Energy Licensing Board (AELB). 2. Nominate one personnel who has the required criteria to AELB to be gazette as Radiation Protection Officer. 3. Informs Radiation Protection Officer of his/her responsibilities as RPO. 4. Ensures that radiation protection program that have been accepted are inaccordance with theAELB arefollowed and implemented. 5. Ensures all medical examinations are performed by registered Medical Officer approved by AELB. 6. ·Provides,updates and keeps all record as required by AELB. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
28 | P a g e iv) RESPONSIBILITIES OF RADIATION PROTECTION OFFICER Radiation Protection Officer is the person with 'on site' responsibility for radiation protection matters. RPO primary task is to ensure that normal good practice is observed in order to keep radiation dosage to staff and public as low as is reasonably achievable. RPO should be directly involved with the work with ionizing radiations, preferably in a line management position that will allow him / her to exercise close supervision to ensure that the work is done in accordance with the local rules, though the RPO need not be present all the time. In some large establishments the RPO may not be the immediate line manager or supervisor overseeing the work with ionizing radiation. In these cases a system, which may involve more than one person, should operate to ensure that adequate supervision is maintained. Responsibilities of RPO • The RPO should: a) Know and understand the requirements of the Local Rules and Regulations (Act 304, 1984) as they affect the work he / she supervises. b) Command sufficient respect from the people doing the work as will allow him / her to exercise the necessary supervision of radiation protection. c) Assisting the management to establish Radiation Protection Program. d) Implement and maintain Radiation Protection Services. e) Maintain all records and correspondence necessary to ensure compliance with relevant regulations / standard. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
29 | P a g e f) Supervise any new operations. g) Supervise and coordinate action during emergencies. h) Supervise decontamination procedures. i) Understand the necessary precautions to be taken in the work which is being done and the extent to which these precautions will restrict exposure. The RPO will liaise with the Head of Department on policy matters and on untoward occurrences. • Monitoring The RPO will implement the appropriate personal monitoring scheme within the department, which will normally involve: 1) Distribution and collection of personal Film Badge. 2) Investigation of abnormal readings. 3) Maintaining staff awareness of exposure levels. The RPO will ensure that departmental contamination and environmental monitors are checked and calibrated regularly. • Training The RPO will ensure that staffs receive such information and training as is necessary for them to carry out their work in accordance with the regulations, and that new employee read and understand the relevant sections of the Local Rules & Regulations (Act 304,1984). POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
30 | P a g e • Document Control The RPO is responsible for provision and maintenance of the Departmental Radiation Safety Documentation (i.e.Local Rules,Policies and Procedures). • Contingency Plans The RPO will be involved in the preparation of contingency plans and will ensure that staffs are able to implement these effectively.RPO will investigate reports of over exposure due to equipment malfunction. v) RESPONSIBILITIES OF RADIATION PROTECTION SUPERVISOR Radiation Protection Supervisor assigned to ensure that all operations within his area conducted according to the rules and procedures of the establishment .He must ensure the following: 1) All operations within his area are conducted safely according to the written rules and instructions. 2) Personnel under his supervision are trained in safe practices and procedures related to the operations inhis area. 3) Equipments and working areas are properly surveyed at the end of each working period. 4) Potential hazards of new equipments and procedures within his area are evaluated. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
31 | P a g e vi) RESPONSIBILITIES OF RADIATION WORKERS Radiation Workers shall: 1) Follow any rules and procedures for protection and safety specified by employer / licensee / RPO. 2) Use properly the monitoring devices and protective equipments and clothing provided by employer to limit or assess any possible exposure. 3) Co-operate with the employer/licensee/RPO with respect to protection and safety and the operation of radiation protection programme. 4) Provide the employer / licensee / RPO with relevant information on their past and current involvement with ionizing radiation sources. 5) Abstrain from any willful action that could put themselves or others in situations that lead to unnecessary exposure or contravene the requirements of the regulations / standards. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
32 | P a g e vii) RADIATION PROTECTION PROGRAMME 1. Assessment of the potential hazards. 2. Incorporation of safety features. 3. Operational Rules and Procedures. 4. Establishment and implementation of personnel and area surveillance. 5. Calibration and maintenance of instruments. 6. Establishment of a system for collection and keeping the records: • Inventory of radiation sources • Personnel dose records • Medical examination records • Area monitoring data • Environmental monitoring data • Effluent monitoring data / waste disposal • Inventory and records of measuring instruments • Record of personnel training • Records of unusual occurrences 7. Formulation of emergency plan and procedures. 8. Trainingof the workers. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
33 | P a g e PERSONAL DOSE MONITORING i) Film Badge In order to monitor the effectiveness of local rules and systems of work,and to help ensure that the annual dose received is less than 5 0 mSv/yr, personal dosimeters are issued to occupationally exposed workers. The doses recorded by these dosimeters are assessed regularly by the departmental Radiation Protection Officer through Malaysia Nuclear Agency where results are given monthly which is then documented. In the case of fluoroscopic work where a lead-rubber protective apron is worn, many years of monitoring locally has shown that for most employees the dose measured by a dosimeter under the apron is so low as to be virtually indistinguishable from background radiation. Therefore, it has been agreed that, for persons working regularly in fluoroscopy,the dosimeter should be worn outside the apron at shoulder height, so assessing the dose received by those parts of the body not protected by the apron. As a rule of thumb, the effective dose to those wearing over-apron dosimeters in fluoroscopy is approximately one tenth of the dosimeter reading. In addition,staff who may approach 3/10 th of the dose limit are monitored with two dosimeters, one over-apron and, a second dosimeter under-apron. Pregnant staff working in fluoroscopy will generally also wear an under-apron dosimeter at waist level in addition to an over-apron dosimeter. The fetal dose will be approximately half the under apron dose, and should not exceed 10mSv/yr. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
34 | P a g e INFORMATION OF DOSE REPORTS 1) The reporting dose is in whole body dose equivalents unit in millisievert (mSv) where 1.0mSv = 1.0mJ/kg. 2) Types and energies of radiation are presented according to the following codes: i) X / Gamma Rays ii) Beta Rays iii) Background Radiation 3) Types of radiation are only taken into account where the dose exceeds 0.6mSv, lower than that its Radiation quality (energy) are categoried according to DIN 6816; A:< 10 keV (very soft) B: 10-29 keV (soft) C: 20-74 keV (medium hard) D: 75-199 keV (hard) E: 200-400 keV (very hard) F: >400 keV (ultra hard) G: unidentified / background a) Radiation quality (energy) can only be estimated when the dose is above 0.4mSv and recorded energy is independent of dose quantity. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
35 | P a g e b) The reported dose is a net dose, that is the dose exceeding the background radiation. Annual dose of natural background radiation level is about 2mSv. c) Minimum dose level recorded is 0.2mSv where the dose is in between 0.1mSv - 0.2mSv, if dose is below than 0.1mSv the dose is recorded as 0mSv. d) The reported dose is a whole body dose and the whole body annual dose limit for radiation workers is 50m5v (mSv). Radiation Protection Regulations(Basic Safety Standard) 1988 under the Atomic energy Licensing Act 304,1984. e) ICRP Publication 60, 1990 has recommended that the effective dose for radiation workers 20mSv. f) The accumulated dose is calculated based on the annual dose monitoring over one calendar year. g) Name and film identification number of personal is fixed and shall not be transferable. h) The error in a dose measurement is within the interval of -33% and 50% at the 95% confidence level(ICRP35). POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
36 | P a g e DOSE REDUCTION POLICY Introduction The IonizingRadiations Regulations 1988 require that: • Hospital shall ensure that any equipment under their control which is used in connection with a medical exposure is of such design or construction and is so installed and maintained as to be capable of restricting so far as is reasonably practicable the exposure to ionizing radiation of any person who is undergoing/medical exposure to the extent that this is compatible with the clinical purpose or research objectives in view. • No person shall clinically or physically direct a medical exposure except in accordance with accepted diagnostic practice. • Persons physically directing a medical exposure shall select procedures such as to ensure a dose of ionizing radiation to the patient as low as reasonably practicable in order to achieve the required diagnostic or therapeutic dose. Quality Control / Planned Preventive Maintenance • All new radiation equipment and work areas shall be tested by the Engineering Division,MOH or authorized agent to ensure correct and safe operation for patients, staff, and members of the public. • Planned Preventive Maintenance I QC for all machines are prescheduled at the beginning of the year and copies of the scheduled time table are distributed to the Head of Radiology department for reference. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
37 | P a g e • All radiation generating equipment is tested at least annually by the authorized Class H agent to ensure that it continues to function safely and correctly. • Individual departments shall have a Dose Reduction strategy developed in conjunction with the Radiologist, to ensure that good practice is maintained. (For example,diagnostic radiology departments should monitor and publish Film Rejects Rates / Image Rejects Rates and monitor FilmProcessor Performance / Computed Radiography) QualityAssurance Programme (QAP} QAP shall comprise of the following: • Quality Control (QC} of equipment, processor and associated facilities. All the X-Ray equipment, processor, computed radiograph and associated facilities shall be maintained and calibrated wherever applicable. The performance and safety standards of the X-Ray equipment, processor, computed radiograph and associated facilities shall be in accordance with the regulatory requirements and relevant code of practice. • Monitoring and analysis of Film Reject Rate / Image Reject Rate. Monitor and analysis of film reject rate / image reject rate shall be instituted and reported every month. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
38 | P a g e Training Regular update / training sesions shall be provided for staff working with ionizing radiations. Staff Doses • All doses should be kept as low as reasonably achievable. • The Dose Monitoring Policy is designed to help identify which staffs receive the largest doses so that steps can be taken to reduce these doses where possible. Patient Doses • All exposures must be clinically justified, and the use of non-ionizing techniques should be considered. • The required diagnostic information,or required therapeutic effect should be achieved using as low a dose as reasonably achievable. • Diagnostic doses should never be so high as to cause deterministic effects. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
39 | P a g e RADIOLOGICAL SAFETY Radiation Protection Basics i) Distance • Exposure decreases inversely the square of distance-inverse square law. • If you double the distance the exposure rate drops by factor of four. • Effective means of reducing radiation exposure in Diagnostic Radiology. • Room size-operator site-switch on cord ii) Time • Minimize the time that you are in contact with radioactive material to reduce exposure. • Exposure technique factors (kV,mA and time) are integral part of any examination. • Exposure short then dose is low. • Sharing of "time"exposed. iii) Shielding • All types of radiation are attenuated to a greater or lesser extent by the use of appropriate shielding. • In Diagnostic Radiology,lead is an excellent choice of shielding material. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
40 | P a g e • Protection of the patient 1) The radiologist shall limit, cancel or defer the X-ray examination if he considers the expected information to be irrelevant or already available. 2) Experienced radiographers should draw the attention of the clinician involved to cases where the necessity for the X-Ray examination or number of views involved may be reviewed. 3) Minimising need for repeated X-Ray examinations. The need for repeating an X-Ray examination should be avoided when it adds to the radiation dose to the patient without also contributing to the diagnostic information 4) The operation conditions for bedside radiography are frequently difficult and correct positioning and beam limitation require a great deal of thought and care. It is likely that in these conditions, the patient will receive more radiation than necessary and the other patients in adjacent accommodation may also be irradiated. Bedside radiography should therefore strongly be discouraged unless it is very necessary. 5) Protective clothing of at least 0.25mm lead equivalent shall be worn and precautions shall be taken to ensure that no other person is exposed unnecessarily if bedside radiography is performed. 6) Forradiography inthe ward, minimum distance of: a) The operator from the tube and patient : b) The other patients (who shall not be in the path of the X-Ray beam) from the tube and the patient being radiographed; shall be 2m. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
41 | P a g e • Standards methods of control of doses to patients: a) Using the light beam diaphragm useful X-ray beam to the area of clinical interest not exceeding the size of cassette used. b) Use the highest practicable kilovoltage (kV). The use of higher kV reduces the dose to the patient. c) Use of fastest image recording device compatible with optimal image quality. d) High resolution image intensifying screens/CR, where available. e) Avoidance of repeats for technical or administrative reasons also practicing of long term monitoring and evaluating programmes such as Reject Film Analysis for overall reduction of unnecessary repeats. f) Use of specific organ shielding. • Protection of the embryo / foetus a) Irradiation of the foetus shall be minimised. Where irradiation of the foetus is necessary it shall be hold to the minimum consistent with images of good diagnostic quality. As far as it is possible care shall be taken to avoid X-ray examinations involving the pelvic and lower abdominal regions of patients who are pregnant unless such examinations are of importance in connection with present management of the patients. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
42 | P a g e b) Where the X-Ray examination being requested does not directly relate to investigation of the patient's current complaint and does involve potential irradiation of the uterus the referring practitioner should where practicable arrange that the examination be with regards to 10 days rule or 28 days rule where applicable. c) X-Ray examinations performed during the course of pregnancy and not involving the abdominal or pelvic regions should keep the useful X-Ray beam well-collimated to the area of interest (i.e. to avoid irradiation of the foetus) and when necessary that region should be shielded with a lead apron. The apron should have a lead equivalence of not less than 0.5mm. • 10 Day Rule If she is not sure about her possibility of pregnancy, or pregnancy could not be excluded, she could be asked whether her period is overdue. If it is not overdue and the date of L.M.P. is within 28 days, then proceed with the examination except for high dose procedures (such as abdominal CT,Pelvic CT,Barium Enema and any other special X-Ray examinations), in which the examinations should be postponed to the early part of the menstrual cycle -the "limited return to the 10-day-rule". POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
43 | P a g e • 10 Day Rule For High Dose Procedures If a female patient can confirm that she is pregnant and her menstrual period has been clearly missed (also the 10-day-rule and 28-day-rule cannot apply), then any decision to proceed with the examination should be taken by the referring physician in its clinical necessity ( e.g. urgent X-Ray examination when benefits are likely to far outweigh any small risk from irradiation). Attention should also be paid to ensure minimization of exposure to any embryo or fetus. • 28 Day Rule If she is not sure about her possibility of pregnancy, or pregnancy could not be excluded, she could be asked whether her period is overdue. If it is overdue, then observe the 28- day-rule for normal radiological procedure. *28dayrule for Normal Radiological Procedures POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
44 | P a g e • Protection of the gonads Where the gonads lie in or very close to the useful X-Ray beam, and collimation cannot be used to avoid their irradiation, the gonads should be shielded unless such shielding would obscure structures relevant to the examination. • Personal Monitoring inFluoroscopy andlnterventional Radiology In fluoroscopy, where a personal dose monitor is worn over the apron, an over-apron dose of 3,400uSv per month over 8 months corresponds to a whole body dose of around 2mSv. It should be noted that a lead rubber apron will fully cover the abdomen,and that the dose to the foetus willbe certainlybe less than 1mSv if the monthly over-apron dose is less than 3,400 uSv. A pregnant woman working in fluoroscopy should normally be issued with a second personal dosemeter ("baby's badge") to beworn atwaist height under their lead apron. • Protection of Personnel a) The exposure of radiation workers shall not exceed the dose equivalent limits and should not exceed one-tenth of the dose equivalent limits. The dose equivalent limits are given in schedule Appendix A. b) Only those personnel required to assist, or in the course of training should be present during the performance of X-Ray examinations. c) Personnel required to be present during the X-Ray examination shall wear a lead apron having a lead equivalence not less than 0.25mm and shall not remain any closer to the patient and X-Ray tube than is necessary. A double-sided apron should be worn by personnel who may receive radiation posteriorly and laterally as well as anteriorly. d) Motion restricting devices shall be applied to the patient insofar as it is practicable and devices for remote holding of the film cassette shall be used wherever feasible. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
45 | P a g e e) Personnel not required to be in attendance shall not remain in the fluoroscopy room. Personnel required to be in the X-Ray room during fluoroscopy shall as much as is reasonably achievable be protected from exposure to scattered radiation. The fluoroscopist shall wear a lead apron having a lead equivalence which shall be not less than 0.25mm and should be0.5mm. f) The Radiologist / Radiographer / Nurse shall wear a lead glove on any hand used to palpate the patient. The glove shall have a lead equivalence of not less than 0.25mm and should have a lead equivalence of 0.5mm. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
46 | P a g e PREGNANT PATIENT IN DIAGNOSTIC PROCEDURE Introduction • In all women of reproductive capacity, the clinician requesting the examination should consider the possibility of pregnancy. • The latest national guidelines acknowledge that there is no risk to the conceptus following irradiation during the first 10 days of the menstrual cycle. However, in the interval between 10 days and the date at which the next menstrual cycle is due there is a small risk for high dose procedures such as pelvic or abdominal CT and barium enemas. • At diagnostic dose levels, the only adverse effect of radiation on the conceptus is an increased risk of cancer induction. Dose levels are too low to induce death or malformations. Therefore, invasive fetal diagnostic procedures or termination of the pregnancy are not justified. • The accompanying flow diagram indicates the general procedure to be followed. Where necessary Local Rules should give any specific requirements for particular work areas. (Appendix C) • The senior radiographer is responsible for ensuring that all staff are familiar with the correct procedure, and that normal good radiographic practice is carried out to ensure that radiation doses are kept as low as is reasonably achievable. Particular Advice on Establishing Whether Patient May Be Pregnant • In order to ensure that the examination is carried out within 28 days of the last menstrual period (LMP) patients should be asked, "Are you or may you be pregnant?" or "Is your last menstrual period overdue?". POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
47 | P a g e To assist inobtainingcorrect information the followingprecautions should betaken:- a) Advisory notices should be prominently displayed in X-Ray departments. b) X-Ray request forms should have a space to allow for insertion of the LMP by the referring clinician. c) The examining operator (e.g. radiographer, medical physicist) to check the dates of LMP especially if there is a long delay between request and exposure. • If the operator does not obtain satisfactory assurance the request should be referred back to the requesting Clinician or department, or to a Radiologist. • Thisadvice may be ignored inthefollowingcases: a) Women who have been on the contraceptive pill / implant / injection for three months or more, or have an IUDfitted. b) Women who have been sterilized. c) Women who are outside the age range of 12 - 50 or are post menopausal. POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
48 | P a g e APPENDIX A and B Table 1: (Rules 8(1),9,11 and 12. Radiation Protection Regulations (Basic Safety Standard) 1988 (Individu) (Had Dos) POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
49 | P a g e APPENDIX C POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI
50 | P a g e APPENDIX D POLISI PERLINDUNGAN SINARAN JABATAN RADIOLOGI