BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 24 February 2010 Agenda Item: 7 Paper No: D Title: ANNUAL RADIATION PROTECTION REPORT 2009 Purpose: To provide assurance to the Board of Directors with regard to the Trust s radiation protection arrangements Summary: The Trust has three Radiation Protection Advisers and they have jointly reported on Radiation Protection in the Trust for 2009. There are no significant issues to report. The work of the Trust s three advisers is commended. Recommendation: For scrutiny Prepared by: Trust Radiation Protection Advisers Presented by: MARTIN SMITS Director of Nursing and Patient Services This report is relevant to: (Please tick relevant box) Assurance Framework Risk Register I/D No. Healthcare Standards: Financial implications YES / NO Please specify which standard Monitor compliance Human Resources implications YES / NO Internal monitoring Legal implications YES / NO
Medical Physics Group Poole Hospital NHS Foundation Trust Longfleet Road, Poole. BH15 2JB Tel: 01202 442590 Fax: 01202 442189 Chairman s email: andrew.hunt@poole.nhs.uk Radiation Protection Advisers (RPA) End of Year Report - 2009 Contents: 1. Summary 2. Diagnostic Radiology 3. Nuclear Medicine 4. Radiotherapy 5. Non-ionising Radiations 1. SUMMARY 1.1 Radiation Protection Committee (RPC) The RPC held meetings on 7 May and 19 November 2009. The minutes of these meetings are sent to the Risk Management Committee for scrutiny and comment. Written Terms of Reference for the RPC are reviewed at regular intervals and copies sent to the Risk Management Committee for approval. 1.2 Radiation Protection Advisers (RPAs) Regulation 13 of the Ionising Radiations Regulations, 1999 require the Trust to appoint an accredited RPA (according to the HSE criteria of competence). Following the retirement of Lars Jansson in September 2009, Kat Dixon (Head of Nuclear Medicine) has been formally appointed by the Trust as RPA for Diagnostic Radiology and Nuclear Medicine. Ted Procter (Head of Radiotherapy Physics) has also been appointed for Diagnostic Radiology, in addition to his role as RPA for Radiotherapy. Andrew Hunt (Head of Medical Physics) has applied for RPA accreditation from the national accrediting body RPA2000. Once Andrew is an accredited RPA, Andrew will act as the primary RPA for Diagnostic Radiology, Kat will act as primary RPA for Nuclear Medicine and Ted will act as primary RPA for Radiotherapy. Each RPA should be able to provide temporary cover for colleagues in the event of absence. In the longer-term additional staff will be accredited as RPAs, which will provide a more robust provision to the Trust. It has also been agreed that another three members of staff (one from each area of Medical Physics) will work towards gaining RPA accreditation. 1.3 Revised Radiation Safety Policy This policy was reviewed by the Radiation Protection Committee (RPC) in November 2009 and will be submitted to the Trust Board for approval. A major addition to the policy is section 33, which sets out the Trust s and employee s responsibilities when viewing medical images. 1.4 CBRN Policy Following a meeting with Craig Brown (Trust emergency planning lead), Kat Dixon is reviewing the CBRN policy in respect of radiological incidents.
1.5 National Arrangements for Incidents Involving Radioactivity (NAIR) The Trust (through the Medical Physics Group) is registered as a stage 1 NAIR responder. Radioactive materials are used for many purposes in industry, medicine and research and there are thousands of transport movements associated with these activities each year. NAIR was set up to protect the public from hazards arising from the use and transport of radioactive materials and in situations where no formal contingency plans exist. The Radiation Protection Division of the Health Protection Agency (HPA) co-ordinates the NAIR arrangements. NAIR provides quick and widely available assistance to the police and other emergency services where no radiation expert is otherwise available. Assistance is provided in two stages and is drawn from hospitals, the nuclear industry and government departments. Stage 1 assistance is normally provided by a radiation expert, who, with the aid of simple monitoring equipment, can tell whether a hazard exists and advise the police on appropriate action. If necessary, the police will be advised to obtain Stage 2 assistance. A revised Trust NAIR team has now been established, comprising 6 members of the Medical Physics Group. Planning meetings have been held, a fully revised NAIR emergency kit is now available, communications links have been reviewed & updated and regular NAIR preparation meetings will be held. 2. DIAGNOSTIC RADIOLOGY Personal Radiation badge results indicate that all radiation staff doses are below the relevant dose limits. A review of which staff need to wear radiation badges in theatres is underway and will be discussed at the May meeting of the RPC. The contract for the provision of radiation badges is due for renewal. This contract is negotiated by Southampton Hospital on behalf of the Region and the Trust will be advised shortly. A number of radiation incidents have been reported to the CQC during 2009. Incidents are reported to the RPA by appropriate Radiation Protection Supervisors (RPS). The mechanism for reporting has been reviewed. A Mock HSE inspection was conducted in Main X-Ray at Poole Hospital NHS Trust and reported to the RPC. An area which requires improvement is review of risk assessment for procedures involving radiation exposure to staff and patients. This review is underway and will report in May. Two new members of staff have started in Diagnostic Radiology Physics, which has increased capacity by 100%. As a result, environmental monitoring has been conducted, confirming the status of all radiation Controlled Areas. Radiation surveys of all x-ray equipment have been performed in the past 12 months, with no outstanding issues. The patient Dose Reference Levels (DRL) are reviewed annually to reflect the measurements performed. Generally all recorded doses are within the national or local DRL, with some minor exceptions, which are under investigation and will be reported to the next RPA. 3. NUCLEAR MEDICINE Kat Dixon has taken over the role as Head of and RPA for Nuclear Medicine. The refurbishment of Tyneham (now Sandbanks) Ward, meant the designation of a suitable temporary room on the ward for radionuclide treatment. The design of the new radionuclide treatment room was approved and assessed by the previous RPA. Papers\BoD Feb 10 D - Radiation Protection Annual Report cover.doc Page 3 of 5
4. RADIOTHERAPY 4.1 The new brachytherapy suite with HDR treatment unit was commissioned in May 2009. Radiation dose measurements confirm that areas around the treatment room experience dose levels below limits for non-designated public areas. The Ir-192 source is subject to HASS regulations and security measures are approved by the CTSA. 4.2 A review of RPS appointments has been effected to reflect the change to operational areas resulting in three new appointments. Each member of staff has attended an appropriate RPS training course. 4.3 An Environment Agency inspection on 20 July revealed nothing untoward. Inspections will now be on an annual basis due to the HDR Ir-192 HASS. 4.4 One reportable (IRMER) radiation incident reported to CQC, with an internal investigation underway. 4.5 A patient undergoing prostate brachytherapy treatment was under-dosed by ~ 25%. An external beam top-up was therefore given. Procedures and protocols have been updated to prevent a repeat. As an under-dose this incident is not reportable under the IRMER regulations. 4.6 A new national error reporting system (as part of Towards Safer Radiotherapy ) is being established. Radiotherapy incidents will in future be uploaded to the national database via Datix. 5. NON-IONISING RADIATIONS 5.1 A review of the calibration of physiotherapy lasers was undertaken, with recommendations and calibration protocol written. Laser safety training courses for staff have been arranged throughout the year. New national guidance on laser safety is being incorporated in to local safety policies. Opthalmic laser treatment for neonates has been established, with a review of the associated laser safety procedures. 5.2 No reported incidents in MR scanning. Adherence to new national guidance was reviewed and found to be good. The purchase of a 3T MR scanner will require the review of safety procedures. 5.3 No safety incidents in diagnostic ultrasound, although the procurement and QA procedures for ultrasound need attention. 5.4 Review of UV treatment radiometry procedures in Dermatology is underway, with protocols for nursing staff being written. Physics will continue to check the UV radiometry on an annual basis. 5.5 The European Directive EC/40/2004 has been delayed until 2012. The Trust will be required to assess the electromagnetic environment to assess staff exposure. Interference in ultrasound images is probably caused by stray RF signals within the Trust site. This is currently under investigation. Note: The following documents are available for scrutiny by members of the Board of Directors. RPA reports for May & November 2009. Revised Radiation Protection Policy (November 2009) Radiation Protection Committee Minutes (May & November 2009). Diagnostic Radiology Physics Group Report. Papers\BoD Feb 10 D - Radiation Protection Annual Report cover.doc Page 4 of 5
Report produced by: Andrew Hunt (Head of Medical Physics), Kat Dixon (Head of Nuclear Medicine) & Ted Procter (Head of Radiotherapy Physics) 26 January 2010. Papers\BoD Feb 10 D - Radiation Protection Annual Report cover.doc Page 5 of 5