irmer from dream to reality

IRMER from dream to reality

STATUTORY INSTRUMENTS

2000 No. 1059

HEALTH AND SAFETY

The Ionising Radiation (Medical Exposure) Regulations 2000

Made 13th April 2000

Laid before Parliament 14th April 2000

Coming into force

except for regulation 4(1) and4(2)

13th May 2000

regulation 4(1) and 4(2) 1st January 2001

Basic Principles

• Justification

• Optimisation

• Roles & Responsibilities (employers, referrers, practitioners, operators, MP experts)

• Procedures & Protocols

• Adequate training & Audit

POPUMET >>> IRMER

• Regulations: 12 >>> 14

• Schedules: 1 >>> 2

• Pages: 31/2 >>> 16

• DoH Inspectors: 4 >>> 8?

Employer's Procedures to ...(a) identify patient correctly

(b) identify referrers, practitioners and operator;

(c) for medico-legal exposures;

(d) for making enquiries of females of childbearing age to establish whether the individual is or may be pregnant or breastfeeding;

(e) ensure that QA programmes are followed;

(f) for the assessment of patient dose;

(g) diagnostic reference levels;

Employer's Procedures to ...

(i) (nuclear medicine)

(j) recording result and exposure factors

(k) minimise accidents.

(a) identify patient correctly

(b) identify referrers, practitioners and operator;

(c) for medico-legal exposures;

(d) for making enquiries of females of childbearing age to establish whether the individual is or may be pregnant or breastfeeding;

(e) ensure that QA programmes are followed;

(f) for the assessment of patient dose;

(g) diagnostic reference levels;

(h) (biomedical research)

Where did we start?

• Draft action plan written

• What is required?

• Are we doing it already?• If not what do we do and who does it?.

IRMER Radiology Group• John Saunderson, Viv Whitton (RPAs)

• Martine Nutman (Radiology Manager)

• Dr Ged Avery

• Jane Thundercliffe (RPS HRI)

• Mike Wroe (RPS CHH)

• Trevor Parker (RPS A&E)

• Others as and when.

Action Plan• -

• Web-site for Procedures.

www.hullrad.org.uk

New/Revised Procedures

• Comforters & carers

• Patient identification

• Referrers, practitioners & operators

• Medico-legal exposures

• Quality assurance

• Untoward incidents.

Comforters and Carers


"individuals who (other than as part of their profession) knowingly and willingly incur an exposure to ionising radiation in the support or comfort of another person who is undergoing, or has undergone a medical exposure"


"individuals who (other than as part of their profession) knowingly and willingly incur an exposure to ionising radiation in the support or comfort of another person who is undergoing, or has undergone a medical exposure"

Dose constraint required.

RADIATION PROTECTION

POLICY AND PROCEDURES

NUMBER : 19

COMFORTER & CARERS

and Others Exposed Via the Medical Exposure of Another

Person

Who are COMFORTER AND CARERS?

"COMFORTERS AND CARERS", under IRR991 are defined as "individuals who (other than as

part of their profession2) knowingly and willingly incur an exposure to ionising radiation in the

support or comfort of another person who is undergoing, or has undergone a medical exposure"

COMFORTER AND CARERS may include members of the public who, for example

visit patients in hospital after those patients have been administed with

radiopharmaceuticals or are undergoing brachytherapy

offer support for those patients at home who have undergone certain nuclear

medicine procedures, or had sealed sources permanently implanted

(in some cases) offer support to a young child or disabled person while that person is

X-rayed

and are likely to receive more than the public dose limit of 1 mSv a year resulting from

direct radiation or contamination during the comfort and support they offer.

If they are unlikely to receive more than 1 mSv a year then they need not be classified

as COMFORTER AND CARERS under IRR99.

IRR99 also allows a separate dose limit for persons who may be exposed to radiation

resulting from the medical exposure of another. This limit is 5 mSv in 5 years. This limit is

1 The Ionising Radiations Regulations 1999


• e.g. parent holding a child being X-rayed

• not a nurse, care assistant, etc.

• if < 1 mSv public dose limit, not “C&C”

• 5 mSv dose constraint

• if pregnant 1 mSv dose constraint

• must be aware of the risk.

Scatter Dosee.g. Lat. Lumbar spine

• No lead apron: 0.6 mGy @ 30 cm

• With 0.35 mm apron: 0.06 mGy @ 30 cm

• Public dose limit = 1 mSv 17 patients

• C&C constraint = 5 mSv 83 patients

• Staff limit = 6 mSv 100 patients.

Doses Relative to Lum. Sp.

• Chest: x 0.02

• Skull: x 0.04

• Thoracic spine, pelvis: x 0.5

• Abdomen: x 0.8

• IVU: x 1.5

• Ba. Enema: x 4.1

• CT abdomen: x 5.9.

Patient Identification

HULL AND EAST YORKSHIRE HOSPITALSNHS TRUST

RADIOLOGY DEPARTMENT

PATIENT IDENTIFICATION PROTOCOL

RECEPTION

All outpatients must identify themselves at reception on arrival. Responsibility: receptionist who receives the patient on arrival Appropriate checks: a) Appointment letter if applicable

b) Name c) Date of birth d) Address if applicable e) See special circumstances

EXAMINATIONS IN ALL IMAGING MODALITIES

All outpatients and inpatients must identify themselves before exposure toionising radiation.

Responsibility: Radiographer in charge of the procedure. Appropriate checks: a) Name

b) Date of birthc) Address if applicabled) Wristbands on inpatientse) LMP checks to comply with 28 day rule on

women between the ages of 12 and 50f) See special circumstances

FLUOROSCOPY PROCEDURES

All outpatients and inpatients must identify themselves before exposure toionising radiation

Responsibility: Radiographer in charge of the fluoroscopy session. Appropriate checks: a) Name

b) Date of birthc) Address if applicabled) Wristbands on inpatientse) LMP checks to comply with 28 day rule on

women between the ages 12 - 50f) see special ciircumstances

SPECIAL CIRCUMSTANCES

Responsibility: Radiographer in charge of the examination.

PAEDIATRIC PATIENTS WITH RELATIVE OR CARER The appropriate identity checks should be done with the child if they are

able to answer for themselves. If this is not the case the relative or carershould answer for the child

PATIENTS WITH LEARNING DIFFICULTIES If the patient is unable to identify themselves verbally then identification

must be sought from an escort or relative if present. Otherwise the referringdepartment/Doctor must be contacted

PATIENTS WITH LANGUAGE DIFFICULTIES Escort or relative accompanying can be used to verify patient identification.

Otherwise use hospital interpreters

PATIENTS WITH HEARING OR SENSORY IMPAIRMENT An escort or relative can be used to verify patient identification if present. Otherwise use writing or sign language

HELPERS/STUDENT RADIOGRAPHERS CHECKING PATIENTIDENTIFICATION It is the radiographer’s responsibility to ensure that the correct patient is

irradiated at all times. Student’s can check patient’s identification by theabove methods

Identifying Referrers, Practitioners

& Operators



NUMBER : HEYH01

Hul l & East Yorksh i re Hosp i ta ls NHS Trust

REFERRERS, PRACTITIONERS & OPERATORS

Procedure to Identify Individuals Entitled to Act as Referrer, Practitioner or

Operator

- DIAGNOSTIC PROCEDURES1 -

(i) REFERRERS - Medically Qualified

Clinically justified referrals for diagnostic procedures using ionising radiation will be

accepted from registered medical and dental practitioners. Referrals will also be

accepted from provisionally registered practitioners working under the direct supervision

of a fully registered colleague.

It is not feasible for the Trust to maintain up to date lists of all medical practitioners in

hospitals and general practice. All requests arising from such will be assumed to

originate with a qualified medical or dental practitioner and to be signed by the

responsible clinician. The Trust will, as far as is possible, make it clear to referrers that

these are the expectations and any departure from these will be a violation of the

Regulations2.

With the introduction of order coms, the person requesting the examination will have

been delegated a password to enable them to request. This will have been post

verification by the Department performing the medical exposure and subject to the

referrer working to set referral protocols. This system will be reviewed yearly.

1 Including interventional radiology2 Ionising Radiation (Medical Exposures) Regulations 2000 (IRMER)

(iii) PRACTITIONERS

This is inclusive of all grades of Radiologist within their area of expertise. Other

appropriately qualified and trained members of staff may act as practitioners as agreed

by the Department performing the medical exposure, in discussion with the Clinical Lead

and within a defined range of procedures.

If any doubt exists as to roles / responsibilities and the patient would be put at risk if the

procedure did not continue, then the examination should be performed. All details must

be recorded and the situation reviewed / assessed to avoid a future reoccurrence.

(iv) OPERATORS

e.g. radiologists, radiographers, appropriately supervised trainees/students, medical

physicists, medical technologists, dark room technicians, and X-ray engineers.

Individuals will only be allowed to act as operators in those areas for which they have

received appropriate training.

Occasionally, staff with no radiological background may need to act as operators, e.g.

clinicians performing clinical procedures under fluoroscopic guidance. Such staff will be

required to undergo such training as agreed by the appropriate professional organisation

and Royal Colleges. The number of persons requiring such training, should be kept to a

minimum by ensuring that, whenever possible a qualified radiographer acts as operator.

- THERAPEUTIC PROCEDURES -

(v) REFERRERS - Medically Qualified

As for diagnostic procedures.

(vi) REFERRERS - Non-medically Qualified

Referrers(requests medical exposure)

• registered medical and dental practitioners (order coms password required)

• non-medical referrers must be approved for specific requests by Radiology Dept.

Practitioners(justifies exposures)

• radiologists

• others as approved by Dept.

Operators(performs practical aspects)

e.g.• radiologists, • radiographers, • appropriately supervised trainees/students, • medical physicists, • medical technologists, • dark room technicians, • X-ray engineers• authorise exposure under a practitioner.

Medico-legal Exposures

Hull & East Yorkshire Hospitals Radiation Protection Service



NUMBER : 21

MEDICO-LEGAL EXPOSURES

Procedure to Observed in Case of Medico-Legal Exposures

Medico-legal exposures are those taken for insurance or legal purposes where there is not expected

to be a direct health benefit to the patient.

When justifying the procedure the practitioner must take any non-medical benefits to the patient into

account. Medico-legal exposures will only be undertaken with the consent of the patient.

For such requests, the cards must be reviewed by a Radiologist / discussed with the Department

performing the exposure.

The practitioner and operator should pay special attention ti the need to keep doses arising from

medio-legal exposures as low as reasonably practicable.

Quality Assurance

Hull & East Yorkshire. Hospitals Radiation Protection Service



NUMBER : 20

QUALITY ASSURANCE

It is a requirement, both under the Ionising Radiation Regulations 1999 and IRMER 2000, that

Quality Assurance Programs be implemented and that the employer shall have adequate procedures

in place to ensure that they are carried out. This also implies regular review of policy and

procedure(s) method.

1. Equipment

a. A regular program of tests shall be carried out and recorded by the operators. The

content, frequency and acceptable range of results will be in line with accepted national

practice (currently IPEM 77) as defined by the Radiology Manager and RPA or their

representatives.

b. More comprehensive and independent tests will be carried out annually by the Radiation

Protection Service with reports submitted to the Radiology Manager.

c. Acceptance surveys will be carried out for all new equipment and following major

repair/replacement which may affect patient dose or image quality.

2. Standard Operating Procedures

a. It is the responsibility of the Radiation Protection Supervisor and other senior staff to

ensure that agreed working practices are maintained and any discrepancy reported to the

Service Manager.

b. Audit of compliance will be carried out on an annual basis by the Radiation Protection

Service.

3. Review

The Service Manager, Lead Clinician and Radiation Protection Advisor will meet regularly

(and at least annually) to review results of Quality Assurance Audit. Recommendations will

be given to the Clinical Risk committee and Divisional Management.

Ref: IPEM Report No. 77, Recommended Standards for the Routine Performance Testing of Diagnostic X-Ray Imaging Systems, IPEM/CoR/NRPB, IPEM 1997

Quality Assurance

• Equipment

• - regular by operators

• - annually by Rad. Pro. Service

• acceptance tests for new or repairs that affect dose

• Procedures - annual audit by Rad Pro Service.

Incidents•Any untoward occurrence which may result in excess radiation to staff or patients must be referred to the Radiation Protection Supervisor and the Radiation Protection Adviser, who will estimate the dose and liase with management, HSE, DoH, HMIP, etc. as appropriate

•Suspect equipment must be withdrawn from service and labelled according.

Patient Doses Much Greater Than Intended

• x 20 - extremities, skull, chest, etc.

• x 10 - lumbar spine, abdomen, pelvis, mammography and other examinations not referred to elsewhere,

• x 3 - fluoroscopy, digital radiography, C.T

Investigation

establishing what happened

identifying the failure

deciding on remedial action to minimise the chance of a similar failure

estimating the doses involved

decide whether patient informed (usually yes).

Still to do . . .

Still to Do

• -

“Much wisdom, much grief;

the more the knowledge, the more the sorrow.”Eccl. Chapter 1 verse 18

The IR(ME)R Inspection Experience

• image used by a colleague from London at a recent presentation on IR(ME)R

• Worth a thousand words

• Well describes the process on our working lives!

irmer from dream to reality

Health & Medicine