CHAPTER 1 -- PREFACE
The University of Kentucky strives to provide a safe and healthful
environment for all persons associated with the University, including
faculty, staff, students, and visitors. Attainment of this goal
requires the cooperation and commitment of all persons involved.
The University emphasizes safety education and training as the primary means of achieving this goal. While the Radiation Safety Office, the department responsible for radiation safety functions within the University, provides training and performs periodic safety inspections, department heads, faculty members, and supervisors are directly responsible for maintaining an atmosphere that promotes full compliance with University safety policies and procedures.
With regard to radiation safety matters, the Radiation Safety Committee, appointed by the President, establishes radiation policies and procedures for the University in accordance with requirements set forth by State and Federal regulatory agencies. Responsibility for carrying out these policies and procedures rests with the Radiation Safety Officer, who directs the Radiation Safety Office.
Essential elements of the University's radiation safety program are presented in this Radiation Safety Manual. The safety program has been carefully developed to assist all radiation users in utilizing the unique advantages of radiation sources while meeting their safety responsibilities in as efficient and non-intrusive manner as possible. In addition, radiation safety philosophy and regulations include an objective of maintaining all exposures at levels as far below regulatory limits as can reasonably be achieved. The University strongly supports this "As Low As Reasonably Achievable" (ALARA) safety goal. The policies and procedures found in this manual were designed to promote the achievement of this goal.
In this era of increasing concern for occupational safety and for the environment, it is essential that all members of the University community become and remain thoroughly familiar with their responsibilities for compliance with health and safety regulations, including these radiation safety policies and procedures. Please study the contents of this manual. Know and practice these and all other safety rules. Thank you for your cooperation.
CHAPTER 2 -- UK RADIATION SAFETY PROGRAM
INTRODUCTION
The Kentucky Cabinet for Health Services, Radiation Health and Toxic Agents Branch, authorizes the University of Kentucky to use radiation-producing devices in operations, education, research and development activities. The University’s Radiation Safety Committee authorizes individuals to use these devices. Prospective users must submit proposals to the Committee for review and approval. This allows the University great flexibility in dealing with the multitude of device uses on its various campuses. It also places equally great responsibility on investigators and administration to handle radiation-producing devices safely, following established policies, procedures and regulations.
This manual summarizes the terms of the University's authorization to use various radiation producing devices. A copy must be available in each Authorized User's facility where radiation-producing devices are used. Copies of special precautions, regulations, and other operating procedures specified by the Radiation Safety Committee or Radiation Safety Officer must also be maintained available to laboratory personnel and Radiation Safety Office staff. Everyone involved with the use of radiation-producing devices in any way is required to be familiar with the provisions of this manual.
RESPONSIBILITIES
Radiation Safety Committee:
The Radiation Safety Committee is responsible for establishing policies governing the procurement, use, storage and disposal of radiation-producing devices. The Committee includes individuals experienced in the use of radiation sources in medicine and research at the University. The Committee consists of a Chairman, Radiation Safety Officer, representatives of management and nursing service, and four members each from the medical and main campus sectors. Committee duties include:
The Committee meets at least once each calendar quarter. The Committee and its Chairman, is appointed by the President as a sub-committee of the Environmental Health and Safety Committee, to which it provides reports at least annually.
Radiation Safety Officer:
The Radiation Safety Officer has administrative responsibility for the University's radiation safety program. The Radiation Safety Office staff provides a wide range of specific radiation protection services such as personnel monitoring, facility surveys, maintenance of records required by the State, consultation on the safe use of radiation producing devices and training.
The Radiation Safety Officer reviews all applications for radiation-producing device use, as well as location, procedure and disposal. The Radiation Safety Officer recommends approval or disapproval to the Radiation Safety Committee of application for the use of radiation-producing devices. The Radiation Safety Officer may approve a change in location or operating procedures. He/she may suspend any project or use that is found to be a threat to health or property.
The Radiation Safety Officer is responsible for investigating overexposures, accidents, losses, thefts, unauthorized receipts, uses, transfers, disposals, and other deviations from approved radiation safety practice, and implementing corrective actions as necessary. The Radiation Safety Officer is also responsible for implementing written policies and procedures for the following:
Authorized Users
An Authorized User is a faculty/staff employee who has been approved to use radiation-producing devices by the Radiation Safety Committee. Authorized Users are responsible for ensuring that students and staff using radiation producing devices under his/her authorization are trained in safe laboratory practices, are familiar with the terms of the authorization and are complying with University policies and applicable regulations. The Radiation Safety Office offers periodic training sessions to assist the Authorized User in this regard. The Authorized User will normally be the principal investigator of a research project or the faculty member responsible for a course with laboratory or field exercises in which radiation producing devices are used. Although faculty members may use radiation-producing devices under another faculty member's authorization, each faculty member is encouraged to obtain his/her own authorization.
Questions regarding radiation-producing device registration, type, use and location should be directed to the Radiation Safety Office, 323-6777.
VENDOR RADIATION SAFETY
All vendors, who sell or service radiation-producing equipment at UK, must have a radiation safety program that includes at least the following:
The vendors must provide program documentation to the University upon request.
Vendor representatives who are in the room during radiation-producing procedures must wear monitoring devices, appropriate aprons and other shielding, and other PPE appropriate to the situation.
The company must provide the monitoring devices. The University will provide aprons, shields, and other PPE for use by the vendor representatives.
If the vendor does not need to be in the procedure room, he/she should use the observation window.
Request for Special Safety Investigations
The Kentucky Administrative Radiation Regulations, 902 KAR 100, makes provisions for employees to request an inspection or evaluation of conditions which they believe may constitute a health or safety hazard. University employees are encouraged to report such conditions to the Radiation Safety Office and to request a "Special Investigation" into the need for corrective action. Employees are encouraged to seek resolution of a hazardous condition through the Radiation Safety Office. A person requesting an inspection may request confidentiality and by law, his/her name will not appear on any record or made available to the public, to his/her immediate supervisor, or department head. After the Radiation Safety Office has concluded its investigation, the results will be communicated, in writing, to the party requesting the investigation and to other appropriate University personnel with due consideration of requests for anonymity. If it is determined that there are reasonable grounds to believe that a violation or danger exists, corrective action will be initiated. If corrective action cannot be implemented within a reasonable period of time, the Radiation Safety Officer may terminate the operations until corrective action is taken.
CHAPTER 3 -- ACQUISITION OF A RADIATION-PRODUCING DEVICE
Prior to obtaining a radiation-producing device the facility Authorized User must:
REGISTRATION
All machines capable of producing ionizing radiation must be registered with the UK Radiation Safety Office. The following types must be registered:
Registrants using x-ray machines shall provide the Radiation Safety Office with documentation of the type, make, model, location, and maximum radiation output of the device before installation. A copy of the radiation survey performed at the installation and acceptance testing shall be maintained for inspection, including exposure rates in all adjacent rooms. Radiation surveys shall be repeated after major maintenance, modification or relocation of the device.
To register the radiation-producing device or accelerator, provide the Radiation Safety Office with a completed Registered form (Appendix A).
Before installation of an x-ray device, a radiation shielding plan and specifications must be produced and filed with the regulatory agency.
An initial radiation safety survey of the equipment and all adjacent rooms, shall be conducted and a copy maintained. Similar radiation surveys shall be repeated after major maintenance, modification or relocation.
The Radiation Safety Office must be notified prior to any device installation, maintenance, modification or relocation, discontinuation or transfer of a radiation-producing device. Reports of transfer (surplus, sale, gift, etc.) must include the name and address of the transferee.
CHAPTER 4 -- RADIATION WORKER REGISTRATION AND TRAINING
All radiation workers must complete a
Radiation Worker Registration Form. This form provides essential information for issuing a radiation monitoring badge, and provides information on training and experience. The Radiation Safety Officer (or his/her designee) will review registration forms and schedule necessary training sessions. The Radiation Safety Office is to be informed of all changes in personnel working with radiation sources. Radiation worker updates should be provided when a worker is added, deleted or transfers to another Authorized User.
Training
All individuals using radiation-producing devices will receive radiation safety training offered by the Radiation Safety Office. Training must be completed within four months of using a radiation-producing device. In addition individuals will be trained on the operation of the particular radiation producing device he/she will be using and actions to take in the event of an emergency.
In some cases, such as with analytical and cabinet x-ray devices, the Authorized User will give the safety training, with the course content approved by the Radiation Safety Office.
Medical x-ray operators are certified by the State and no further training is required.
CHAPTER 5 -- RADIATION PROTECTION POLICIES AND PROCEDURES
Radiation producing devices do not make anything radioactive and do not produce radiation contamination (certain particle accelerators may be an exception). External radiation exposure is from x-rays only (with the possible exception of clinic or research accelerators). Applying basic radiation control measures can control the external dose.
Radiation Control Measures
Time/Distance/Shielding: The principal objective of radiation protection is to ensure that the dose received by any individual is as low as reasonably achievable (ALARA), while not exceeding the maximum permissible limit. Any one, or a combination, of the following methods may achieve this objective:
Time. Limit the time of exposure. For illustrative purposes, a person entering a relatively high radiation field of 1000 millirem/hr, but for only 30 seconds, would receive a relatively low dose of 8 millirem. The maximum permissible whole body dose is 5000 millirem per calendar year for occupational workers.
Distance. The inverse square law states that radiation intensity from a point source varies inversely as the square of the distance from the source. The formula is:
By increasing the distance between the source of exposure and an individual, the dose received can be significantly reduced. When an individual doubles his/her distance from a source, the dose will usually be reduced by approximately three-fourths.
Shielding. Absorbing material, or shields, can be incorporated to reduce exposure levels. The specific shielding material and thickness is dependent on the amount and type of radiation involved. Lead shielding is generally used for diagnostic and other low-energy x-rays, while concrete and steel are often used with higher energy sources such as accelerators. The Radiation Safety Office will assist in designing and specifying appropriate shielding.
Exposure. The "strength" (killivoltage, milliamphreage, etc.) of the radiation source. By reducing the intensity of the radiation used (lowering the current settings on a radiation producing machine), dose can be reduced.
The fundamental objectives of radiation protection measures are to limit exposure to external radiation to levels that are always within the established dose limits, and as low as reasonably achievable.
Exposure Limits
External radiation levels should be kept to less than 0.1 millirem/hr at 5 centimeters from the source surface or source housing and to levels as low as reasonably achievable.
For x-ray sources, the units of roentgens, rads, and rems may be considered equivalent.
Survey Instruments
To facilitate safe practice in the University, the Radiation Safety Committee requires that an appropriate calibrated survey meter be available in each authorized laboratory area. "Appropriate" in most cases means a thin window Geiger-Mueller type meter (end window or pancake type) that will detect very low energy x-rays or an ion chamber meter. A "laboratory area" may be one laboratory or a series of connecting laboratory spaces. Laboratories located on different floors or in different buildings each need their own meter.
Instruments must be calibrated annually. Calibrations will be performed by the Radiation Safety Office without charge. The Radiation Safety Office should be informed of the purchase of a new instrument, repair of an instrument, or factory calibration of an existing instrument.
Posting and Labeling Requirements
The Radiation Safety Office is responsible for the posting of all lab or room radiation warning signs. Labeling equipment and lab supplies with radiation warning tape is the responsibility of the Authorized User. The user also must post the Notice To Employees Form KR441, and Emergency Procedures. A copy of the UK Radiation Producing Devices Safety Manual must be readily available.
Inspections
The KY Cabinet for Health Services, the Radiation Safety Office and other safety services inspect x-ray machines periodically for safety practices and regulatory compliance.
CHAPTER 6 -- PERSONNEL RADIATION EXPOSURE MONITORING
Personnel monitoring devices (film badges, TLD, pocket dosimeters, etc.) are provided by the Radiation Safety Office to measure an individual's radiation exposure from X-ray sources. The standard monitoring device is a clip-on badge or ring badge bearing the individuals name, date of the monitoring period and a unique identification number. The badges are provided, processed and reported through a commercial service company, which meets current requirements of the National Institute of Standards and Technology National Voluntary Laboratory Accreditation Program (NVLAP).
Monitorinq Requirements: Radiation protection regulations and UK policy require that appropriate personnel monitoring equipment be provided to individuals who:
Procedures for Monitoring Devices: Authorized Users must file a Radiation Worker Registration Form for each individual who may work with radiation sources. This form provides for the basic information regarding training and experience and personnel monitoring needs. Initial personnel monitoring decisions will be based on this information. Further evaluations, and re-evaluations, will be made through radiation employee registration updates, application reviews, personnel monitoring reports, ALARA investigations, surveys and individual interviews by responsible Radiation Safety staff members.
Badges may be exchanged on a monthly or quarterly basis. Badges must be returned to the Radiation Safety Office by the tenth of the month so that they may be properly processed.
The Radiation Safety Officer may require the use of pocket dosimeters, ring badges, or other monitoring devices when particular procedures are in operation.
The Radiation Safety Office will request prior radiation dose histories from all past employers and will maintain all personnel occupational radiation dose records.
It will be the responsibility of each individual badge recipient to wear and use the badge(s) properly. Authorized Users are responsible for assuring their radiation workers are wearing badges appropriately and that badges are returned on time for processing. Authorized Users/radiation workers may be penalized for late or lost badges.
Use of Personnel Monitoring Devices: The whole body badge (or other device) is to be worn on the body where it will most likely approximate the radiation exposure to the head and torso of the wearer. A badge assigned for whole body monitoring is not to be used to monitor the extremities (hands, forearms, feet, ankles). Separate badges must be assigned for extremity monitoring. Only the individual assigned the badge shall wear it and only at University facilities.
Generally, whole body badges are to be worn between the waist and the neck. When a protective apron is worn, the badge is to be worn at the collar, outside the apron. The Radiation Safety Officer should be consulted for advice in these circumstances.
Extremity monitoring badges (rings) are available in large or small sizes for the right or left hand. Ring badges should be worn whenever working with applicable sources.
Exposure of a personnel monitoring device to deceptively indicate a dose delivered to an individual is prohibited by state regulations.
Personnel Monitoring Reports: Exposure reports are currently monthly and quarterly. Each report includes the name, monitoring period date, dose (millirem) for the immediate past period, current calendar quarter and calendar year.
The personnel monitoring reports are on file in the Radiation Safety Office. They are available for all badged employees to review. The reports are considered medical records and may not be released without written consent.
UK Pregnant Employee - Fetal Dose Policy: The UK fetal dose policy incorporates safety information and radiation dose guidelines for ensuring safe radiation limits for the embryo/fetus of occupationally exposed employees. Pregnant radiation workers should notify the Radiation Safety Office in writing as soon as possible after learning of their pregnancy.
A potentially harmful situation arises when a pregnant worker is exposed to radiation. Exposure of such a worker to ionizing radiation from either external or internal sources would also involve exposure of the embryo or fetus. A number of studies have indicated that the embryo or fetus is more sensitive than an adult, particularly during the first three months after conception, when a woman may not be aware that she is pregnant.
Federal and state regulations require that special precautions be taken to limit exposure to radiation sources when an occupationally exposed woman could be pregnant.
The current maximum permissible radiation exposure is 500 millirem for the duration of the gestation period, and the monthly exposure should be limited to 50 millirem. Fetal monitoring (double badging) is available at the Radiation Safety Office.
In order to be recognized as pregnant, for the purpose of exposure limits, a person must declare in writing to the University that she is pregnant.
It is recommended that the pregnant person avoid higher radiation exposure procedures such as x-ray fluoroscopy.
ALARA Levels and Notifications: There are two notification levels for the ALARA program, Level I and Level II. Level I notifications involve a radiation worker receiving greater than 10 percent of the maximum allowable dose (prorated for a month's exposure period). The recipient is notified in writing when their exposure meets this level's criteria. The notification requests that the worker review their work procedures in order to reduce exposure, if feasible.
Level II notifications involve a radiation worker receiving greater than 30 percent of the maximum allowable dose (prorated for a month's exposure period). The recipient is notified when their exposure meets this level's criteria. In addition to reviewing procedures as with Level I, Level II requires the worker to respond in writing to the Radiation Safety Office. The response must include the cause of the exposure and a consideration of actions that may be taken to reduce the probability of a recurrence.
Overexposure: If an exposure exceeds the maximum allowable dose, the employee and supervisor will be notified and the required reports will be filed with the State of Kentucky Cabinet for Health services .
The University is committed to minimizing radiation exposure to all persons associated with the University. Therefore, the As Low As Reasonably Achievable (ALARA) philosophy is adopted as policy for the University. The Radiation Safety Committee, with the Radiation Safety Officer as its delegated representative, will develop and implement policies and procedures to ensure radiation exposures are ALARA.
The following policies and procedures are utilized to keep radiation exposures ALARA:
CHAPTER 8 -- ANALYTICAL X-RAY SAFETY PROCEDURES
X-ray diffraction and spectrographic devices generate in-beam radiation dose rates of 30 to 7000 rads/sec. Severe tissue damage can be inflicted by very brief exposures to these high dose rates. Surgical treatment or amputation may be required when small body parts, such as fingers, receive greater than 1000 rads.
It is imperative that stringent safety precautions be applied when using these devices. Safety precautions include mechanical and electrical interlocks as well as proper training and instruction. The following safety procedures have been established to help prevent accidents. Adherence to these rules is mandatory.
Analytical X-ray facilities will be inspected annually.
The following X-ray emergency procedure must be posted at each analytical X-ray device:
ANALYTICAL X-RAY MACHINES
Radiation Emergency Procedures
IF YOU ARE EXPOSED TO THE DIRECT X-RAY BEAM, OR SUSPECT AN EXPOSURE, IMMEDIATELY FOLLOW THESE STEPS:
1. Shut off the x-ray beam.
Medical Advice/Incident Reporting
Safety Procedures
X-Ray diffraction and spectrographic devices generate in-beam radiation dose rates of 30 to 7000 rads/sec. Severe tissue damage can be inflicted by very brief exposures to these high dose rates. Surgical treatment or amputation may be required when small body parts, such as fingers, receive greater than 1000 rads.
It is imperative that stringent safety precautions be applied when using these devices. Safety precautions include mechanical and electrical guards as well as proper training and instruction. The following safety procedures have been established to help prevent accidents. Adherence to these rules is mandatory.
1. NO PERSON SHALL BE PERMITTED TO OPERATE ANALYTICAL X-RAY MACHINES CHAPTER 9 -- DENTAL X-RAY UNITS
In performing intra-oral dental radiography the following rules shall apply:
Dental x-ray facilities should be inspected once every three years unless certification or other reasons require a different schedule.
CHAPTER 10 -- DIAGNOSTIC X-RAY UNITS
Technique Chart. In the vicinity of each x-ray system's control panel a chart shall be provided which specifies pertinent examination information. The chart shall include but not be limited to the following:
Personnel in X-ray Room. Except for patients who cannot be moved out of the room, only staff and ancillary personnel required for the medical procedure or training shall be in the room during the radiographic exposure. The patients and personnel shall be protected as follows:
When an x-ray examination is performed in the patient’s room, or for difficult patients in the trauma setting, the radiologic technologist sometimes needs assistance in positioning the patient. Since the need for assistance is highly variable and unpredictable, Diagnostic Radiology is not staffed to provide the extra hands necessary to complete these exams successfully. Nationwide, the standard practice is for the patient’s care team or a family member to provide this extra assistance with positioning. UK policy requires that persons who are not routinely exposed to radiation or a family member provide this assistance, to the maximum extent practicable, since it would unacceptably increase the risk of adverse health effects already borne by workers who are routinely exposed to radiation as part of their job duties. The amount of radiation received by a person providing positioning assistance is very low and is considered by the radiation safety community to be safe, especially when the precautions mentioned below are observed.
Radiologic technologists who request positioning assistance will make every effort to keep the radiation exposure of those providing assistance to levels that are as low as reasonably achievable. The assisters (staff or family members) will be shown how to position themselves in the safest and most effective way. A lead apron and lead gloves will be given to the assister, and the assister will stand so that they are outside of the primary radiation beam to the greatest extent practicable. Pregnant staff or family members will not be used to provide positioning assistance. No one person will be asked to routinely hold patients. An assister who is already wearing a film badge will position the badge at the collar outside the apron during the procedure.
Fluoroscope Procedures
Operating Procedures and Auxiliary Equipment. The following operating procedures and auxiliary equipment shall be utilized, if applicable, in the operation of a fluoroscopic x-ray system:
Medical diagnostic facilities, to satisfy JCAHO standards, should be inspected annually.
CHAPTER 11 -- PARTICLE ACCELERATORS
A label bearing essentially the words "CAUTION - RADIATION - THIS MACHINE PRODUCES RADIATION WHEN ENERGIZED" shall be placed near switches that energize portions of the machine. Labels shall use the conventional colors (magenta or purple on yellow background) and bear the conventional radiation symbol.
Written operating procedures pertaining to radiation safety shall be established for each accelerator facility.
Written emergency procedures pertaining to radiation safety shall be established and posted in a conspicuous location. These shall list the telephone number(s) of the radiation safety officer and shall include the following actions to be taken if a known, or suspected, accident involving radiation exposure occurs:
CHAPTER 12 -- VETERINARY X-RAY UNITS
In performing veterinary radiography the following rules shall apply:
Veterinary X-ray facilities should be inspected every three years.
CHAPTER 13 -- MISCELLANEOUS DEVICES
No person is required to register the following:
Electronic equipment that produces radiation incidental to its operation for other purposes provided the dose equivalent rate averaged over an area of ten (10) square centimeters does not exceed five-tenths (0.5) mrem per hour at five (5) centimeters from an accessible surface of the equipment.
Domestic television receivers are exempt from the regulations.
Any electronic circuit with voltage above approximately 1000 volts may produce x-rays. Usually, such devices are designed and constructed such that there is no significant exposure on the exterior surface of the device. The U.S. FDA regulates electronic devices such that this limit is equal or less than 0.5 millirem per hour at 5 centimeters from the surface.
Electron microscopes may need to be inspected due to CAP or other certification bodies. Such inspections will be conducted upon request to the Radiation Safety Office. These devices do not require registration or safety inspections.
If a radiation safety survey is wanted by anyone, call the Radiation Safety Office, 323-6777, and make a request.
Appendix A -- X-ray Registration Form
UNIVERSITY OF KENTUCKY
X-ray Registration Form
Instructions: Complete all information and forward two copies to the Radiation Safety Office, 102 Animal Pathology.
____Existing ____New
1. Identify person(s) who will (a) supervise use of the machine and (b) all personnel who will use the machine (attach sheet if necessary). ______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
2. Location (Bldg. & Rm. #) of machine______________________________________________________________
3. Type of use (check all that apply):
__ Medical: __ Diagnostic __ Therapeutic _________________________________________________________________________________________
4. Machine Type: 5. Manufacturer/Model _____________________________________________________________________
Serial # _________________________________________________________________________________
6. Maximum Rated kVp ____________ mA ____________
Note: All X-ray machine operators must wear a personnel monitoring device (badge), which is provided by the Radiation Safety Office. Other requirements may also apply, depending on the type of machine and applications. Please contact the Radiation Safety Office if you need a badge or have any questions.
Responsible Person ___________________________ _____________________________ _________________
For use by Radiation Safety Office only:
Comments _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Appendix B -- RADIATION WORKER REGISTRATION FORM
Absorbed Dose
the amount of energy imparted to matter by ionizing radiation per unit mass of irradiated material. The unit of absorbed dose is the Rad, which is 100 ergs/gram.
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