RADIATION SAFETY MANUAL

Transcription

1 THE UNIVERSITY OF TEXAS MEDICAL BRANCH RADIATION SAFETY MANUAL ENVIRONMENTAL HEALTH AND SAFETY Revised: April, 2016

2 RADIATION SAFETY MANUAL Table of Contents Chapter 1 : General Information Radiation Emergency Information Use and Distribution of the Radiation Safety Manual Radiation Safety Committee Radiation Safety Officer and Staff Chapter 2 : Licensing Radioactive Material for Use Authorized Users Permit to Use Radioactive Material Ordering Radioactive Material Receipt and Documentation of Radioactive Material Transferring Radioactive Material Training Requirements for Personnel Who Work With Radioactive Materials Personnel Monitoring Record Keeping Chapter 3 : General Rules and Guidelines for Handling RAM Routine Laboratory Procedures Emergency Procedures Emergency Weather Procedures Disposal of Radioactive Materials Use of Radioactive Materials in Animals Guidelines for Area Contamination Surveys Chapter 4 : Bioassay Program Guidelines for Individuals Working With I-125 and I Guidelines for Individuals Working With H Chapter 5 : Management of Patients Undergoing Brachytherapy Introduction Radiation Safety Staff Responsibilities Radiation Oncology Department Staff Responsibilities Nursing Instructions Chapter 6 : Management of Patients Receiving Therapeutic Amounts of Radionuclides Introduction

3 General Information Radiation Safety Programs Nuclear Medicine Staff Responsibilities Nursing Service Staff Responsibilities Environmental Services and Dietary Services Staff Responsibilities Chapter 7 : General Instructions for Auxiliary Personnel Instructions for Maintenance Personnel Instructions for Smoke Detector Disposal Instructions for University Police Instructions for Environmental Services Personnel Instructions for Pathologists Dealing with Radioactive Body Tissues APPENDIX A: EXAMPLES OF SIGNS AND LABELS APPENDIX B: GLOSSARY

4 CHAPTER 1 : GENERAL INFORMATION Radiation Emergency Information Telephone Directory ENVIRONMENTAL HEALTH AND SAFETY Luz Cheng, Senior Director DAY (409) Radiation & Biosafety Programs & NIGHT (409) Radiation Safety Officer (UTMB Operator) DAY (409) EHS On-Call NIGHT (409) (UTMB Operator) RADIOACTIVE WASTE PICK-UP QUESTIONS DAY DIVISION OF RADIATION ONCOLOGY DAY DIVISION OF NUCLEAR MEDICINE DAY CAMPUS POLICE DAY NIGHT (409) CAMPUS FIRE DEPARTMENT DAY NIGHT (409) How to Report An Emergency STEP PROCEDURE Give your name Give your location: room and building Give the phone number you are using Describe the nature of the emergency: Is there a personal injury? Is there a threat of injury? 1-1

5 General Information Use and Distribution of the Radiation Safety Manual Who Needs The Radiation Safety Manual is issued through the Radiation Safety Program. It is available to: all personnel at UTMB who use, supervise, or control the use of radioactive materials or radiation -producing machinery (such as X-ray machines) personnel who might have reason to enter areas where sources of radiation are present Location of Manuals Manuals should be located in: Every laboratory authorized to use radioactive materials Areas where radiation producing machines are present Certain nursing stations Certain department offices (e.g., Environmental Services, Facilities Operations and Management, i.e. University Police) Accountability Updates to the Manual Manuals are numbered for purposes of inventory and updating. Individuals to whom manuals are issued are asked to return their manuals if they terminate employment at UTMB. Individuals who have possession of manuals issued to particular departments, divisions, offices, work stations, etc., should pass these on to their successors or return them to Radiation Safety when they terminate employment at UTMB. Changes and corrections to this manual will be issued by Radiation Safety when needed. Such updates will be distributed to all individuals who possess a copy of the manual. Upon receipt of the update, make changes in accordance with instructions accompanying the update and notify all individuals. 1-2

6 General Information Radiation Safety Committee Purpose The Radiation Safety Committee (RSC), established in 1968 as the Committee on Ionizing Radiation, is responsible for ensuring that radioactive materials and radiation producing devices are used safely and in accordance with State and Federal regulations. Responsibilities The RSC is responsible for: Formulating general policy governing the use of radiation-producing equipment and radioactive materials Reviewing and approving all requests for the use of radiation-producing machines and radioactive material at the University Determining that all individuals authorized to use radiation-producing machines and radioactive materials have sufficient training and experience to enable them to perform their duties safely Establishing a program to ensure that all individuals whose duties may require them to work in the vicinity of radioactive material or radiation-producing machines are properly instructed about all appropriate health and safety matters Conducting an annual review of the Radiation Safety Program to determine that all activities are being conducted safely and in accordance with Texas Regulations for Control of Radiation and the University s license Function The Committee meets at least quarterly. Members include: A representative of the Administration The Radiation Safety Officer A representative of the nursing staff Physicians with expertise in the use of radioactive materials and radiation-producing machines for diagnosis and therapy Individuals with expertise in the use of radioactive materials for non-human research Other members shall be appointed at the discretion of the University President. 1-3

7 General Information Radiation Safety Officer and Staff Radiation Safety Officer Radiation Safety Staff The Radiation Safety Officer is appointed by the President of UTMB. The Radiation Safety staff of Environmental Health and Safety: Assists in the development of general policies for control of radiation Collects and disseminates information relative to radiation protection Evaluates equipment and physical facilities Evaluates operational techniques and procedures Provides radiation safety training Conducts an inspection program to assure that laboratory facilities and procedures are in accordance with UTMB policies and 25 TAC 289 Conducts testing programs for containment systems Provides advice on decontamination of facilities and equipment following spills or prior to remodeling or modification of facilities Responds to emergencies and investigates accidental exposures Aids in completion of the Application for Permit to Use Radioactive Material either as a new permit, an amendment to an existing permit, or a renewal of an existing permit Conducts a program of weekly and monthly wipe tests in the laboratory areas where the radioactive materials are handled Conducts a bioassay program for internal deposition of radionuclides Issues personnel dosimetry devices Receives and inspects packages containing radioactive materials Maintains and updates an inventory of radioactive materials and radiation producing machines Processes outgoing shipments of radioactive materials in accordance with present federal and state regulations Calibrates portable radiation survey instruments Surveys microwave ovens, x-ray cabinets and electron microscopes for radiation leakage Maintains records necessary to comply with 25 TAC

8 CHAPTER 2 : LICENSING RADIOACTIVE MATERIAL FOR USE Authorized Users Introduction A license to possess and use radioactive materials has been issued to The University of Texas Medical Branch by the Texas Department of State Health Services. The license is called a Specific License of Broad Scope because it permits the flexibility that is required for patient care and research in a dynamic medical center. At the same time, it requires UTMB to maintain a well-managed and documented program to ensure that radioactive materials are used safely. Under the terms of this license, the Radiation Safety Committee is delegated the responsibility for authorizing qualified individuals to use radioactive materials. Use of Radioactive Material Definition of Faculty Authorized Users The use of radioactive material at UTMB requires authorization from the UTMB Radiation Safety Committee. Only those individuals who, by virtue of their training and experience have been designated as Authorized Users by the Radiation Safety Committee or those individuals supervised by Authorized Users (referred to as Technical Staff) may use radioactive materials at UTMB. Those faculty members who, because of their training and experience, have been designated by the Radiation Safety Committee as being qualified to use radioactive material at UTMB are referred to as FACULTY AUTHORIZED USERS. Authorized Users are directly responsible for all aspects of radiation safety associated with his/her possession and use of radioactive material and the use by the Technical Staff that they supervise. The UTMB Radiation Safety Officer, by virtue of their appointment to the office by the UTMB Administration, shall be designated as a Faculty Authorized User regardless of their actual faculty status. Non-Faculty Authorized Users Permit Administrators In some circumstances, individuals who hold a doctorate level degree and are qualified by virtue of training and experience to use radioactive material, but are not members of the UTMB faculty (e.g. research fellows), may be designated Non-Faculty Authorized Users. These individuals may use radioactive material only in conjunction with a Faculty Authorized User who is willing to be accountable for the radioactive material and to ensure that all UTMB policies are followed. In those situations where two or more Authorized Users are using the same facilities for the use of radioactive materials, only one permit will be issued for the area. The Committee will ask that one of the Faculty Authorized Users be designated as the PERMIT ADMINISTRATOR. The Permit Administrator serves as a point of contact for all correspondence regarding activities under the Permit. The UTMB Radiation Safety Officer shall be designated as the Permit Administrator for the permit issued to the Radiation Safety Office by the Radiation Safety Committee. Technical Staff Time Limit for Becoming an Authorized User Those individuals who use radioactive materials under the supervision of an Authorized User and have met the training requirements set forth by the UTMB Radiation Safety Committee (see TRAINING REQUIREMENTS FOR PERSONNEL WHO WORK WITH RADIOACTIVE MATERIALS in the UTMB Radiation Safety Manual.) All faculty members who use radioactive material at UTMB are required to make application to the Radiation Safety Committee and become Authorized Users as soon as possible. 2-5

9 Licensing Radioactive Material for Use Authorized Users (continued) Using Radionuclides Prior to Receiving Authorized User Status The Radiation Safety Committee recognizes that there are certain circumstances when a faculty member may need to use radioactive material before the Committee has granted Authorized User status. When these circumstances arise, the faculty member can use radionuclides on an existing Radioactive Materials Use Permit as Technical Staff, providing: The faculty member complies with the Training Requirements for Personnel Who Work with Radioactive Materials section of the Radiation Safety Manual The administrator of the permit is willing to take responsibility for the faculty member s use of the radioactive material A faculty member, who is in the process of making application to become an Authorized User and wishes to start using radioactive material in the interim, may do so for a maximum of six months under this provision. A faculty member whose application has been denied by the Committee due to insufficient training and/or experience may use radioactive materials under this provision with the condition that the training and experience requirements be completed within six months of the Committee s decision or by the end of the next training course presented by Radiation Safety that is designed to meet the training requirement. If a faculty member fails to meet the time constraints set forth in this policy, the Permit Administrator of the permit under which the faculty member has been using radioactive materials will be informed by the Radiation Safety Committee to disallow the faculty member s continued use of radioactive material. Responsibilities The Authorized User is directly responsible for all aspects of radiation safety associated with his possession and use of radioactive materials. This responsibility includes: Complying with 25 TAC 289 Complying with conditions of the UTMB Radioactive Materials License Complying with the conditions of their permit Complying with the UTMB Radiation Safety Manual and Policies of the Radiation Safety Committee Providing instructions on safe and proper radiation practices to all persons working within the facilities of the Authorized User Maintaining adequate control of the radioactive material to ensure that areas beyond the Authorized User s control are not adversely affected by its use Providing necessary equipment for safe work with radioactive material Properly labeling all radiation sources and areas Notifying Radiation Safety of any accident or abnormal incident involving or suspected of involving radioactive material Informing Radiation Safety of any changes in personnel and any significant changes in lab design or procedures 2-6

10 Licensing Radioactive Material for Use Authorized Users (continued) Absence of Authorized User IF THE AUTHORIZED USER IS TO BE ABSENT FROM THE CAMPUS FOR AN INTERVAL OF TIME Greater Than Three Weeks: Three Weeks or Less: Either Suspend the use of the Ensure that the use of the radioactive material and radioactive material will ensure its safe storage for be under the supervision the duration of the of a qualified technical absence staff member (see Training Requirements ) Or Submit to Radiation Comply with rules for Safety the name of a absence greater than three qualified individual who weeks will assume responsibility for the safe use of the radioactive material. (This individual must be approved as an Authorized User by the Radiation Safety Committee and must submit a signed statement of intent to Radiation Safety.) Authorized Users leaving UTMB for a visiting professorship at another institution and desiring to have radioactive materials transferred there should refer to Transfer of Radioactive Materials. 2-7

11 Licensing Radioactive Material For Use Authorized Users (continued) Resignation of Authorized User STEP PROCEDURE 1 Notify Radiation Safety at least two weeks in advance of the departure. 2 Complete and return to Radiation Safety all Radionuclide Data Forms for any radioactive waste or materials. 3 Ensure that all equipment and facilities used for handling radionuclides are free of radioactive contamination. NOTE: This includes both equipment being taken to the new location and equipment remaining at UTMB. If you were the sole Authorized User on the permit for the facilities being vacated, contact Radiation Safety to have final wipe tests performed after all radioactive materials have been removed; and, upon being notified by Radiation Safety that the facility is free of radioactive contamination, remove all signs and tape indicating radionuclide use. 4 Return to Radiation Safety all Radiation Safety Manuals issued to the Authorized User. 5 Return any personnel dosimetry devices issued to the Authorized User. 6 Ensure proper disposition of radioactive material: IF Radioactive materials are not to be used again Radioactive materials are going to another UTMB Authorized User Radioactive materials are going to the User s new location THEN Dispose of all of them by following routine disposal procedures and call for pickup by the Environmental Protection Management. Transfer them. (See Transfer of Radionuclides) Bring them to Radiation Safety for future delivery (Call Radiation Safety to arrange this.) 7 Have a post operational bioassay performed by EHS if you are participating in bioassay program. Upon completion of all of these procedures, the Radiation Safety Program will provide a clearance signature on the School of Medicine Faculty Release Form. 2-8

12 Licensing Radioactive Material for Use Permit to Use Radioactive Material Radioactive Material Use Permit (a.k.a. Permit) Application Permits A Permit is issued by the UTMB Radiation Safety Committee to identify a location (e.g. a laboratory or group of laboratories) where the use of radioactive materials is permitted, the Authorized User or Users responsible for the radioactive material specified on the Permit, the Permit Administrator, the radionuclides permitted to be used, the maximum on hand limit per nuclide and other conditions or restrictions for radioactive material use. Where more than one Authorized User is listed on the Permit, each is jointly and severally responsible. Any qualified faculty member who wishes to become an Authorized User of radioactive materials must submit an application to the Radiation Safety Committee describing: Training and experience Facilities Radiation measuring equipment Special safety devices Procedures for control of radioactive material and radiation Emergency procedures Waste disposal methods To obtain a permit to use radioactive materials: STEP PROCEDURE 1 Complete an application. 2 Have your facility inspected by the Radiation Safety staff. 3 The completed application and staff recommendation will be presented to the Radiation Safety Committee for approval at its next regularly scheduled meeting. 4 If the application is approved by the RSC, a permit will be issued. The permit will list the Authorized Users, the radionuclides, the physical form, the amounts authorized for use, the type of use, and any special conditions imposed by the Radiation Safety Committee. Permits are valid for three years. Application for permits and a guide for completing them are available from the Radiation Safety Program s office. Call Radiation Safety to have a copy sent to you. The Radiation Safety Staff will assist all applicants in completing the forms. Amendment of Permits Requests for relatively minor changes in a permit may be submitted in memo form to Radiation Safety. If the requests involve the addition of a new Authorized User, new procedures, new radioactive materials, or a change in hazard level, supportive information will be requested. An application to amend the permit must be submitted to the Radiation Safety Committee for approval. 2-9 Revised

13 Licensing Radioactive Material for Use Permit To Use Radioactive Material (continued) Renewal of Permits Radioactive Material Use Permits expire on the last day of the month indicated on the permit. Prior to that date, Radiation Safety will send a completed renewal application for the Permit Administrator to review, sign, and return. Applications for renewal of permits must be submitted to Radiation Safety by the close of business on the last day of the month prior to the expiration month. If the permit is not to be renewed, the application form is to be returned with a memo stating the Permit Administrator s intent to let the permit expire. Authorized Users who do not submit renewals or respond to a request for additional information within the time limits specified will be asked to deliver their radioactive material to Radiation Safety for disposal. Compliance Inspection Of Permits Inactive Status of Authorized Users Radiation Safety Program staff conducts semi-annual surveys for permit compliance in all areas authorized for storage and use of radioactive material. The Permit Administrator is notified a week before the inspection. Results are mailed within seven (7) working days. Actions that are required to bring a permit back into compliance are to be completed within seven (7) working days of receipt of the deficiency notification. If an Authorized User has not used radioactive materials or keep radioactive materials in inventory for a period of 1 year or more, the Radiation Safety Program will recommend to the Authorized User to request to place the permit in an Inactive Status. Once the permit is Inactive, the Authorized User is no longer directly responsible for all aspects of radiation safety associated with his possession and use of radioactive materials as listed on page 2-6 of the Radiation Safety Manual. If at some point, the Authorized User determines that he will need to use radioactive materials, he must contact Radiation Safety and submit a written request to put the permit back to the Active Status. Permits are in effect for 3 years. If the request is made within the 3 years, the approval can be done administratively by the Radiation Safety Program and reported to the Radiation Safety Committee. If it is made after the permit expires, a complete renewal application must be submitted to the Radiation Safety Committee for approval. 2-10

14 Licensing Radioactive Material for Use Ordering Radioactive Material Purchasing Purchases of radioactive material must be approved by Radiation Safety prior to the ordering of the material. Purchase requests are prepared electronically in PeopleSoft. Radiation Safety will approve order three times daily during normal working hours. STEP PROCEDURE 1 An Authorized User or the Authorized User s designee may submit orders to Radiation Safety. This delegation must be made in writing to Radiation Safety. 2 Prepare a purchase request in PeopleSoft indicating that the order is radioactive and the permit number for the Authorized User. 3 The description of the material to be ordered must have: Radionuclide Chemical form Activity in mci Vendor 4 The delivery code for the shipment must be L Following the approval, Radiation Safety will electronically forward the requisition number to the purchasing department or back to the submitter for ordering. Free Samples Evaluation Kits If you expect to receive free samples or evaluation kits containing radioactive material, contact the Radiation Safety Office for further instructions. 2-11

15 Licensing Radioactive Material for Use Receipt and Documentation of Radioactive Material Receiving When radioactive material is received in Radiation Safety, the staff will: Check the package for damage and/or contamination and then remove the inner container Place a Radioactive Material Control (RMC) number on each container Prepare a Radionuclide Data Form (original and duplicate) for each RMC number assigned Notify the Authorized User or his/her representative that the shipment has arrived Transfer the receiving report and the Radionuclide Data Form with the radioactive material to the Authorized User The Authorized User or his representative will: Pick up the radioactive material within 1 working day after notification by Radiation Safety Verify the type and quantity of radioactive material Sign and date the Radionuclide Data Form Obtain receiving report and Radionuclide Data Form Return directly to the laboratory with the radioactive material NOTE: Any radioactive material packages delivered directly to the lab are to be taken to Radiation Safety for processing. Radionuclide Data Form The Radionuclide Data Form accompanies any radioactive material that is processed through Radiation Safety. The form should be completed according to these guidelines: Radiation Safety staff will: Enter requisition number in space provided Enter the Radioactive Material Control number assigned to this particular shipment in the space marked RMC # and on the containers used for storage of the material Complete the Receipt Survey section Enter the following information in the spaces provided in the Identification section: o Nuclide o Chemical form o Total mci o Vendor The Authorized User or his representative will: Sign and print one s name and date the form on the space provided at the time of receipt. Complete those parts of the IDENTIFICATION section not used by Radiation Safety (optional). Complete the USAGE section as appropriate (see Disposal of Radioactive Materials ). 2-12

16 Licensing Radioactive Material for Use Receipt And Documentation Of Radioactive Material (cont.) Radionuclide Data Form (continued) Complete the DISPOSAL section as appropriate (see Disposal of Radioactive Materials ). Return the original (white) copy to Radiation Safety when all of the material has been disposed 2-13

17 Licensing Radioactive Material for Use Transferring Radioactive Material Introduction Transfer Within UTMB Radioactive material shall not be transferred to or from anyone else, either on campus or off campus, without prior approval by Radiation Safety. This approval can be obtained by telephone or . The Authorized User from whom the material will be transferred will: Obtain authorization from Radiation Safety to transfer the material Obtain a new RMC # for the material being transferred Enter the date, activity and the new RMC # assigned by Radiation Safety on the original Radionuclide Data Form in the DISPOSAL section (e.g. 2/10/02, 1.0 mci transfer to ABC-123) Mark the container of the material being transferred with the new RMC # Retain the forms issued to him/her for this material (the recipient will be issued a new Radionuclide Data Form corresponding to the new RMC # for the amount transferred to him/her) The Authorized User receiving the material will: Contact Radiation Safety within two working days if the new Radionuclide Data Form is not received in the mail Maintain a record of the use and disposal of the transferred material on the form provided Radiation Safety will: Approve or deny the transfer request based on recipient s permit and current inventory Assign a new RMC # for the recipient Enter transfer on recipients computer inventory record Issue a Radionuclide Data Form to the recipient for the transferred material Transfers to UTMB From Off Campus The recipient (UTMB Authorized User) will: Inform Radiation Safety of what they intend to have transferred Remind the sender to contact their own Radiation Safety Officer for further instructions Provide Radiation Safety with the name and telephone number of the sender s Radiation Safety Officer Radiation Safety will: Contact shipper s Radiation Safety Officer Send copy of UTMB license to shipper s Radiation Safety Officer Instruct the sender to ship the material, UTMB Health & Safety Services, Radiation Safety Program, 301University, Galveston, TX

18 Licensing Radioactive Material for Use Transferring Radioactive Material (continued) Transfers From UTMB to Off-Campus The sender (UTMB Authorized User) will: Notify Radiation Safety at least 5 days before the transfer date Provide EHS with the name and telephone number of the recipient s Radiation Safety Officer Make arrangements for actual transportation to the recipient s Radiation Safety Officer Radiation Safety will: Provide assistance in preparing the radioactive material for shipment (i.e. packaging, labeling and documentation) Contact the recipient s Radiation Safety Officer to obtain a copy of that institution s license and other shipping instructions 2-15

19 Licensing Radioactive Material for Use Training Requirements for Personnel Who Work With Radioactive Materials Introduction Appropriate training for any individuals who work with or in the vicinity of radioactive material or radiation-producing machines is an essential part of any radiation safety program. This includes all individuals who work with radioactive materials at UTMB laboratories, regardless of employment classification (e.g., family member, post-doctoral fellow, graduate student, research associate, laboratory technical assistant). The University has an obligation to its employees and students to provide them with: A safe working environment An awareness of the hazards to which they may be exposed Training in methods to protect themselves against those hazards This training is required by the Texas Regulations for Control of Radiation (TRCR). It must be a joint effort between Radiation Safety and the individuals authorized to use radioactive material or radiation-producing machines. All individuals who work with or in the vicinity of radioactive material must be knowledgeable about the potential health hazards associated with the use of radioactive materials, methods and procedures to minimize exposure to radiation, and their rights and responsibilities under the TRCR and the UTMB Radiation Safety Program. UTMB Instruction In order to ensure that adequate training is obtained, Environmental Health and Safety conducts a training course titled Basic Radiation Safety in the Laboratory. All individuals who work with radioactive material must successfully complete the course at one of the two sessions immediately following commencement of their work with radioactive material. Successful completion of this course is a requisite for working with radioactive materials at this University. In some instances faculty members desiring to work with radioactive materials in large quantities will be required to attend the Radiation Protection in Research course. Training Exemptions Exemptions will be granted on an individual basis to: Individuals who can document comparable training at another institution Authorized Users who are exempt by virtue of the acceptance of their training and experience by the Radiation Safety Committee for Authorized User status Individuals who have had comparable training but have no documentation may be granted an exemption upon passing a written exam encompassing the type of material covered in the course All other exemptions will be determined on an individual basis by Radiation Safety. 2-16

20 Licensing Radioactive Material for Use Training Requirements For Personnel Who Work With Radioactive Materials (continued) Note Prior to successful completion of the course, or receiving an exemption, individuals may work with radioactive material only under the direct supervision and in the physical presence of another individual who has been appropriately trained. This policy does not exempt Authorized Users from their responsibility to provide inservice training for personnel working in their laboratory. Annual Radiation Safety Training All technical staff who will be working in the laboratory with unsealed radioactive materials shall receive radiation safety training before the individual begins working in the laboratory and annually thereafter. Each individual should know: The type and quantities of radioactive materials or radiation producing machines that are used or stored in each laboratory area The nature of the hazard associated with each type of radioactive material or radiation-producing machine Laboratory safety procedures designed to protect the worker against harmful effects of radiation The proper use of protective equipment (e.g., syringe shields, lead aprons, remote handling devices, etc.) Procedures to follow in case of a spill or other accidents involving radioactive material or radiation producing machines Training may be provided by an Authorized User approved by the UTMB Radiation Safety Committee. Alternatively, a one-hour radiation safety refresher course is provided by Radiation Safety to all individuals working with radioactive material in the laboratory. The training is offered once a month. The refresher may be substituted for the annual inservice training required of Authorized Users to provide to their technical staff. Authorized users not handling radioactive material are exempt from the requirement to complete annual radiation safety training. Documentation All radiation safety-related training or education that employees receive, whether from Radiation Safety or within the laboratory, shall be properly documented and maintained on file for review. Radiation Safety will provide assistance in design of in-service training programs upon request. 2-17

21 Licensing Radioactive Material for Use Personnel Monitoring Criteria for Monitoring The Texas Regulations for Control of Radiation requires that anyone who is likely to receive a dose in excess of 10 percent of the maximum permissible occupational dose in any calendar year must wear a personnel monitoring device. The RSC has determined that personnel monitoring devices shall be worn at UTMB by anyone in the following categories: Personnel working with x-ray producing devices with the exception of electron microscopes, cabinet x-ray units and dental units (excludes medical students) Personnel who work in the vicinity of radioactive material or radiation-producing machines in the Department of Radiation Oncology Personnel who work in the vicinity of radioactive material in the Division of Nuclear Medicine Personnel working with radionuclides that emit beta particles with energies greater than 1 MeV or gamma rays when these radionuclides are used in quantities exceeding 5 mci of activity Any persons required to enter a posted high radiation area Requests for personnel monitoring devices for special uses will be evaluated on an individual basis and the approval of Radiation Safety will be required. Pregnant Females Monitoring Devices Radiation Safety provides monitoring for a Declared Pregnant Female. A Declared Pregnant Female is a woman who has voluntarily declared her pregnancy in writing to the Radiation Safety Officer. In addition, Radiation Safety provides a consultation service to discuss working safely with radioactive materials and radiation producing machines during a pregnancy. Currently, UTMB uses Optically Stimulated Luminescent dosimeters (OSL) for whole body, fetal and environmental monitoring and thermoluminescent dosimeters (TLDs) for extremity monitoring. Only NVLAP accredited dosimetry services are used. These and other monitoring devices are outlined below. DEVICE ASSIGNED TO EXCHANGE SCHEDULE Ring Badge Individuals in higher-risk areas for hand exposures TLD ring dosimeters are exchanged monthly or quarterly depending on the POCKET DOSIMETERS (pocket ion chambers) OSL Personnel for a one-time only use (obtained by special request) Individuals in both highrisk and low-risk areas area s level of risk Are to be returned to Radiation Safety upon completion of use OSL dosimeter packets are exchanged monthly or quarterly depending on the area s level of risk 2-18 Revised 4/25/16

22 Licensing Radioactive Material for Use Personnel Monitoring (continued) Monitoring Reports All personnel dosimeters are processed commercially. The exposure reports are sent to Radiation Safety and reviewed by the staff. Any exposures that exceed the maximum permissible limits or are much higher than average are discussed with the individual and the individual s supervisor and appropriate steps are taken to prevent reoccurrence. Any individual may receive a copy of his/her exposure history by requesting it in writing from Radiation Safety. Purpose The sole purpose of the personnel dosimeter is to record a radiation exposure. IT DOES NOT PROTECT AGAINST RADIATION! In-service Training The Radiation Safety Program provides a training program on the care and use of personnel dosimeters. Attendance is required prior to the issuance of a dosimeter. The training class is held twice weekly. Proper Use and Care of Badges Personnel dosimeters must be properly used and cared for in order to give an accurate reading. The following guidelines outline proper care: Attach the badge near the collar of your upper garment (or at the waist) and wear at all times while on duty. If you are wearing a lead apron, the badge should be worn at the collar outside the apron. Note: Individuals who wear an apron, thyroid shield and eye shield of at least 0.25 mm lead equivalent (0.5 mm for individuals working around fluoroscopic machines lacking lead drapes) may request in writing a variance to be permitted to wear their badge under their apron. Leave the badge in a safe place when you are not on duty. Make sure it is away from all sources of radiation. Personnel dosimeters should not be taken off campus. Never wear a badge issued to another person or allow anyone else to wear yours. Take care not to send the badge to the laundry with the uniform or lab coat. Make sure to return the badge at the proper time to exchange for a new one. This is your responsibility. Do not puncture or remove the dosimeter from the holder. 2-19

23 Licensing Radioactive Material for Use Personnel Monitoring (continued) Care of Badges (continued) If you lose or damage your dosimeter, a replacement must be obtained from Radiation Safety immediately. A Lost or Damaged Personnel Dosimeter report must also be obtained from Radiation Safety. Upon completion of this form, an exposure will be assessed for the time period of the lost dosimeter and added to your exposure history. Report any other incident relative to the wearing of the badge (such as possible accidental exposure when the badge is not worn) to Radiation Safety. Do not wear your badge during any medical procedure that involves radiation or radioactive material in which you are the patient. Return of Personnel Dosimeter Return your personnel dosimeters to Radiation Safety by the 7 th working day of the new wear period. If you do not, you will receive a Lost and Damaged Personnel Dosimeter Report form and be instructed to return either the completed form or the dosimeter by the 21 st working day of the new wear period. Consequences of Failure to Return Dosimeter Individuals who work with radionuclides: Individuals who work with radiation-producing machines: If either the dosimeter or the form is not returned by the 21 st working day, Radiation Safety will not approve purchase or receipt of radionuclides for the Radioactive Materials Use Permit under which you work until the dosimeter or the form is returned. If either the dosimeter or the form is not returned by the 21 st working day, Radiation Safety will notify your Department Chairman that you are not permitted to operate radiationproducing equipment until the dosimeter or the form is returned. Exemptions Exemptions regarding the deadline for returning the dosimeter or form will be granted on an individual basis for individuals on vacation, sick leave, etc. 2-20

24 Licensing Radioactive Material For Use Record Keeping Required Records The following duplicate records maintained by the Permit Administrator shall be kept until the next audit by Radiation Safety: Radionuclide Data Forms (2 years from date of final disposal of material) Radioactive Waste Disposal Forms (2 years from date of final disposal of material) Radiation Safety Surveys Survey Meter Calibration Wipe test (see below) Original records of activities performed by the Permit Administrator or his staff shall be maintained as stated below: In-service training of laboratory personnel (indefinitely) Calibration of Dose Calibrators (5 years) Wipe test records of surveys not performed by Radiation Safety (indefinitely) These records shall be transferred to Radiation Safety upon termination of the permit. 2-21

25 CHAPTER 3 : GENERAL RULES AND GUIDELINES FOR HANDLING RAM Routine Laboratory Procedures Introduction A set of written procedures is required for each laboratory or area where radioactive materials are used. These procedures must describe specific rules applicable to that area. The location of these procedures shall be known and accessible to all individuals who work in the area. The following general rules apply to all personnel who use radioactive material and should be incorporated into each laboratory s written procedures. Signs and Notices Areas where radioactive materials are used must be posted in accordance with the Texas Regulations for Control of Radiation. The following signs will be conspicuously posted and replaced if defaced. Caution Radioactive Materials signs on all doors to laboratories and storage areas Notice to Employees BRC Form Regulation Card (indicating where copies of 25 TAC 289 and other documents are located) Emergency Procedures Personnel Protection For your health and safety, it is imperative that you follow the rules concerning radioactive materials. If you have any questions about the following procedures, ask your supervisor or call Radiation Safety. When required by Radiation Safety, wear personnel dosimeters and finger dosimeters. Wear lab coats or other protective clothing as an outer garment at all times while in the laboratory. Maintain good hygiene by: o o o Keeping fingernails short and clean Thoroughly washing hands and arms before handling any object that goes into the mouth, nose or eyes Not handling radioactive material if there is a break in the skin below the wrist or by wearing 2 pairs of gloves when handling the material Keep the laboratory neat and clean. Label permanent areas used for radioactive work (including sinks and equipment) with Caution Radioactive Material tape. The following activities are prohibited anywhere in a laboratory or in any other location in which radioactive materials are stored or used: eating, drinking, smoking, chewing gum, etc., or otherwise placing items in the mouth, applying cosmetics, storing or preparing food or drink for human consumption, storing items or utensils used for human food or drink preparations or consumption. NOTE: A specific exception to this rule will be allowed upon written request as it relates solely to the preparation or consumption of food or drink by research subjects or patients involved in approved human research protocol, or human diagnostic or therapeutic medical procedures involving the consumption of radioactive material. 3-22

26 General Rules and Guidelines for Handling Radioactive Materials Routine Laboratory Procedures (continued) Storage of Radioactive Materials Keep radioactive material in a leak-proof container. Label all radioactive material containers with an appropriate label stating: - The radionuclide - The amount of activity - The date Label refrigerators or freezers with a Caution Radioactive Material sign and do not store food or beverages for human consumption in them. Secure and lock storage areas when materials are left unattended. Handling of Radioactive Materials Wear disposable gloves when handling unsealed radioactive materials. In some uses, remote handling devices may be required by Radiation Safety. Never pipette radioactive materials (or any other materials while working with radioactive material) by mouth. Use absorbent padding or other material in areas where radioactive material is handled. Perform iodinations and use volatile radioactive material only in a fume hood specifically approved for such use by Radiation Safety. If you do not have an approved hood, contact Radiation Safety to arrange for the use of a suitable hood. Surveys Laboratory personnel will routinely survey the laboratory for contamination. See section entitled Area Contamination Surveys on page 3-40 for guidelines. Bioassays Laboratory personnel must comply with the policies of Radiation Safety and RSC for bioassays or other personnel surveillance operations. (See Bioassay Program, page 4-43) Radioactive Waste Materials Place radioactive waste only in specially marked receptacles. Disposal of limited quantities of radioactive liquid waste into specifically designated sinks may be permitted by Radiation Safety. For further information on disposal, refer to Disposal of Radioactive Material on page

27 General Rules and Guidelines for Handling Radioactive Materials Routine Laboratory Procedures (continued) Incident Reporting Notify Radiation Safety immediately by telephone of all incidents involving: Radioactive contamination (external or internal) of personnel Radioactive contamination of a large area or that you are unable to manage with the resources readily available to you Release of radioactive material to the environment Loss of radioactive material (including radioactive waste) Known or suspected excess radiation exposure to general public or lab personnel Loss or damage to personnel dosimeters Notify Radiation Safety within one week of incidents involving radioactive material or other sources of radiation that are less severe than those listed above. Equipment Repair Notify Radiation Safety prior to the repair or removal of any equipment that may be contaminated with radioactive material or that contains a source of radiation. 3-24

28 General Rules and Guidelines for Handling Radioactive Materials Emergency Procedures Introduction During the course of routine operations, radioactive material may be spilled, causing contamination of lab areas, personnel, or equipment. Correct action taken during such an emergency can prevent spread of the contamination. Written Instruction A set of written procedures describing the specific steps to be taken in the event of a spill of radioactive material shall be posted in a prominent location in each laboratory or area where radioactive materials are stored or used. These procedures shall be established on an individual basis applicable to the particular area, according to the type and quantity of material used. They should include: Specific location of radioactive waste containers Specific type and location of survey meters Emergency telephone numbers Minor Spills MINOR SPILLS can be generally considered as those that do contaminate small areas of laboratory surfaces or equipment, but do not result in: External or internal contamination of personnel Excessive external radiation exposure to personnel Serious delay in work procedures The following steps should be taken in case of minor spills: STEP PROCEDURE 1 Notify all persons in the area that a spill has occurred. 2 Cover the spill with absorbent paper. 3 Using disposable gloves carefully fold the absorbent paper and pad; insert it in a plastic bag and dispose of it in a radioactive waste container. In another container, dispose of all other contaminated material such as disposable gloves. 4 With a window GM survey meter, check the area around the spill, and your hands and clothing for contamination. Perform follow-up wipe tests and decontaminate as necessary. 5 Report the incident to Radiation Safety. 3-25

29 General Rules and Guidelines for Handling Radioactive Materials Emergency Procedures (continued) Major Spills MAJOR SPILLS may result in any or all of the following: Contamination of large surface areas Internal or external contamination of personnel Excessive external radiation exposure to personnel Serious delay in work procedure The following steps should be taken in case of major spills: STEP PROCEDURE 1 Notify all persons not involved in the spill to vacate the room. 2 Cover the spill with absorbent pads, but do not attempt to clean it up. Confine the movement of all potentially contaminated personnel to prevent the further spread of contamination. Prevent personnel from entering the contaminated area. 3 If possible, return stock vials to their shields, but only if it can be done without further contamination or without significantly increasing your radiation exposure. 4 Notify Radiation Safety and the laboratory supervisor. 5 Remove and store contaminated clothing for further evaluation by Radiation Safety. If the spill is on the skin, flush thoroughly and wash with mild soap and lukewarm water. 3-26

30 General Rules and Guidelines for Handling Radioactive Materials Emergency Weather Procedures Introduction High water flooding and hurricane force winds can cause damage to laboratories that could result in spread of radioactive contamination. This emergency procedure is designed to minimize the potential for the spread of contamination. The specific response will depend upon the existing and expected weather conditions. Pre-Planning Emergency weather preparedness begins long before the threat of inclement weather exists. The following measures will make it easier to prepare the lab should the emergency weather plan actually be implemented. Keep radioactive materials in your inventory at a minimum. Get rid of old materials in storage. Do not allow radioactive waste to accumulate in your lab. If your lab has outside windows, identify secure areas within the lab for storage, such as inside refrigerators or built-in cabinets with doors that stay shut. Keep all emergency telephone numbers posted in the lab updated. Keep plastic or other waterproof containers at hand. You may need them to store your materials. Keep a supply of Radioactive tape or labels on hand. 3-27

31 General Rules and Guidelines for Handling Radioactive Materials Emergency Weather Procedures (continued) Emergency In the event of a weather emergency, you should take the following minimum actions: AREA Areas susceptible to flooding (basement and ground floor labs) Areas susceptible to damage from high winds (labs with windows) INSTRUCTIONS Weather permitting, Radiation Safety staff will instruct you to take radioactive waste to the designated waste facility for disposal. NOTE: Due to limited space, only waste from flood prone areas will be accepted. Weather not permitting, or if Radiation Safety s waste facility has been secured, move your radioactive waste to designated areas above the first floor for temporary storage. Move radioactive materials (other than waste) to designated areas above the first floor for temporary storage (call Radiation Safety for the location at the designated temporary storage area for your lab). If possible, place radioactive materials, in waterproof or plastic containers. Securely close all radioactive material containers so that they will not lose their contents should they be upset Clearly mark all radioactive material containers as Radioactive and note their contents (radionuclide, activity, and RMC #). Move radioactive materials and wastes to secure locations, such as: - Refrigerators - Storage cabinets with doors -Storage closets - Rooms not susceptible to damage from high winds or - Flying debris Tape shut all storage cabinets containing radioactive material that do not have secure latches. Close all radioactive waste containers and get them off the floor. Check the lab area to be sure no radioactive material has been left out on an open lab bench. 3-28

32 General Rules and Guidelines for Handling Radioactive Materials Emergency Weather Procedures (continued) Emergency Actions (continued) Areas susceptible to damage from high winds (labs with windows) Label all storage locations not already so marked with Caution Radioactive Material labels (labels on temporary storage locations must be removed after the radioactive materials are returned to their normal location). Lock all areas where radioactive materials are stored (e.g. laboratory doors, refrigerators in corridors, etc.). 3-29

33 General Rules and Guidelines for Handling Radioactive Materials Disposal of Radioactive Materials Introduction Each authorized user is responsible for ensuring that the material under his permit is disposed of properly. No radioactive materials shall be disposed of except in the following ways: Release into the sanitary sewage system Segregation and disposal Administration to a Patient Release into the Sanitary Sewage System According to the 25 TAC 289 once radioactive material is administered to a patient, no further account of its disposal is required. However, if excreta are collected from a patient receiving a large therapeutic dose of radioactive material, the excreta should be stored for decay prior to actual disposal. To release radioactive material into the sanitary sewage system, the following criteria must be observed. (Information about the maximum activity of a radionuclide that may be disposed of per day may be obtained from Radiation Safety): UTMB policy #8.1.6 Disposal of Hazardous waste states regulations and conditions of the UTMB license be followed Only material that is soluble or dispersible in water and is not prohibited from sewage disposal because of its chemical or biological nature will be disposed of in this manner The Radionuclide Data Form must reflect the activity (in millicuries) that is disposed Disposal may be made only via sinks specifically approved for that purpose by Radiation Safety Material being disposed must be flushed with copious amounts of water to ensure proper dilution Liquid scintillation cocktail including environmentally safe cocktails must not be disposed of via the sanitary sewage system 3-30

34 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Segregation and Disposal All radioactive material that is not administered to a patient or released into the sanitary sewage system must be segregated in the following categories (do not mix waste categories within a waste container): CATEGORY Dry Solid Waste, halflife greater than 300 days: Dry Solid Waste, halflife less than 300 days: Sharps: L.S. Vials: Stock Vials: Bulk Liquid: Waste from RIA kits: Animals/ Bedding: DESCRIPTION Non-liquid items such as gloves, pipets, pipet tips, test tubes, petri dishes, paper towels, diapers, chux, containers of needles, etc. (NOTE: All wastes must be non-pathogenic. See Radioactive Pathogenic Wastes). NO LS VIALS CONTAINING LIQUID MAY BE PLACED IN DRY SOLID WASTE BOXES. Non-liquid items such as gloves, pipets, pipet tips, test tubes, petri dishes, paper towels, diapers, chux, containers of needles, etc. (NOTE: All wastes must be non-pathogenic. See Radioactive Pathogenic Wastes ). NO LS VIALS CONTAINING LIQUID MAY BE PLACED IN DRY SOLID WASTE BOXES. ALL RADIOACTIVE LABELS MUST BE OBLITERATED PRIOR TO DISPOSAL. Place in an approved puncture resistant container (sharps container), solidify and then place in the appropriate dry solid waste box. This includes needles, Pasteur pipets, broken glass, etc. Use only the small size (1 cubic foot) boxes supplied by Environmental Protection Management. NO GLOVES, PIPETS, STOCK VIALS, BACTEC VIALS, PAPER TOWELS, AQUEOUS NON-SCINTILLATION VIALS, ETC. MAY BE PLACED IN THE LS VIAL BOXES. Segregate vials in the appropriate box as follows: a) H-3, C-14 b) P-32, P-33 only c) S-35 only Call Radiation Safety, ext , if your radionuclide is not listed in any category. Collect stock vials separately from other waste. Short-lived materials must be separated from long-lived ones. Liquids collected because they are not permitted to be disposed of via sanitary sewage system. (i.e., toxic or not miscible with water). Collect in quantities of 1 gallon or less in a tightly sealed container. Each container must have a Radioactive Waste Disposal Form. If the kits contain C-14, H-3, or I-125, call Radiation Safety for disposal instructions. If the kit contains other nuclides, the waste may be disposed of as Dry, Solid waste. Radioactive animals and contaminated bedding must be collected separately from other radioactive wastes. Animals must be triple bagged, labeled with tape marked radioactive and stored in a freezer designated for radioactive material use. For animals treated with pathogenic agents, call Radiation Safety for instructions. 3-31

35 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Segregation And Disposal (continued) Documentation Of Use and Disposal Radionuclide Data Form Radioactive waste containers for proper segregation of waste (with the exception of bulk liquids and stock vials) will be provided to each lab by Environmental Protection Management. Information on where to obtain shields for waste containers is provided by Radiation Safety. Proper documentation of the use and disposal of radioactive material is the responsibility of the Authorized Users. Radiation Safety will supply forms for this purpose. The Radionuclide Data Form is used to track each shipment of radioactive material from receipt by Radiation Safety through disposal by the Authorized User and his staff (see RECEIPT AND DOCUMENTATION OF RADIOACTIVE MATERIAL section). At the time of use an entry should be made in the USAGE section indicating: who used it, amount of material used, the type of experiment and date used. At the time of disposal an entry shall be made in the DISPOSAL section indicating: date disposed, method of disposal and the activity in mci When all of the radioactive material has been disposed, total the activity for each disposal method in the space provided at the bottom of the DISPOSAL section. All of the activity shown in the IDENTIFICATION section must be accounted for in the DISPOSAL section. After completion, the original (white) copy is returned to Radiation Safety. The duplicate copy (generally pink or yellow) is kept by the Permit Administrator. Example of See sample on page Properly Completed Radionuclide Data Form 3-32

36 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) How to Complete A Radioactive Waste Disposal Form The Radioactive Waste Disposal Form is used to identify the contents of each waste container and must accompany each radioactive waste container that has been filled and is ready for removal from the laboratory. It must be completed and attached to each waste container. (Exceptions: as many as seven small bulk liquid containers, less than one gallon each, containing the same chemical constituents, may be listed on one form.) Below are instructions for filling out each section properly SECTION Physical/ Chemical Description RMC # Activity Radionuclide Type Certification WHAT INFORMATION IS NEEDED Must be an actual description of the contents (e.g., plastic LS vials, test tubes, gloves, diapers, etc.) The words Trash or Garbage will not suffice. For bulk liquids list the chemical names, concentrations and total volume in each container. For animals list total weight in grams. The Radioactive Material Control number that corresponds to the source of activity must be listed for each entry. Use millicurie (mci) units only Chemical element and mass number (e.g., I-125) that corresponds to the RMC #). Properly identify the material category. An Authorized User must sign the form or someone designated in writing to Radiation Safety by an Authorized User. Because of legal requirements, there can be no exceptions. Each entry on the waste disposal form MUST be completed. If one form is not enough to list container contents, attach additional forms numbered consecutively. Each form must be signed. If you have any questions, call Radiation Safety. Example of properly completed Radioactive Waste Disposal Form see sample on page

37 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Example of Properly Completed Radionuclide Data Form 3-34

38 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Example of a Properly Completed Radioactive Waste Disposal Form 3-35

39 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Pick-Up Procedures When requesting a pick-up of radioactive material, the following rules should be observed: Environmental Protection Management picks up radioactive waste only on Tuesday or Thursday. Be sure to contact EPM at least 24 hours in advance of the desired pick-up day. Log on to to request a radioactive waste pick-up and provide the appropriate information (type of waste, number of boxes, number of stock vials, type of animal, etc.) Refusal of Waste Improperly documented or segregated waste will not be accepted by Environmental Protection Management. If evidence of improper segregation or documentation is discovered by Environmental Protection Management after waste has been removed from the lab, the waste container and its contents will be returned to the lab for proper segregation and documentation as necessary. If waste has been refused for pick-up, the lab will be issued a Notice of Attempted Pickup (see sample page 3-16) stating the reason for the refusal. Radiation Safety will assist the lab with resolving the problem. After the deficiency is corrected, the lab must call in to request another waste pick-up. Special Rules for Stock Vials Some specific guidelines for the handling and disposal of stock vials are listed below: Stock vials are not to be disposed of via any radioactive waste container in the lab. Environmental Protection Management will pick them up as separate items. As many as eight stock vials may be listed on one Radioactive Waste Disposal Form. Special Rules for Bulk Liquids Some specific guidelines for the handling and disposal of bulk liquids are listed below: Bulk liquid waste must be collected in closable containers. Container size should not exceed 1 gal (4 liters) for ease of handling. The Radioactive Waste Disposal Form for each container shall list the contents by chemical name, concentration and total volume, in the Physical/Chemical Description section. Container type (glass or plastics) should be compatible with chemicals disposed. 3-36

40 General Rules and Guidelines for Handling Radioactive Materials Example of Notice of Attempted Pick-up Form 3-37

41 General Rules and Guidelines for Handling Radioactive Materials Disposal Of Radioactive Materials (continued) Disposal of Radioactive Animals Environmental Protection Management and Radiation Safety will pick up and dispose of radioactive animals. For disposal of other animals, call the Animal Resources Center. Some specific guidelines for radioactive animal disposal are listed below: Animals shall be double-bagged in plastic bags (large animals shall be triple-bagged and labeled with tape marked RADIOACTIVE. ) Care must be taken to keep the outside of the bag free from blood. Prior to pick-up, store your animal carcasses and beddings in freezers designated for radioactive use. A properly completed Radioactive Waste Disposal Form (see section titled DISPOSAL OF RADIOACTIVE MATERIALS ) must accompany each bag. Ensure that the form does not get contaminated with blood making it unreadable. Animal excreta can either be disposed of through sewage as liquid radioactive waste or mixed with the bedding and carcasses. 3-38

42 General Rules and Guidelines for Handling Radioactive Materials Use of Radioactive Materials in Animals Introduction All use of radioactive material in animals must be specifically authorized by the Radiation Safety Committee and the Animal Care and Use Committee. Application for Authorization to Use Radioactive Materials in Animals Individuals desiring to use radioactive materials in animals must, as part of their application for or amendment to a Radioactive Material Use Permit, describe the precautions and procedures to be used in handling and care of animals. Radiation Safety will assist in writing these procedures. The information provided should address the following areas: TOPIC Facilities for injecting radioactive material into animals Labeling of cages for the injected animals Type of cage used to contain the animal Monitoring and decontamination of cages Segregation of the injected animals from other animals Disposal of animal excreta Ventilation Instructions of animal handlers INFORMATION NEEDED Describe procedures for restraining animals during injection and the method for containing any radioactive material lost during injection. For small animals, a tray lined with absorbent material should be used. For large animals, some other method may be required. The label should include the type of radionuclide, quantity of material injected per animal, date of injection, and the Authorized User. (Cage labeling is especially important for animals that are not sacrificed within a short period of time after injection.) What type of cage will be used? If contamination is likely to be a problem, a metabolic-type cage should be considered. If animal cages are to be returned to Animal Resources Center after use, describe procedures for decontaminating and monitoring cages. Records of radiation levels and wipe tests should be maintained. Are long-term retention studies being conducted? If so, this information is especially important. Describe the methods to be used for disposal, e.g., through sewage as liquid waste, or mixed with saw dust and wood shavings and incinerated. Will the radioactive material to be administered be volatile? Will it be excreted in respiratory air, or in a volatile form? If so, special consideration must be given to ventilation. If it is excreted in urine or feces, dust-free bedding should be used. Describe the indoctrination of animal handlers that you will provide. This should include dose levels, time limitation and special handling requirements that you specify for your animals and/or their excreta. In general, once injected with radioactive material, animals should be housed in the laboratory. They are not to be returned to the central animal care facilities without specific approval of Radiation Safety and the Director of the Animal Resources Center. 3-39

43 General Rules and Guidelines for Handling Radioactive Materials Guidelines for Area Contamination Surveys Frequency of Surveys The required frequency for area surveys depends on the procedures performed and the quantities of radionuclide used. DAILY: WEEKLY: MONTHLY: Perform a survey of all areas where radioactive material for human used is eluted, prepared, or injected. Perform surveys either before or after operations, with a low-range, thin-window GM survey meter and decontaminate if necessary. Perform wipe test surveys in laboratory areas where radioactive materials are used daily or monthly. Perform wipe test surveys in laboratory areas were radioactive materials are used in amounts less than 1 millicurie per experiment. Maintain a record of all survey results as specified by the UTMB Radioactive Material License. If desired, Radiation Safety will perform these required (weekly and monthly only) wipe tests and maintain the appropriate records free of charge. Using Survey Instruments The purpose of survey instruments is to reveal the presence of unsuspected loose or fixed contamination and also to measure general area radiation levels to ensure that they are not excessive. The use of a survey instrument for contamination survey does not eliminate the requirement to perform scheduled wipe tests, but should be used to ensure that contamination is not present in other areas of the laboratory, on personnel or equipment. A survey instrument should be available in any laboratory where radioactive material is sufficient to produce significant radiation levels or contamination. As a general rule, a survey instrument should be available if the quantities used exceed 1 mci (except for weak beta emitters such as H-3). Usually, survey instruments are purchased by the principal investigator or individual authorized to use the radioactive material (they are not provided by Radiation Safety). Instrumentation Calibration Instrument Selection Radiation Safety calibrates all survey instruments on at least an annual basis. Instrument selection should be based on the following criteria: Survey instruments should normally be of the Geiger-Mueller (GM) type. If levels exceed 10 mr/hr, then both an ionization chamber and GM detector should be available. Survey instruments should be lightweight, readily portable, and easily handled by laboratory personnel. The instrument should be simple to operate and the scale should read in both mr/hr and counts per minute. 3-40

44 General Rules and Guidelines for Handling Radioactive Materials Guidelines For Area Contamination Surveys (continued) Instrument Selection (continued) The Geiger-Mueller detector should be a thin-window type to permit detection of surface contamination by such low-energy emitters as Carbon-14 and Sulfur-35. Instruments should be easy to calibrate. Even though a laboratory may be working with only one radionuclide, a nuclidespecific instrument should not be obtained unless the principal investigator knows with certainty that no other nuclides will be added at later date. This consideration is important in order to reduce subsequent cost factors for purchase of new equipment. Instruments should be accurate within 10% on a full scale. Radiation Safety should be notified when a laboratory purchases a new meter. Radiation Safety can also provide recommendations for purchasing the proper instrument. Instructions for Conducting Contamination Surveys Using GM Survey Meters Surveys for contamination using a GM Survey meter should be conducted in the following manner. (This procedure is applicable for thin-window detectors only and only for gross amounts of contamination. It is not a substitute for wipe tests). STEP PROCEDURE 1 Turn survey instrument on and check for proper operation. A battery check is important. 2 Select several radioactive material work areas in the laboratory and several areas where work with radioactive materials does not occur, but where contamination might be spread. 3 Low-background Radiation Areas: Move the probe very slowly over the surfaces to be checked. The probe should be perpendicular to and within ¼ inch of the surface. High-background Radiation Areas: Take wipe tests of selected areas and count by holding wipes within ¼ inch of the thin-window with the detector located in a low-background area. Note: Low-background Radiation Area means that, in general, the average meter reading due to ambient background radiation does not exceed 200 CPM (approx mr/hr). 4 If the instrument meter reading is 100 CPM above background, contamination is present. 5 Decontaminate and perform follow-up wipe tests. 6 After performing wipe tests, go over these areas with the survey instrument. 3-41

45 General Rules and Guidelines for Handling Radioactive Materials Guide-Lines For Area Contamination Surveys (continued) Important Significant meter readings after decontamination and negative wipe tests may indicate fixed contamination. CONTACT RADIATION SAFETY IMMEDIATELY FOR ASSISTANCE! Instruction for Area Wipe Tests Area wipe tests should be conducted in the following manner: STEP PROCEDURE 1 Put on disposable gloves if you are handling potentially contaminated items or if you are directly handling the wipe medium. (Gloves are not required if you use hemostats to hold the cotton used for wiping.) Note: If you suspect contamination on the floor, wear shoe covers also. 2 Using filter paper, cotton or another suitable wipe medium, wipe an area of 100 cm 2 of a large surface. (Wipe an entire surface if only a small item is being tested). 3 Code the wipes or the counting vials and survey map information of the area wiped. 4 Count the wipes in an appropriate counter for one minute each. (If the same wipe is to be counted for gamma radiation in a sodium iodide counter and beta radiation in a liquid scintillation counter, be sure to do the gamma count before adding the liquid scintillation cocktail. 5 Convert counts per minute (CPM) to Ci or dpm. 6 Record this information and retain it for inspection purposes for two years. Contamination Action Levels If wipes indicate 100 pci/100 cm 2 or greater above background, the area wiped shall be considered contaminated. Decontaminate, re-wipe and determine new contamination level. Record this data. Repeat this cycle until wipes indicate less than 100 pci/cm

46 CHAPTER 4 : BIOASSAY PROGRAM Guidelines for Individuals Working With I-125 and I-131 Introduction Radioiodinated solutions and compounds undergo decomposition that may result in the volatilization of radioiodine. If this occurs, individuals working with these materials have a potential for accidental uptake of radioactive iodine. Once inside the body, the iodine concentrates in the thyroid and irradiates that organ. This bioassay program will enable the Radiation Safety staff to determine the radioiodine burden in an individual s thyroid and calculate the radiation dose to the thyroid. In addition, the program will monitor the effectiveness of radionuclide handling procedures. This program is designed to meet Texas Department of State Health Services requirements for bioassay of I-125 and I-131. Program Participation All individuals who handle unsealed I-125 and I-131 in quantities exceeding those listed in the following table and those who work nearby (within a few meters) shall participate in this bioassay program. The quantities in the table apply to that amount handled either in a single usage or the total amount handled over a period of three consecutive months. Individual Authorized Users are responsible for supplying Radiation Safety with the names of those who meet the criteria for inclusion in the bioassay program. Authorized Users shall not permit anyone who meets any of the criteria to work with or near radioiodine until they have undergone a baseline bioassay. Levels Requiring ACTIVITY LEVELS ABOVE WHICH BIOASSAY FOR I-125 OR I-131 Bioassay IS REQUIRED: TYPE OF OPERATION ACTIVITY HANDLED IN UNSEALED FORM Volatile/Dispersible Bound to Non-Volatile Agent Processes in open room or bench, with possible escape of iodine from process vessels 0.1 mci 1 mci Processes with possible escape of iodine carried out within a fume hood of adequate design, face velocity and performance 1 mci 10 mci reliability Processes carried out with glove boxes, ordinarily closed, but with possible release of iodine with occasional exposure to contaminated box/box leakage 10 mci 100 mci 4-43

47 Bioassay Program Guidelines For Individuals Working With I-125 And I-131 (continued) Frequency TYPE OF BIOASSAY NECESSARY WHEN HOW OFTEN? Baseline or Preoperational Bioassay Beginning work with I-125 or I-131 in quantities necessitating participation in Once, prior to beginning work with radioiodine the bioassay program Routine Working with quantities of radioiodine that necessitate participation in the bioassay program, to be done within 72 (but not less than 6 hours) of working with radioiodine Biweekly (After three months of routine biweekly bioassays, the frequency may be reduced to quarterly, upon approval of the Radiation Safety Officer). For those who work under conditions, which present a high potential for uptake, routine bioassay may be done more often Diagnostic An individual has exceeded action level As determined by the Radiation Emergency Post-operational There is a possibility that an individual has received an uptake in excess of 0.5 Ci of I-125 or 0.14 Ci of I-131, to be done as soon as possible following the incident Work with radionuclides is terminated, to be done within three days (but not less than 6 hours) after discontinuing operations with radionuclides Safety Officer Each time it is suspected that an individual has received an excessive uptake Once, before the individual leaves the University 4-44

48 Bioassay Program Guidelines For Individuals Working With I-125 And I-131 (continued) Action Levels The thyroid burden at the time of measurement should not exceed: 0.12 Ci of I Ci of I-131 A corresponding appropriate amount of a mixture of these two isotopes Corresponding Actions Whenever the above Action Levels are exceeded the following actions shall be taken: Radiation Safety shall conduct an investigation of radioiodine handling procedures, and, if it is determined that continuation of current operations would cause further uptake, use of radioiodine shall be discontinued until further corrective actions can be implemented. The affected individual will be restricted from further work with radioiodine until the thyroid burden is less than the Action Levels. Diagnostic bioassays will be performed on the affected individual at biweekly intervals until the thyroid burden is less than the Action Levels. Radiation Safety staff will calculate the committed thyroid dose, make exposure record entries and notify the TDSHS as appropriate. If the affected individual or others working in the same area are on a quarterly bioassay schedule at the time Action Levels are exceeded, reinstate the biweekly schedule until it can be demonstrated that further work with radioiodine will not cause the Action Levels to be exceeded. In addition to the above actions, whenever the thyroid burden exceeds 0.5 Ci I-125, 0.14 Ci I-131, or a corresponding appropriate amount of a mixture of these two isotopes: Refer the case to appropriate medical consultation, and Radiation Safety office Perform diagnostic bioassays at weekly intervals until the thyroid burden is less than the values stated above 4-45

49 Bioassay Program Guidelines For Individuals Working With I-125 And I-131 (continued) Bioassay Testing Procedure The procedure for bioassay testing involves the following: Based on information provided by the Authorized User, Radiation Safety shall contact those individuals involved and schedule a baseline bioassay. Individuals participating in the program shall notify Radiation Safety following their initial contact with radioiodine to schedule the first routine bioassay (to be performed within 6-72 hours). Upon completion of this first bioassay, a schedule shall be established for further testing. Any individual involved in a radiological incident who may have exceeded the limits of 0.5 Ci I-125 or 0.14 Ci I-131 shall notify Radiation Safety immediately. Any individual who is participating in this program shall notify Radiation Safety prior to leaving this University. Bioassays shall be performed by individuals designated by the Radiation Safety Officer and shall be conducted in accordance with the detailed procedure contained in the Radiation Safety Program Standard Operating Procedures Manual. 4-46

50 Bioassay Program Guidelines for Individuals Working With H-3 Introduction Program Participation Bioassay Testing Procedure Tritium does not present an external exposure hazard because the low energy beta particle emitted cannot penetrate the outer dead layer of skin. The hazard to personnel is through internal contamination. The critical organ for tritium uptake is the whole body water. Three to four hours after intake, tritiated water is uniformly distributed in all body water. All individuals who handle unsealed H-3 in quantities exceeding 80 mci shall participate in this bioassay program. The procedure for bioassay testing involves the following: At least one day prior to working with quantities of H-3 in excess of 80 mci, contact Radiation Safety to arrange for a baseline bioassay. On the day of the experiment, go to Radiation Safety to pick up a urine specimen cup and instructions on urine collection. On the first working day after the experiment, bring the specimen to Radiation Safety. If a H-3 uptake is detected in the sample, a schedule shall be established for further testing. The Radiation Safety Officer shall determine if any other actions are necessary. If you have participated in this bioassay program and plan to leave UTMB or no longer work with H-3, notify Radiation Safety for a post-operational bioassay. 4-47

51 CHAPTER 5 : MANAGEMENT OF PATIENTS UNDERGOING BRACHYTHERAPY Introduction Overview The University of Texas Medical Branch utilizes ionizing radiation: In medical research As a diagnostic agent As a therapeutic agent This chapter deals with the use of radioactive material in sealed sources inserted into body cavities or surgically implanted for the treatment of cancer. All personnel involved in the treatment or care of these patients should be familiar with the recommendations in this section. Note All patients undergoing brachytherapy will be located in a private room as designated by Radiation Safety. 5-48

52 Management of Patients Undergoing Brachytherapy Radiation Safety Staff Responsibilities Training Design The Radiation Safety Officer will determine the needs for training and establish a system to provide training consistent with the recommendations of: National Council on Radiation Protection and Measurements The Joint Commission Training will be provided to various medical personnel to include: Nursing Services Environmental Services Food and Nutrition Services Staff Physicians Regulation Compliance In order to guarantee compliance with recommendations of the NCRP, TJC and the 25 TAC 289, Radiation Safety will conduct spot checks of radiation therapy activities such as: Posting of signs and labels Source accountability Staff awareness Record keeping Radiation Safety will maintain the records necessary to show compliance with the regulations of various responsible agencies. 5-49

53 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities Consent Form The Radiation Oncology Department must discuss with the patient the hazards and risks involved with brachytherapy and obtain a signed consent form. Notification of Radiation Safety Prior to source implantation, Radiation Safety must be notified of the following information: Date of insertion Estimated length of treatment Radionuclide used Radionuclide activity Hospital and room in which the patient is housed Briefing Attendant Staff All attendant staff will be briefed on the course of treatment planned, to include: Approximate dose rates Estimated length of treatment Reminder of rules and precautions for visitors and staff After Insertion After insertion of radiation sources, the Radiation Oncology Department must: Post a warning sign on or by the patient s door Place warning tag on laundry and trash bags in the patient s room Place yellow wristband on patient Place a warning sign on patient s chart Complete the form Nursing Instructions for Patients Treated with Brachytherapy Sources and place it in the patient s chart Perform radiation level survey 5-50

54 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Example of Warning Sign This is an example of the warning sign that is to be placed on or by the door of a brachytherapy patient s room: 5-51

55 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Example of Warning Sign for Outside of the Patient s Chart This is an example of the warning sign that is to be placed on the outside of the patient s chart: 5-52

56 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Example of Wristband This yellow wristband is to be placed on a patient s wrist. Example of Laundry/Trash Tag This is an example of the tag that is to be placed on the laundry and trash bags that are located in the room of the brachytherapy patient. Caution: Contents May Be Radioactive. Do not Remove From This Room. PRECAUCION: Contenious Pueden Ser Radioactivos. No Vaya A Remover De Este Cuarto 5-53

57 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Example of Nursing Instruction Form This is an example of the Nursing Instruction Form that is to be completed for radiation therapy patients with permanent implants. PERMANENT IMPLANT CAUTION PATIENT CONTAINS RADIOACTIVE MATERIAL NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES Patient s Name: UH # Room Number: Physician s Name: Radionuclide: Activity: Number of Sources: Date and Time of Administration: Date and Time Sources Are To Be Removed: Exposure Rate at: 1 meter from Patient: mr/hr. Exposure Rate at Adjacent Room Closest to Patient: mr/hr. Exposure rate at: Hallway at Point Closest to Patient: mr/hr. Instrument Model: SN: Date and Time Sources Removed: Number of Sources Removed: By: Surveys After Source Removal Performed By: (RETURN THIS SHEET TO RADIATION SAFETY, RT. 1111, UPON COMPLETION OF THERAPY) 1. Do not spend any more time in patient s room than is necessary to care for patient. In particular, time at patient s bedside should be kept to a minimum. 2. Place laundry in linen bag and save until surveyed and released by Radiation Oncology or Radiation Safety. 3. Housekeeping staff may not enter the room unless escorted by a nurse. Only essential cleaning should be done. 4. Visitors must be 18 years or older. 5. Patient may not have pregnant visitors. 6. Visitors should remain at least 6 feet from the patients and should not stay more than 2 hours per day. 7. A dismissal survey must be performed before patient is discharged. IN CASE OF EMERGENCY CALL: On-Duty Off-Duty Dr.: Pager # Dr.: Dr. Steve Morrill Pager # (409) Home # (409) Radiation Safety Office University Operator x

58 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Example of Nursing Instruction Form This is an example of the Nursing Instruction Form that is to be completed for radiation oncology patients with temporary implants. TEMPORARY IMPLANT CAUTION PATIENT CONTAINS RADIOACTIVE MATERIAL NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES Patient s Name: UH # Room Number: Physician s Name: Radionuclide: Activity: Number of Sources: Date and Time of Administration: Date and Time Sources Are To Be Removed: Exposure Rate at: 1 meter from Patient: mr/hr. Exposure Rate at Adjacent Room Closest to Patient: mr/hr. Exposure rate at: Hallway at Point Closest to Patient: mr/hr. Instrument Model: SN: Date and Time Sources Removed: Number of Sources Removed: By: Surveys After Source Removal Performed By: (RETURN THIS SHEET TO RADIATION SAFETY, RT. 1111, UPON COMPLETION OF THERAPY) 1. Do not spend any more time in patient s room than is necessary to care for patient. In particular, time at patient s bedside should be kept to a minimum. 2. Place laundry in linen bag and save until surveyed and released by Radiation Oncology or Radiation Safety. 3. Housekeeping staff may not enter the room unless escorted by a nurse. Only essential cleaning should be done. 4. Visitors must be 18 years or older. 5. Patient may not have pregnant visitors. 6. Visitors should remain at least 6 feet from the patients and should not stay more than 2 hours per day. 7. A dismissal survey must be performed before patient is discharged. IN CASE OF EMERGENCY CALL: On-Duty Off-Duty Dr.: Pager # Dr.: Dr. Steve Morrill Pager # (409) Home # (409) Radiation Safety Office University Operator x

59 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Radiation Level Surveys The patient s room and all surrounding areas will be surveyed as soon as possible after the sources have been implanted. The exposure rate measurement will be recorded on the nursing instruction sheet: In the patient s room, one meter from the patient In the hallway at the nearest point to the patient In all adjacent rooms along the wall common to the patient s room Radiation Levels Radiation levels in unrestricted areas will be maintained at less than the limits specified in the 25 TAC 289 and the UTMB license (5 mrem/hr in stairways, restrooms, hallways and other fleetingly occupied areas, and 2 mrem/hr in adjacent rooms containing patients or hospital personnel). If radiation levels cannot be maintained less than these limits, notify Radiation Safety immediately. Conclusion of Treatment IMPLANT TYPE PROCEDURE Temporary At the time of removal, conduct a physical inventory of sources removed, record on Nursing Instruction Sheet and compare against number of sources implanted for verification. Permanent (Au-198 I-125 seeds) Using a suitable instrument, survey the patient to guarantee that all radiation sources have been removed. Survey the patient s room and surrounding area to ensure no source of radiation is left behind. If all sources are accounted for and there is no evidence of sources left behind in the room or in the patient, remove all radiation signs and labels, complete the entries required on the Nursing Instruction Sheet and return it to Radiation Safety; if not, notify the Radiation Safety Officer immediately. Do not release patients from hospital without authority of the Radiation Safety Officer until the implanted activity is calculated to be less than 30 mci. Using an ion chamber type instrument, measure the exposure rate 1 meter from the umbilicus with the patient standing. Do not release patients without the authority of the Radiation Safety Officer if the exposure rate exceeds 5 mr/hr. Record the calculated activity and 1 meter exposure rate on Nursing Instruction Sheet. 5-56

60 Management of Patients Undergoing Brachytherapy Radiation Oncology Department Staff Responsibilities (continued) Conclusion of Treatment IMPLANT TYPE Permanent (Au-128 And I-125 seeds) PROCEDURE Instruct the patient and/or family members regarding special radiation safety precautions to be followed after release from hospital. Survey the patient s room and surrounding area to ensure that no source of radiation is left behind. Remove all radiation signs and labels, complete the Nursing Instruction Sheet and return it to Radiation Safety. Inventory of Sources A physical inventory of the number of sources removed will be conducted at the time of removal and compared against the number implanted for verification. 5-57

61 Management of Patients Undergoing Brachytherapy Nursing Instructions Questions Personnel Dosimeters Nursing personnel are encouraged to contact the Radiation Oncology Department with any questions about patient care. Contact Radiation Safety in regard to radiation safety precautions. For additional instructions see the section titled Personnel Monitoring in this Manual. Specific Patient Care Guidelines The physician s order sheet may contain special instructions for nursing care. All nurses should read these instructions before caring for the patient. Some of the basic guidelines for specific patient care are the following: No patient should receive a bed bath while radiation sources are in place. Perineal care is not given during gynecologic treatment. The perineal pad may be changed when necessary, unless orders to the contrary are on the sheet. Special orders will be written for oral hygiene for patients with oral implants. If a patient s bed has been moved away from the wall, do not move it. (It has been moved in order to reduce radiation levels in adjacent areas). Exposure Time Pregnant Women Environmental Services Staff Nurses should spend only the minimum time near the patient in order to perform routine nursing care. No nurse, visitor, or attendant who is pregnant is allowed in the room of a brachytherapy patient while sources are implanted. Female visitors should be asked whether they are pregnant. A member of the nursing staff must accompany housekeeping staff into patient rooms. Only essential cleaning should be done. Trash and laundry should not be removed from the patient s room unless cleared by the Radiation Oncology Department or Radiation Safety. Hospital Staff In general, unless specific instructions to the contrary are written, hospital staff not directly associated with the treatment of the patient should not be permitted to enter the patient s room. If in doubt, call the Radiation Oncology Department or Radiation Safety. 5-58

62 Management of Patients Undergoing Brachytherapy Nursing Instructions (continued) Loose Radioactive Sources Nurses must never touch: Needles Capsules Containers holding brachytherapy sources If a source becomes dislodged, use long forceps to put it in the shielded container provided. After the source has been secured, immediately refer to the Nursing Instruction Sheet for emergency phone numbers. Dressing Changes Surgical dressings and bandages used to cover the area of source insertion may only be changed by the attending physician or radiation oncologist. Dressings may not be discarded until directed by the therapist. Dressings should be kept in a basin until checked. Bed Linens Activities of Patients Visitors All bed linens must be surveyed before being removed from the patient s room. It is important to guarantee that no dislodged radiation sources are accidentally removed with the bed linen. Brachytherapy patients are confined to bed unless an order to the contrary is written. All patients will remain in their assigned rooms during the treatment period. Visitors must be 18 years old or older, unless other instructions are given on the Physician s Order Sheet in the patient s chart. Visitors should: Sit or stand at least six feet from the patient Remain no longer than two hours per day (unless otherwise instructed) No pregnant visitors shall be allowed to visit patients receiving brachytherapy. Emergency Procedures IF the patient dies or requires emergency surgery THEN refer to Nurses Instruction Sheet in the chart for emergency phone numbers. IF a source becomes dislodged THEN, using long-handled tongs or forceps, quickly place source in the shield provided, then refer to Nurses Instruction Sheet for emergency phone numbers. IF the patient must be moved due to fire or other emergency THEN follow standard evacuation procedures with the exception that these patients must remain at least six feet from other patients and staff once relocated. 5-59

63 Management of Patients Undergoing Brachytherapy Nursing Instructions (continued) Conclusion of Treatment At the conclusion of treatment, call the Radiation Oncology Department to: Survey the patient and room Count the radiation sources to ensure that all temporary implants have been removed prior to discharging the patient. After the room has been surveyed and declared free of sources of radiation, all signs and labels will be removed from the room and chart. Until then, treat the room as a radiation area even if the patient is no longer present. 5-60

64 CHAPTER 6 : MANAGEMENT OF PATIENTS RECEIVING THERAPEUTIC AMOUNTS OF RADIONUCLIDES Introduction Overview This chapter will list the responsibilities of the various healthcare personnel involved with or in support of the administration of non-sealed sources of radionuclides in therapeutic amounts. The healthcare personnel addressed in this section include: Nuclear Medicine Radiation Safety Physician, Nursing, Environmental Services and Dietary Staff Forms of Radionuclides Non-sealed sources are used in different forms such as: Solutions Colloidal suspensions Micro spheres Etc. A variety of radionuclides may be employed, such as those listed in Table 6.1: Written Directives A written directive shall be dated and signed by an Authorized User (human-use) prior to administration of any therapeutic dosage of unsealed radioactive material. Written directives shall include the treated individual s name, radiopharmaceutical, dosage, and route of administration. Written directives shall be retained for three (3) years. Source of Information The information presented in this section is based on the recommendations of the National Council on Radiation Protection and Measurements Report No. 37 entitled, Precautions in the Management of Patients Who Have Received Therapeutic Amounts of Radionuclides. ; USNRC REG GUIDE 8.39 (April 1997); and 25 TAC

65 Management of Patients Receiving Therapeutic Amounts of Radionuclides General Information Precautions Individuals (patients or research subjects) treated with quantities of radionuclides such that the Total Effective Dose Equivalent (TEDE) to any other individual from exposure to the treated individual is likely to exceed 0.5 rem will be placed in a private room with a bathroom. Release of Individuals Containing Radionuclides Individuals who have been treated with radionuclides may be released if the TEDE to any other individual from exposure to the treated individual is not likely to exceed 0.5rem. Individuals containing the radionuclides listed in Table 6.1 may be considered to not likely expose other individuals to greater than 0.5 rem if the activity remaining at time of release is at or below the value in Column 1; or, the highest dose rate at one meter (1 m) from the treated individual is at or below the value in Column 2. The values in Column 1 do not include consideration of the dose to a breast-feeding infant or child from ingestion of radiopharmaceuticals contained in the treated individual s breast milk. (See Table 6.2 for radiopharmaceuticals and activities that could result in TEDE greater than 0.5 rem should breast-feeding not be interrupted or discontinued.) For radionuclides not listed in Table 6.1, calculations will be performed in accordance with methods listed in USNRC REGULATORY GUIDE 8.39 (April 1997) to determine when the individual may be released. Copies of such calculations will be retained for three (3) years after date of release of the individual. Instructions to Released Individuals The treated individual, their parent or guardian shall be provided with written instructions on recommended actions to follow to maintain doses to other individuals As Low As Reasonably Achievable (ALARA) if the TEDE to any other individual is likely to exceed 0.1 rem. Individuals containing the radionuclides listed in Table 6.1 may be considered to likely expose other individuals to greater than 0.1rem if the activity remaining at time of release is at or above the value in Column 3 or the highest dose rate at one meter (1 m) from the treated individual is at or above the value in Column 4. The values in Column 3 do not include consideration of the dose to a breast-feeding infant or child from ingestion of radiopharmaceuticals contained in the treated individual s breast milk. (See Table 6.2 for radiopharmaceuticals and activities that could result in TEDE greater than 0.1 rem should breast-feeding not be interrupted or discontinued.) For radionuclides not listed in Table 6.1, calculations will be performed in accordance with methods listed in USNRC REGULATORY GUIDE 8.39 (April 1997) to determine when the individual may be released without required instructions. Copies of such calculations will be retained for three (3) years after date of release of the individual. 6-62

66 Management of Patients Receiving Therapeutic Amounts of Radionuclides General Information (continued) TABLE 6.1 : Activities and Dose Rates for Authorizing Release of Individuals Treated with Radionuclides and for Required Written Instructions Column 1 Column 2 Column 3 Column 4 Radionuclide (mci) (mrem/hr) (mci) (mrem/hr) Ag Au Cr Cu Cu Ga I I I In P 32 ** ** ** ** Re Re Sc Se Sm Sn 117m Sr 89 ** ** ** ** Tc 99m Tl Y 90 ** ** ** ** Yb ** activity and dose rate limits are not applicable in the case of these radionuclides because of the minimal exposures to members of the public resulting from activities normally administered for diagnostic or therapeutic purposes. Individuals who Could Be Breast-feeding After Release Treated individuals who could be breast-feeding an infant or child and contain radiopharmaceuticals above the activity values listed in Table 6.2, Column 1, could expose the infant or child to a TEDE greater than 0.5 rem if there is no interruption or cessation of breast-feeding. Treated individuals who could be breast-feeding an infant or child and contain radiopharmaceuticals above the activity values listed in Table 6.2, Column 2, could expose the infant or child to a TEDE greater than 0.1 rem if there is no interruption or cessation of breast-feeding. Treated individuals containing radiopharmaceuticals in amounts above those in Table 6.2 may be released provided that the following conditions are met: The treated individual, their parent or guardian is provided with written instructions on the discontinuation or interruption of breast-feeding; The consequences of failing to follow the instructions are provided in writing to the treated individual, their parent or guardian; Other instructions for maintaining doses to others ALARA are provided; and The treated individual does not exceed the values in Table 6.1, Column

67 Management of Patients Receiving Therapeutic Amounts of Radionuclides General Information (continued) If a radiopharmaceutical not listed in Table 6.2 is administered to a patient who could be breast-feeding, a determination shall be made whether a breast-feeding infant or child could exceed a TEDE of either 0.1 rem or 0.5 rem and written instructions shall be provided accordingly. TABLE 6.2 : Activities and Pharmaceuticals Resulting in Doses to Breast-feeding Infants and Children in Excess of 0.5 rem and 0.1 rem Column 1 Column 2 Radiopharmaceutical (mci) (mci) (results in (results in >0.5 rem) >0.1 rem) I 131 NaI I 123 NaI I 123 OIH 20 4 I 123 mibg 10 2 I 125 OIH I 131 OIH Tc 99m DTPA Tc 99m MAA Tc 99m Pertechnetate 15 3 Tc 99m DISIDA Tc 99m Glucoheptonate Tc 99m HAM Tc 99m MIBI Tc 99m MDP Tc 99m PYP Tc 99m Red Blood Cells In-vivo Labeling Tc 99m Red Blood Cells In-vitro Labeling Tc 99m Sulphur Colloid 35 7 Tc 99m DTPA Aerosol Tc 99m MAG Tc 99m White Blood Cells 15 4 Ga 67 Citrate Cr 51 EDTA In 111 White Blood Cells Tl 201 Chloride

68 Management of Patients Receiving Therapeutic Amounts of Radionuclides General Information (continued) Release Documentation Contaminated Areas A record shall be maintain for each treated individual released that shall include the basis for authorizing the release of the individual and the instructions provided to individuals who could be breast-feeding infants or children after release that could result in a TEDE exceeding 0.5 rem to the infant or child. Such records shall be retained for three (3) years after date of release of the individual. Patients treated for thyroid carcinoma with Iodine-131 may contaminate areas of their hospital room through perspiration, urine, feces, or vomit. Any area that is likely to become contaminated will be covered with protective material appropriate for the amounts of contamination expected. I-131 Patients The following procedures should be followed for disposal of contaminated items for Removal of Iodine-131 patients: Contaminated Items ITEM LINENS DISPOSABLE ITEMS NON-DISPOSABLE ITEMS PROCEDURE Nuclear Medicine will survey all linens for contamination before removal from the patient s room and, if necessary, hold them for decay. Disposable plates, cups, eating utensils, tissues, surgical dressings, and other waste items will be placed in a specially designated container. The material will be collected, checked for contamination, and disposed of as normal or radioactive waste as appropriate. Non-disposable items such as watches, sphygmomanometers and other patient care equipment will be held in the patient s room and checked for contamination by Nuclear Machine. These items will be returned to normal use, held for decay, or decontaminated as appropriate for the level of contamination. 6-65

69 Management of Patients Receiving Therapeutic Amounts at Radionuclides Radiation Safety Programs Training Design The Radiation Safety Officer will determine the needs for training and establish a system to provide training consistent with the recommendations of: National Council on Radiation Protection and Measurements Joint Commission on the Accreditation of Healthcare Organizations Other appropriate agencies and organizations Training will be provided to various medical personnel, to include: Nursing Services Environmental Services Dietary Staff Physicians Management of Patient Rooms Radiation Safety will assist in the clearance and release of the patient s room and contents. The staff will inform the Nuclear Medicine staff concerning acceptable levels of contamination remaining in the patient s room upon release. Nuclear Medicine staff will decontaminate if necessary. Regulation Compliance Radiation Safety is responsible for ensuring compliance with the recommendations of the NCRP, TJC and Texas Regulations for Control of Radiation and will maintain documentation to show compliance with these regulations unless the requirement for maintenance of documentation is otherwise specified. 6-66

70 Management at Patients Receiving Therapeutic Amounts of Radionuclides Nuclear Medicine Staff Responsibilities Administration and Release of Individuals Receiving Radionuclide Treatment Nuclear Medicine shall ensure that a written directive has been properly executed for the administration of the radiopharmaceutical; and that the written directive is maintained for a period of three (3) years from the date of administration. Nuclear Medicine shall determine: if the quantity of radiopharmaceutical administered to the treated individual is likely to expose others to a TEDE greater than 0.5 rem (if so, the individual will not be released from UTMB until they meet the release criteria); when the treated individual can be released from UTMB control; and if the treated individual is likely to be breast-feeding infants or children after release, and if so, what the potential TEDE to the exposed infant or child would be. Upon release, Nuclear Medicine shall provide the treated individual, their parent or guardian with written instructions on recommended actions to follow to maintain doses to other ALARA if the treated individual is likely to expose others to a TEDE greater than 0.1 rem, Nuclear Medicine shall maintain a record for each treated individual released that includes: the basis for authorizing the release of the individual; and the instructions provided to individuals who could be breast-feeding infants or children after release that could result in a TEDE exceeding 0.5 rem to the infant or child. Nuclear Medicine shall ensure that such records are retained for three (3) years after the date of release of the individual. Procedures for Hospitalized Individuals Whenever an individual is admitted to the hospital who is to receive, or has received, radionuclide treatment that: would likely expose other individuals to greater than 0.1rem, or would likely result in significant radioactive contamination of a patient room, Nuclear Medicine shall adhere to the following procedure: 6-67

71 Management at Patients Receiving Therapeutic Amounts of Radionuclides Nuclear Medicine Staff Responsibilities (continued) STEP PROCEDURE 1 Notify Radiation Safety before the administration of radiopharmaceuticals or immediately upon admission if the radionuclide has already been administered. 2 Meet with the patient to: Discuss the purpose of treatment Describe the risks associated with treatment Obtain a signed consent form from patient Discuss steps to be taken by patient to prevent spread of contamination and/or to minimize radiation exposure of others 3 Inform the nursing staff about details of the treatment: Approximate dose Estimated dose rate Reminder of visitors rules Precautions for nurses 4 If radioactive contamination is a serious potential Prepare the patient room prior to the treatment as necessary; Provide a supply of disposable gloves and shoe covers for persons entering the room. 5 Post appropriate radiation/contamination notices: Warning sign on or by the patient s door Warning tags on trash/linen bags in patient s room as necessary if radioactive contamination is a serious potential Warning sign on patient s chart Physician s Order Sheet for radionuclide therapy in the patient s chart 6 Place yellow wristband on patient. 7 Administer the radiopharmaceutical to patient. 8 Measure the exposure rate at one meter from the patient immediately after administration, and then on a daily basis thereafter. Record these rates under progress notes in patient s chart. 9 Measure the exposure rate in all surrounding areas along the walls common to the patient s room. Notify Radiation Safety immediately if the levels cannot be maintained within specified limits. * Record results in patient s chart. 10 Notify the Radiation Safety Office prior to patient discharge. 11 After the patient is discharged, survey the room for contamination. If radioactive contamination is found in the room above acceptable levels as established by the Radiation Safety Program, decontaminate the room to the acceptable levels. * Note: Radiation levels in unrestricted areas will be maintained at less than the limits specified in the Texas Regulations for Control of Radiation and the UTMB license. These limits are: 5 mrem/hr in stairways, restrooms, hallways, and other fleetingly occupied areas; 2 mrem/hr in adjacent rooms containing patients or hospital personnel. 6-68

72 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nuclear Medicine Staff Responsibilities (continued) Example of Warning Sign For Door to Patient s Room This warning sign is to be placed on the door to a patient s room that is receiving radiotherapy. 6-69

73 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nuclear Medicine Staff Responsibilities (continued) Example of Tag for Trash/Laundry This tag is to be placed on bags used to collect laundry or trash in the room of a patient receiving radiotherapy. Caution: Contents May Be Radioactive. Do not Remove From This Room. PRECAUCION: Contenious Pueden Ser Radioactivos. No Vaya A Remover De Este Cuarto. Example of Sign for Patient s Chart This warning sign is to be placed on the cover of the patient s chart. Example of Wristband This yellow wristband is to be placed on a patient s wrist. 6-70

74 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nuclear Medicine Staff Responsibilities (continued) Physician s Order Sheet The Physician s Order Sheet for individuals covered by the above procedure shall at a minimum contain the following information: Patient identifying information Radiopharmaceutical and activity administered Any restrictions on patient movement out of their room Total time per day staff or visitors may remain in the patient room and at what distance Exclusion of pregnant women from entering the room Requirements for wearing personal protective equipment while attending to the patient Restrictions on removing items from the room Names and phone numbers of Nuclear Medicine faculty and staff to call in case of a problem or question Phone number for Radiation Safety Office Restrictions on cleaning the room or admitting another patient until the room has been cleared by either Nuclear Medicine or Radiation Safety Office 6-71

75 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nursing Service Staff Responsibilities Knowledge Of Procedure All nursing staff working with radiotherapy patients are responsible for understanding and following all procedures and instructions. Personal safety and the safety of patients will depend on the use of proper techniques in the care of patients receiving radiopharmaceuticals. Exposure Time Nurses should spend only the time required for ordinary nursing care near the patient. Precautions for Visitors Visitors must: Be 18 years old or older (unless other instructions are noted in the physician s orders on the patient s chart) Remain at least six feet from the patient except for a brief exchange of greetings or to say goodbye Visitors must not: Remain in the patient s room for more than the length of time per day specified in the Physicians Orders Be pregnant (All female visitors should be asked if they are or might be pregnant. No pregnant visitor will be allowed in the patient s room). Precautions for Hospital Staff And Employees In general, unless specific instructions to the contrary are written, hospital staff and employees not directly associated with the treatment of the patient should not be permitted to enter the patient s room. If in doubt, call Nuclear Medicine or Radiation Safety. Activity Of Patients Patients shall be confined to their rooms except as approved by Nuclear Medicine. 6-72

76 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nursing Service Staff Responsibilities (continued) Special Instructions for I-131 Patients For those patients undergoing therapy involving Iodine-131 there are several special precautions required, as outlined in the table below. ITEM URINE FECES MEAL UTENSILS VOMIT PROCEDURE Urine is not routinely collected. If orders are written to collect urine, special containers will be provided by Nuclear Medicine. The patient should collect his/her own urine in the container. If the patient is bedridden, a separate urinal or bedpan should be provided and flushed several times in a designated sink with hot soapy water after use. Handle the urinal or bedpan with double disposable gloves on. After flushing, nurses should wash their hands with gloves on and again with the gloves off. Dispose of gloves in the designated radioactive waste container. Feces need not be routinely saved, unless ordered by Nuclear Medicine. If the nurse collects the excreta, disposable gloves should be worn. After assisting the patient, nurses should wash their hands with gloves on and again with gloves off. The gloves should be placed in the designated radioactive waste container for disposal. Patients who are treated with Iodine-131 in excess of 33 mci will use disposable plates, cups and eating utensils. All vomit must also be kept in the patient s room for disposal. Call Nuclear Medicine if the patient should vomit. Blood and Urine Samples Use of Gloves Routine blood and urine samples are not to be obtained while the patient is undergoing this therapy unless specifically authorized by a Nuclear Medicine physician and Radiation Safety. All staff should wear disposable gloves when handling bed linens, urinals, bedpans, basins, or other containers having any material obtained from the body of the patient. The gloves do not need to be sterile or surgical gloves. After use, these gloves should be left in the patient s room in the designated waste container. Hands should be washed thoroughly with soap and water. Dressing Changes Surgical dressings should be changed only as directed by the physician. Such dressings should not be discarded but should be collected in plastic bags and labeled as radioactive waste. Handle these dressings only with tongs or tweezers. The tongs or tweezers should be placed in a separate plastic bag to be checked for radioactive contamination by Nuclear Medicine. Staff handling these dressings should wear disposable gloves. Disposable Items Non-Disposable Items Disposable items should be used in the care of these patients whenever possible. After use, these items should be placed in the designated waste container. Contact Nuclear Medicine for proper disposal of the contents of the container. All non-disposable items such as watches, books, etc., should be placed in a plastic bag and should be left in the patient s room to be checked before discharge by Nuclear Medicine. 6-73

77 Management of Patients Receiving Therapeutic Amounts of Radionuclides Nursing Staff Responsibilities (continued) Clothes and Linens All clothes, towels and bed linens used by the patient should be placed in the laundry bag provided and should be left in the patient s room to be checked by Nuclear Medicine. Bed linens will not normally be changed since the period for radiation safety precautions is usually only 2-3 days. In Case of Spillage Exercise care to ensure that no urine or vomit is spilled on the bed or floor. If there is suspected contamination from the patient s excreta or vomit, spillage or other causes: Notify Nuclear Medicine and Radiation Safety immediately. Take the necessary precautions until a representative from Nuclear Medicine or Radiation Safety arrives. SEE: Precautions after a Suspected Contamination. Suspected Personnel Contamination If a nurse, attendant or anyone else knows or suspects that his or her skin or clothing is contaminated then: Notify either Nuclear Medicine or Radiation Safety. Remain in the area near the patient s room and do not walk about the hospital. If your hands have become contaminated, wash them immediately with soap and water. Precautions After a Suspected Contamination After a suspected contamination, follow these guidelines: Mark off the entire area of potential contamination. This must be done to prevent further spread of personnel contamination. Control access to and from the area. Make sure that personnel inside the area or those who have entered the area remain for monitoring. Use absorbent material such as paper towels or diapers to contain the spill and prevent further contamination. Do not remove the materials until the Health Physicist from Radiation Safety or a Nuclear Medicine representative arrives. Emergencies Discharge of Patient If a radiotherapy patient should need emergency surgery or should die, notify Nuclear Medicine or Radiation Safety immediately (refer to the physician s order sheet for emergency numbers). Patient resuscitation and stabilization should be pursued immediately. When a patient is discharged, call Nuclear Medicine and request that the room be surveyed for contamination before remaking the room. Nuclear Medicine will contact Radiation Safety for a follow up survey. After the room has been surveyed and declared free of contamination, all signs and labels will be removed from the room and chart. Until then, treat the room as a radiation area even if the patient is no longer present. 6-74

78 Management of Patients Receiving Therapeutic Amounts of Radionuclides Environmental Services and Dietary Services Staff Responsibilities Environmental Services Responsibilities Environmental Services staff will: Enter the patient s room only when accompanied by a nurse. Remove trash for disposal only after it is cleared by Nuclear Medicine or Radiation Safety. Remove linens or other materials only after they are cleared by Nuclear Medicine or Radiation Safety. Upon discharge of the patient, clean the room only after it has been cleared by Nuclear Medicine or Radiation Safety. Dietary Staff Responsibilities The Dietary staff will: Provide disposable utensils for patients being treated for thyroid carcinoma. Not remove any items from the patient s room without prior approval of Nuclear Medicine or Radiation Safety. 6-75

79 CHAPTER 7 : GENERAL INSTRUCTIONS FOR AUXILIARY PERSONNEL Instructions for Maintenance Personnel Introduction Radiation Area Or High-Radiation Area Instructions Radioactive materials and radiation-producing machines are found in many locations on the UTMB campus. Some general guidelines for specific areas are outlined below. Do not enter any of these areas without specific permission to do so either from someone in authority in that area or from Radiation Safety. When specifically authorized to enter such an area: Follow instructions Do work required Leave do not waste time Rooms Marked Radioactive Material STEP PROCEDURE 1 Enter room unless specific signs say Keep Out. 2 Seek someone who works in the room and explain the work that is to be done. 3 Before you begin work, have laboratory personnel check by instrument survey or a wipe test, to make certain that the work area is free of contamination. 4 If you cannot find someone in the area to check with, leave the room and ask at the department office for assistance locating someone who works in that room. 5 If it is an emergency repair job and you cannot get help at the department office, call Radiation Safety. 6 If the area is free of contamination, proceed with the job. While in the area: Do not smoke, eat, drink, or apply cosmetics Do not enter other areas marked off as radioactive material areas Watch for signs of possible contamination, such as broken labeled bottles or vials, or liquid pooled in an area 7-76

80 General Instructions for Auxiliary Personnel Instructions For Maintenance Personnel (continued) Equipment Marked Radioactive Material For sinks, hoods, or other equipment marked Radioactive Material : Have lab personnel check by wipe test or instrument survey to ensure that there is no contamination. If equipment must be taken back to shop, or there are any questions, call Radiation Safety for supervision. Call Radiation Safety to have a hood exhaust duct surveyed. Call Radiation Safety for assistance with clearance and decontamination of equipment that is to be moved. Important Call Environmental Health and Safety, ext , at any time if in doubt about any procedures for handling anything marked radioactive material. 7-77

81 General Instructions for Auxiliary Personnel Instructions for Smoke Detector Disposal Introduction Non-functioning smoke detectors containing radioactive sources that are removed from UTMB facilities by Business Operations & Facilities (BOF) will be disposed of as radioactive waste. This policy outlines the responsibilities of both BOF and Radiation Safety. Radiation Safety Responsibilities Radiation Safety will: Provide a container for BOF to use as a waste receptacle for the smoke detectors and forms for documentation at disposal Pick up the waste when requested Repackage the detectors if required by the commercial radioactive waste contractor BOF Responsibilities BOF will: Dispose of the detector intact, without disassembling the unit, in the waste container provided by Radiation Safety For each detector in the waste container, record the radionuclide and activity on the Radioactive Waste Disposal form provided by Radiation Safety Log on to to request a radioactive waste pick-up Example of a Properly Completed Radioactive Waste Disposal Form 7-78

82 General Instructions for Auxiliary Personnel Instructions for University Police Access to Radiation Areas Radioactive material and radiation-producing devices are found in many locations on the UTMB campus. This poses little or no hazard to security personnel if the guidelines below are followed: A location labeled High Radiation Area should not be entered without calling Radiation Safety personnel first, unless the situation is life threatening A location labeled, Radiation Area can be entered for a short time to protect life or property. For routine matters, contact Radiation Safety personnel first A location labeled Radioactive Material will be safe to enter unless specifically marked Do Not Enter. While in the area: o o o Do not handle containers labeled with radioactive material symbols Do not smoke, eat or drink in these areas Be wary of evidence of spills of radioactive material When to Notify Radiation Safety You should notify Radiation Safety: Before entering a high radiation or radiation area (with the exceptions noted above) If any container labeled Radioactive Material is found broken, crushed or leaking In case of fire in any room labeled Radioactive Material When in doubt, call Radiation Safety! (However, there is no need to contact Radiation Safety for alarms or lights on refrigerators, cold rooms, incubators, etc. Instead, notify the department responsible for the laboratory in which the item is located). Package Delivery Carrier services making delivery of radioactive material packages to UTMB or Shriners Burns Institute after normal working hours will be directed to the security station at the emergency room entrance on Strand Street. The procedure for accepting these deliveries is outlined on the next page. 7-79

83 General Instructions for Auxiliary Personnel Instructions For University Police (continued) Package Delivery STEP PROCEDURE 1 The Dispatcher shall visually inspect all packages at the time of delivery. If the package is DAMAGED (wet, crushed, open, etc.) then: IF Then Damaged (wet, crushed, open, etc.) 1. Do not handle package. 2. Ask the carrier to stay until Radiation Safety personnel have been contacted. 3. Phone Radiation Safety at the after-hours Hospital Operator, ext Intact 1. Check to be sure that package(s) are addressed to UTMB or Shriners Burns Institute. 2. Sign for package. 3. Notify the Sergeant or other Commissioned Officer as soon as possible. 2 The Sergeant or Commissioned Officer contacted shall ensure expeditious transport of the package(s) as follows: If Package is addressed to NUCLEAR MEDICINE Package is addressed to ANY OTHER UTMB DEPARTMENT OR SHRINERS BURNS Then It should be taken to Room 2.476, Clinical Science Building and placed behind the lead shield on the right side of the workbench along the back wall. Large boxes may be placed on the floor in front of the shield. Contact Radiation Safety at the afterhours hospital operator. If it needs refrigeration, place it in the white refrigerator labeled Radioactive Material in the back of the laboratory. * Whenever possible, personnel should remain at least three feet away from packages bearing a DOT Type III Label. An example of this label is on the next page. 7-80

84 General Instructions for Auxiliary Personnel Instructions For University Police (continued) Example of DOT Type III Label 7-81

85 General Instructions for Auxiliary Personnel Instructions for Environmental Services Personnel Introduction In order to prevent the spread of radioactive contamination or the improper disposal of radioactive waste, it is important that housekeeping personnel are aware of the proper way to conduct themselves in areas where radioactive materials are used. There are two separate areas of concern: Laboratories Hospital rooms Conduct in Laboratories Follow these guidelines in laboratories: Note the Caution Radioactive Material sign at entrance to the area Look for and obey any other special instructions at entrances, such as Do Not Enter. If there are no special instructions, enter the room. Do not smoke, eat, drink, or apply cosmetics while in these areas. Do required work as quickly as possible, and then leave the area. Watch for problems: o o If you see a tape-labeled container that has spilled or leaked, leave the area and contact your supervisor. If you have stepped in something that you think is radioactive leave your shoes inside the door to the room, and contact your supervisor. If you do not understand what to do, do not enter the area. Lock the door to the room when you leave. Instructions for Specific Areas WHAT TO DO WITH ITEMS MARKED RADIOACTIVE MATERIAL ITEM/AREA Bench tops labeled with tape Floor area labeled with tape Lab equipment labeled with tape INSTRUCTIONS Do not: Lean on or against it Put anything down on it Handle anything that is on it Do not: Walk in this area Clean the floor in this area Do not: Touch this equipment. 7-82

86 General Instructions for Auxiliary Personnel Instructions For Environmental Services Personnel (continued) Instructions for Specific Areas (continued) WHAT TO DO WITH ITEMS MARKED RADIOACTIVE MATERIALS ITEM/AREA Refrigerators labeled with tape Trash bags or cans labeled with tape Do not open. INSTRUCTIONS Do not empty this trash. If there is any doubt whether or not it is radioactive, do not empty it. Sinks labeled with tape or signs Do not use this sink to get water or dispose of water. Conduct in Hospital Rooms STEP PROCEDURE 1 Note the Caution Radiation Area sign at entrance to a patient s room, and do not enter the room. 2 Go to nursing station on floor. D o 3 Tell a nurse what you need to do in the patient s room. 4 Enter the patient s room only with a nurse present. n D 5 Do only what the nurse instructs you to do. Do not clean areas where radioactive material is spilled unless you are supervised by Nuclear Medicine or Radiation Safety. If there are any questions or problems, contact Radiation Safety at ext or through the hospital operator. 7-83

87 General Instructions for Auxiliary Personnel Instructions for Pathologists Dealing with Radioactive Body Tissues Post-Mortem Procedure Bodies of patients containing administered radioactive material shall not be removed from the patient area without notification of Radiation Safety and the physician in charge of the case. Radiation Safety will determine whether or not a radiation hazard exists in handling the body and will issue instructions accordingly. If Patient has received BRACHYTHERAPY Then The attending physician is responsible for the removal of brachytherapy sources and brachytherapy applicators from patients before the body leaves the patient area. (Once these sealed sources are removed, there is no further radiation problem.) In all other cases, residual radioactive material may still be found in body tissue. Radionuclides may be concentrated in an organ or tumor, or may be distributed through all body tissues or fluids. There is to be an AUTOPSY on the body, or if the body is to be EMBALMED There are RADIOACTIVE FLUIDS PRESENT IN THE BODY There are any RADIOACTIVE TISSUES TO BE RETAINED Radiation Safety should indicate what issues or body fluids are to be removed promptly (at autopsy), and what special precautions should be taken. Every effort should be made to see that they are properly discharged down the drain without spilling on the floor or splashing neighborhood areas. They should immediately be placed in appropriately shielded vessels for storage or for disposal according to procedures approved by Radiation Safety. Each container needs to be labeled with: Date Name and hospital number of patient Radionuclide and activity Date when radiation level will be below permissible level for disposal or handling without precautions Radioactive material tape INJURY OCCURS during an autopsy (where gloves being worn are cut or torn) Radioactive material may be introduced into the wound. In addition to ordinary treatment of the wound, Radiation Safety needs to be consulted with regard to any possible radiation hazard. Accidental Overflow Procedure In case of accidental overflow, the fluid should be taken up immediately, as completely as possible, with absorbent paper and pad held in tongs or forceps and promptly put into a plastic bag and labeled as radioactive waste. Special care should be taken to prevent the floor of the morgue from being contaminated. Such contamination can be transferred to the shoes and so be spread through the institution. 7-84

88 General Instructions for Auxiliary Personnel Instructions For Pathologists Dealing With Radioactive Body Tissues (continued) Accidental Overflow Procedure In addition, the floors of such rooms are often of rough concrete or other material that is difficult to decontaminate, and flushing them or scrubbing them with water may only spread the contamination. To avoid this, tape a large sheet of absorbent material, underlaid with plastic, to the floor before beginning the autopsy, to provide a working region easy to decontaminate. Protective shoe covers should be worn by all personnel in this region and removed before they leave the work area. Wearing plastic aprons and gloves prevents contamination of clothing and skin. Care should be taken in removing protective clothing so as not to contaminate the skin of radionuclide-free areas. 7-85

89 APPENDIX A: EXAMPLES OF SIGNS AND LABELS Examples of Sign Used at Entrance to Patient Room Where Radioactive Material is Used 7-86

90 APPENDIX A: EXAMPLES OF SIGNS AND LABELS (CONTINUED) Example of Sign Used at Entrance of Laboratories Where Radioactive Materials Are Used or Stored 7-87