RUH New Doctors

Safe use of radiation imaging

Once you have read this document, you can request permission to refer patients for x-ray and nuclear medicine procedures at the RUH by completing the relevant box on your new starter form.

If you have questions after reading the information in this document, or if you require training, please contact the imaging physics group:

ruh-tr.MedicalPhysics@nhs.net

01225 824082

Radiation Legislation

There are two sets of legislation dealing with the use of ionising radiation in medicine (x-ray, nuclear medicine, and radiotherapy).

• The Ionising Radiation (Medical Exposure) Regulations 2017 are concerned with the safety of the patient – these are often called IR(ME)R or the IR(ME) Regulations.
• The Ionising Radiations Regulations 2017 (IRR17) are concerned with the protection of members of staff and the public.

All diagnostic and therapeutic procedures involving exposure to ionising radiation for medical purposes carry some risk of radiation-induced cancer in the exposed person. In pregnancy, there is also a cancer risk to the foetus.

It is important therefore that only those medical exposures that are necessary and justifiable should be undertaken. Alternative methods of obtaining the required information should be considered, for example by the use of non-ionising radiation (e.g. MRI or Ultrasound). Radiologists at the RUH are able to discuss possible alternative non-ionising radiation examinations, particularly for imaging pregnant women and children.

The Trust policy on "Radiation Safety" can be found on the RUH intranet and this describes the way in which radiation legislation is implemented in the RUH. In addition, detailed IR(ME)R Employer's procedures are on the X-ray Guidelines page of the RUH intranet. Relevant documents are available in departments that deliver or administer ionising radiation to patients for medical purposes.

The IR(ME) Regulations describe the duties of staff involved in the patient pathway of ionising radiation exposures. The following duty holders are defined: Employer, Referrer, Practitioner, Operator and Medical Physics Expert.

IR(ME)R Referrers

A person who requests an examination involving ionising radiation is described as a referrer. In IR(ME)R terms: "Referrer means a registered health care professional who is entitled in accordance with the employer's procedures to refer individuals for exposure to a practitioner".

• Before requesting an x-ray, referrers must be satisfied that the examination is necessary. Referrers must be aware of the referral criteria for diagnostic examinations which are available to purchase in booklet form or online at www.irefer.org.uk (you can log in automatically when using an RUH computer).
• The referrer must check whether there are previous examinations which are relevant to current diagnosis. Please note that it is possible to retrieve images from other hospitals – the Radiology PACS team are available to advise on this.
• The referrer must provide sufficient detail for the patient to be uniquely identified.
• The referrer must provide sufficient clinical detail to enable the IR(ME)R Practitioner to justify the examination taking into account the anticipated clinical benefit and the radiation risk. This includes the clinical indications, provisional diagnosis and details of the information expected to be obtained from the examination.
• If a referral has been submitted but is no longer required, the referral must be cancelled by telephoning the Radiology Department.
• As a referrer, you are also responsible for ensuring that the image is clinically evaluated within a suitable timeframe. If you are working in orthopaedic outpatients, orthodontics, or using fluoroscopy, you must be aware that your image will not be evaluated by Radiology.
• It is vital that the correct patient always receives the correct radiation exposure – any incidents where a patient receives an incorrect exposure must be reported via Datix, and a notification to the CQC will be submitted if appropriate.

Non-medical referrers (staff who do not have GMC or GDC registration e.g. nurses, physiotherapists) are required to undergo specific training and to work within defined protocols which entitle them to refer patients for radiation exposures that are specific to their clinical role. Training is also available to medical referrers if required.

IR(ME)R Practitioners

The IR(ME) Regulations state that "Practitioner means a registered health care professional, who is entitled in accordance with the employer's procedures to take responsibility for an individual exposure". The role of the practitioner is to assess the referral and decide whether the benefit outweighs the risk.

This justification must be performed for every patient, and for every carer who will be exposed to radiation while supporting a patient. Every use of radiation must be necessary, appropriate, and benefit the management of the patient, taking into account the risk associated with the nature and magnitude of the radiation dose.

In the RUH, the following people are designated as IR(ME)R practitioners:

• Any clinician working for the RUH Trust, who is medically qualified in radiology, oncology, mammography, cardiology, or dentistry may act as an IR(ME)R practitioner for x-ray procedures within their own specialty, including carer exposures.
• Clinicians using the mini c-arm in orthopaedic surgery or trauma assessment act as IR(ME)R practitioners for the mini c-arm exposures.
• Rheumatology clinicians act as IR(ME)R practitioners for DEXA.
• Qualified state-registered radiographers working in Radiology and the Breast Unit at the RUH may act as IR(ME)R practitioners for routine 'plain-film' imaging, fluoroscopic imaging which is carried out outside the main radiology department, and some complex examinations under local protocols.
• IR(ME)R practitioners in nuclear medicine and PET must have a valid IR(M)ER practitioner licence for the administration of radioactive substances.

Clinicians acting as IR(ME)R practitioners are required to undertake additional training for this role every five years. On commencing employment at the RUH in these specialities, please arrange training with the Medical Physics and Bioengineering Department – contact the imaging physics group:

ruh-tr.MedicalPhysics@nhs.net

01225 824082

Radiation and patients with childbearing potential

It is important to establish pregnancy status for patients of childbearing capacity for whom x-ray examination of the trunk of the body is required, or prior to radionuclide administration. Imaging departments have formal procedures for determining pregnancy status of patients between the ages of 12 and 55 (inclusive).

For CT or interventional radiology between the lower costal margin and mid-femur, there are criteria which allow the possibility of pregnancy to be excluded, such as being within the first 10 days of a menstrual period. For lower dose radiology, pregnancy can be excluded if the patient's menstrual period is not overdue.

If pregnancy cannot be excluded and the examination is not urgent this might involve rebooking the examination for an appropriate time in the patient's menstrual cycle. For exposures taking place in theatre, these procedures are included in the RUH pre-operative checklist.

If a patient is found to be pregnant, or if pregnancy cannot be excluded, alternative imaging modalities should be considered. If the examination is urgent, an IR(ME)R practitioner may re-justify the examination, taking into account the patient's condition and the risk to the fetus arising from the radiation dose.

For urgent out of hours exposures, Radiologist guidelines exist which allow the practitioner re-justification to be performed by a middle grade or consultant clinician.

IR(ME)R Operators

The IR(ME) Regulations define an operator as follows: "Operator means any person who is entitled, in accordance with the employer's procedures, to carry out practical aspects of a radiation exposure".

Radiographers, radiologists, dental nurses, and DEXA operators routinely act as operators for x-ray exposures and have equipment specific training. Cardiologists operating a fluoroscopy foot-pedal, and orthopaedic clinicians operating a mini c-arm must also have evidence of equipment-specific training. Technologists and radiographers are operators for nuclear medicine and PET exposures, and occasionally a clinician with an appropriate IR(ME)R practitioner licence will act as an operator in administering a radionuclide to a patient.

Staff must not operate radiation generating equipment unless they have been adequately trained and named on the RUH Trust list of operators for that equipment.

Clinicians who evaluate x-ray images are listed as IR(ME)R operators in the Trust procedures. For images were a Radiologist report is not required, the clinician evaluating the image must record that radiation imaging was used and evaluated e.g. orthopaedic and maxillofacial clinic imaging, fluoroscopy in theatres, cardiac cath labs, endoscopy suite, and pain intervention imaging.

Examinations not directly associated with illness or injury

It is the responsibility of the referrer to indicate on the request the reason that a particular examination is sought e.g. diagnosis, treatment, health screening, research, asymptomatic, non-medical imaging.

All referrals for non-medical imaging (e.g. medico-legal, immigration, pre-employment) must be justified by a radiologist acting as a practitioner, on an individual patient basis, with due regard to the fact that there is no direct clinical benefit to the patient. These exposures must be evaluated by the practitioner who justified the examination. For immigration, the practitioner must be a radiologist who is approved for evaluation of these images.

Research

Prior to a research programme commencing, the chief investigator must obtain approval from the Research Ethics Committee (REC). When ionising radiation is involved, the research proposal must include a Medical Physics Expert assessment of radiation doses and cancer risks, and a Clinical Radiation Expert evaluation of the clinical significance of the proposed exposure.

When the RUH takes part in an approved trial where ionising radiation is involved, an RUH Medical Physics Expert must confirm whether dose constraints can be met and relevant licences are held. The research coordinator must inform the radiology, oncology or nuclear medicine department that a research trial involving medical exposures is planned. They must also ensure that sufficient written information is provided to allow the lead Radiologist for that trial to act as the practitioner, justifying exposures that are part of the trial.

IRR17 - Protection of Staff and Members of the public

Staff working with ionising radiation must read and sign the Local Rules for the relevant area. These set out safe working practices to be followed in that area. Attention is drawn to the following points:

• To protect the public and other members of staff, doors to areas in which radiation is generated should be closed during use.
• Only people who are essential to a procedure should remain in a room where radiation is being generated. When using mobiles x-ray units, the local rules state the size of the radiation area (normally 2m from the part of the patient that is being x-rayed). The radiographer ensures that anyone inside that area is appropriately protected.
• People who remain in an x-ray room should stand behind a fixed lead screen if possible. Anyone remaining close to the patient must wear protective clothing e.g. lead aprons, and make use of all available lead protection e.g. mobile screens, lead glass eye shields, lead drape around the table. This is particularly important in operating theatres and in cardiology where there are a number of people in the room in close proximity to the patient. Distance is an important factor in reducing dose and so it is important that members of staff stand back from the patient and tube when possible.
• Staff must not expose any part of their body to the radiation beam, even if they are wearing protection e.g. lead gloves (i.e. staff must never be visible within the image). Particular care is required to ensure that hands are not exposed to the primary beam during procedures involving fluoroscopy.
• Staff issued with personal dosimeters, including finger and eye monitors, are required to wear them while working with radiation at the RUH, and return the monitors on time at the end of each wear period. This is a legal requirement of the Health and Safety at Work Act, enforced by the HSE.
• For staff working with radiation, staff pregnancy must be notified in writing to their line manager and Radiation Protection Supervisor for the area. A risk assessment will be carried out and additional measures implemented if required.
• If staff work with radiation for more than one employer, they must inform the Radiation Protection Advisers of those employers so that their total occupational radiation dose can be assessed (contact details are shown on x-ray area local rules).

Incidents involving radiation

In line with Trust procedures, a trust incident form (Datix) must be completed for all incidents involving radiation. The Radiation Protection Supervisor (RPS) named in the Local Rules must also be informed of any untoward incidents involving unintended radiation exposures of staff.

The Datix investigating manager will contact the Medical Physics department for a dose estimate and assessment of the cancer risk to those involved. The results will be notified to those concerned and measures taken to reduce the possibility of a repeat incident. Medical Physics will advise on whether each incident should be reported externally to the CQC or HSE.

Working in Imaging Departments and Oncology

In addition to the information contained in this document, clinicians working in Imaging departments and in Oncology must be familiar with all local policies, procedures and training requirements and also read and sign the Local Rules for areas in which they work.

Laura Martin
Radiation Protection Adviser
Royal United Hospital NHS Trust

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