North Western Medical Physics Report of the Radiation Protection

North Western Medical Physics Report of the Radiation Protection Adviser to Pennine Acute Hospitals NHS Trust Fairfield General Hospital North Manchester General Hospital Royal Oldham Hospital Rochdale Infirmary and Manchester, Bury, Heywood (Rochdale & Middleton) and Oldham PCTs Jan 2008 – Dec 2008 Contents o o o o o o o o Summary Personnel Monitoring Unsealed sources Diagnostic Radiology Community Dental Services Magnetic Resonance Imaging UV Radiation General Radiation Protection Issues Summary • Protection arrangements will need to be reviewed when Haematology relocates to Oldham. Dr Rowlands ARSAC certificate will also require renewal in April 2009. • The Trust needs to ensure that investigation of all patient exposure incidents is completed and appropriate bodies are notified. • The Trust has made good progress on rationalising X-ray IRMER procedures across the hospital sites. • Significant progress has been made on dose audits. Several of these are waiting to be reported by NWMP. Outstanding dose audits should be completed in 2009 so that the Trust has a comprehensive set of DRLs. • Progress has been made on standardising QA processes across the Trust and replacing the DXS QA service, but QA arrangements need to be completed as a matter of urgency. • The Trust should consider wider delivery of MR safety training. Personnel Monitoring Monitoring Results In the previous calendar year to 31 December 2007, all members of staff working with ionising radiation within the Trust received annual doses less than one tenth of the appropriate dose limits. In 2008, with most of the results read, all members of Pennine RPA Report 2009.doc Page 1 of 13 Jan 2009 staff were below 1/20 of the appropriate dose limits and are therefore very unlikely to exceed 1/10 of the annual dose limit. Unsealed Sources – North Manchester Pravin Patel carried out the annual radiation protection audit of the Nuclear Medicine department in November 2008, and of the haematology department in December 2008. Nuclear Medicine Service Developments Breast Sentinel Node Service. Sentinel node procedures are now being performed regularly at North Manchester, and less frequently at Oldham. Injections for both groups of patient are carried out in Nuclear Medicine at North Manchester. DATScan. The number of DATscans performed has increased during the past year, therefore there has been an increased use of 123I. However, this has remained within the registration and authorisation under the Radioactive Substances Act. Personnel Monitoring No member of staff received a whole body dose greater than 2mSv during 2008. A rolling programme of finger monitoring is in place. Environmental Monitoring Results of environmental monitoring in the newly extended department were satisfactory. Local Rules Local rules were revised in 2008. ARSAC Dr Randeep Kulshrestha has been appointed as consultant and has obtained a full imaging ARSAC certificate. Dr Yeung at Royal Bolton hospital also holds a certificate for a limited range of imaging studies. Haematology Workload has remained low in the past year, and it is expected that the departments work will move to Oldham in April 2009. Dr Rowlands’ ARSAC certificate is due for renewal in July 2009. However a new certificate would be required in order to carry out work at the Oldham site, as ARSAC certificates are specific to a geographic site. Unsealed Sources – Oldham Haematology Pravin Patel made his RPA visit in August 2007. The 2008 visit has been postponed pending the merger with the department at North Manchester onto the Oldham site, at which point radiation protection arrangements and procedures will be reviewed. Sentinel Node – Theatres and Pathology A few cases have been undertaken in theatres at Oldham. Pathology continue to receive samples from sentinel node procedures at both North Manchester and Oldham. No problems have been identified. Pennine RPA Report 2009.doc Page 2 of 13 Jan 2009 Diagnostic Radiology New Installations NWMP has assessed the following new equipment across the Trust. Recommendations concerned only adjustment of AEC sensitivity in two radiographic rooms and improvement of swing angle accuracy in a tomography room. Progress is being made in testing the Kodak CR readers. CR readers in Oldham and Rochdale are due to be tested in spring 2009. Diagnostic Radiology – Fairfield Risk Assessments Radiation risk assessments are due to be reissued. Local Rules Local rules were reissued in Feb 2006. Routine Safety and Performance Surveys Surveys have been performed on X-ray equipment as shown. Pennine RPA Report 2009.doc Page 3 of 13 Jan 2009 Five sysems had remedial level recommendations, as last year, including radiographic AEC sensitivity and fluoroscopy automatic dose and doserate, automatic collimation and image resolution problems. Calibration of one of the departments QC instruments remained poor. Quality Assurance X-ray QC is ongoing. Incidents NWMP estimated doses for an incident involving an incorrect CT Sinus examination, that was reported to the Healthcare Commission. Dose was also estimated for a pancreas exam, but this was not reportable. Investigation of an incident for a CT Lumbar Spine has not been completed. IR(ME)R The Trust wide review of IRMER procedures has been completed. Rationalisation of examination protocols is also very near completion. CT doses have been audited and reference levels set. Dose survey data for radiography has been collected and is awaiting a report from NWMP. Diagnostic Radiology – North Manchester Risk Assessments Radiation risk assessments have been reviewed. Local Rules Local rules were reviewed in January 2008, with no significant changes needed. Local rules in the Maxillofacial unit were updated in August 2008. RPA Advice NWMP is being consulted over the X-ray extension associated with the women’s and children’s development. Routine Safety and Performance Surveys Surveys have been performed on X-ray equipment as below. Pennine RPA Report 2009.doc Page 4 of 13 Jan 2009 Nine reports had remedial level recommendations, a significant increase from last year (from 18% to 31% of reports). For radiographic systems these mainly concerned high AEC receptor doses. Recommendations on fluoroscopy equipment included high fluorography doses, poor limiting resolution and an automatic collimation problem. In a couple of rooms warning notices were missing or warning lights were not working. Quality Assurance Routine equipment QC by DXS Medical Engineering will finish in March 2009. Work has been done on setting up a replacement programme, but staff changes mean that responsibility for implementation will fall on new departmental managers. Incidents Dose was estimated for an incorrect CT Pelvis examination, though the investigation has not been formally completed. IR(ME)R Trust wide IRMER procedures have been implemented. Patient dose survey data for radiography has been collected and is awaiting a report from NWMP. Patient dose audit for CT should also be a priority. Diagnostic Radiology – Oldham Risk Assessments Radiation risk assessments, mainly issued in July 2006, have been reviewed. Controlled area warning lights associated with the OPG were ambiguous and have been removed. Local Rules Local rules were reviewed in Jan 2008, but the rules in several locations should be reissued this year. Pennine RPA Report 2009.doc Page 5 of 13 Jan 2009 RPA advice. NWMP has given protection advice for new equipment in Room 5. Routine Safety and Performance Surveys Surveys have been performed on X-ray equipment as shown below. Five systems had remedial level recommendations. One of the mammography units had several recommendations requiring attention. Other recommendations concerned collimation, artefacts and snapshot doses on mobile intensifier systems. The department should ensure that NWMP are informed when new X-ray tubes are fitted in order to arrange timely baseline checks. Quality Assurance There is a QA programme but this will need to be reviewed as part of Trust plans to standardise QA. Incidents NWMP estimated the dose for a patient who had an HSG examination and was subsequently found to be pregnant. IR(ME)R Trust wide IRMER procedures have been implemented and examination protocols are being reviewed. Patient dose audit for CT has been completed and DRLs recommended. Patient dose survey data for radiography has been collected and is awaiting a report from NWMP. Diagnostic Radiology – Rochdale Risk Assessments Risk assessments were issued mainly in 2004/5 and are due to be updated. There was a new risk assessment for the temporary CT scanner. Local Rules Local rules in most locations are due to be reissued. Routine Safety and Performance Surveys Surveys have been performed on X-ray equipment as shown below. Five units had remedial level recommendations. One cardiac system and a mobile intensifier had increased automatic fluorography doses while dose rates on another mobile intensifier were significantly lower, compromising image quality. Pennine RPA Report 2009.doc Page 6 of 13 Jan 2009 Quality Assurance Routine equipment QC by DXS Medical Engineering will finish in March 2009. NWMP has been involved in work to set up a replacement programme, but further work is needed to fully implement this. Incidents We are not aware of any incidents in 2008. RPA advice. NWMP gave protection advice for the temporary and replacement CT scanners. IR(ME)R Trust wide IRMER procedures have been implemented and examination protocols are being reviewed. No local issues have been raised. Community Dental Services Manchester PCT Surveys have been performed on X-ray equipment as shown. There are no outstanding remedial actions. Local rules have been updated at the Vallance, Ancoats and Longsight Health Centres. Pennine RPA Report 2009.doc Page 7 of 13 Jan 2009 Bury PCT Surveys have been performed on X-ray equipment as shown. There are no outstanding remedial actions. Local rules and risk assessments were also updated at Radcliffe Health Centre. Heywood, Middleton & Rochdale PCT Surveys have been performed on X-ray equipment as shown. There are no outstanding remedial actions. Local rules and risk assessments were updated at Heywood, Littleborough, Milnrow, Castlemere Health Centres & Buckley Hall. Oldham PCT Surveys have been performed on X-ray equipment as shown. Local rules and risk assessments were updated at South Chadderton and Failsworth Health Centres. NWMP have advised on protection requirements at new PCT developments and also the siting of mobile imaging units. Magnetic Resonance Imaging – Oldham The MRA, Judith Kilgallon with Neil Davis and MR Superintendent Radiographer, Andrew Green, performed an annual safety review in November 2008. The report (attached) raised the following points: • Local Rules were reviewed and have been amended. Further updates to comply with recent MHRA guidelines are planned. • No incidents have been reported between Nov 2007 and Nov 2008. • MR safety training is up-to-date. Further training of booking system staff will be required. Inclusion of MR safety in Trust General Induction has been suggested. • Training of radiographers to request and interpret IOFB X-rays is still pending, as last year. • Several changes have been made in conjunction with Philips to address potential quenching safety issues. Pennine RPA Report 2009.doc Page 8 of 13 Jan 2009 UV Radiation Non-ionising radiation contact, Donald Allan, highlighted the following points in his report (copy attached): • • • Full annual equipment surveys and calibrations have been performed at Oldham and Fairfield in February and November 2008 respectively. Trust should inform NWMP if there are plans to re-commission the North Manchester or Rochdale units. There are currently no concerns about the equipment that is in use. Lasers The Laser Safety Group has met regularly and will report directly to the Clinical Governance Committee. General Radiation Protection Issues Guidance relating to ionising radiation The International Commission on Radiological Protection has recently published “The 2007 recommendations of the ICRP”, publication 103 which summarises current thinking on all matters associated with radiation protection. Consequently the EU are revising the relevant directives which will eventually require changes to the UK legislation. This process will take at least 5 years. NWMP are not aware of anything in the new ICRP recommendations which will indicates significant changes to operational radiation protection will be required. Guidance relating to Magnetic Resonance Imaging The European Commission has recently announced a four-year delay to the implementation date of the Physical Agents (EMF) Directive [referred to here as the Directive – although it should be remembered that there are four Physical Agents Directives, and the other three (covering noise, optical radiation and vibration) are not affected by this delay]. This is explicitly to allow time for the impact of the Directive on MRI to be assessed in more detail, with a view to substantive amendment. Whilst the campaign about the Directive has reached an important stage and secured a proposed delay that would have been unimaginable a few years ago, there are a number of challenges still ahead of us yet, and unfortunately it is too soon to say that the problem of the Directive gone away. The Directive was adopted by the European Union in 2004. It contains limits for occupational exposure to time-varying magnetic fields and to RF, adopted from guidelines previously issued by ICNIRP in 1998. These guidelines are based on cautious interpretation of sparse scientific evidence in order to exclude any possibility of adverse effects, rather than on established thresholds for actual effects. The latest Commission proposal takes the form of a new Directive (containing substantial amendments to the exposure limits) and this will be drafted by the end of 2009, allowing consultation, adoption and transposition by 2012. The transposition deadline is the final date by which member states must implement the Directive. Although the Commission has advised states to put transposition on hold, the Directive is still on the statute books and states may transpose at any time. The Commission will look to ICNIRP for advice on new limits. The Commission’s press release indicates that less stringent recommendations are expected. However, early indications are beginning to emerge from ICNIRP as to possible Pennine RPA Report 2009.doc Page 9 of 13 Jan 2009 changes to the time varying field limits, and while there is likely to be some relaxation, it is not at all clear that this would be sufficient to accommodate all present and foreseeable future MRI practices. It is therefore essential that the MR community remains active and attentive to ongoing developments with regard to the new Directive. The community as a whole must be seen to be respectful of the need to ensure staff safety whilst continuing to lobby for appropriate limits that permit a risk benefit to be applied for both existing and new MR techniques. The Previous MHRA Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use were updated in December 2007 [MHRA DB2007(03)] and incorporate several aspects of updated information and advice. Additionally, the HPA is due to produce patient exposure guidance in2008 (an update to the previous NRPB 2(1) 1991 document) and ICNIRP are expected to revise their static magnetic field guidance in 2008. Optical Radiation Safety Guidelines The EU Physical Agents (Artificial Optical Radiation) Directive was approved by the European Commission in April 2006 and each EU member state must have legislation in place by 2010 to ensure compliance. The aim of the Directive is to ensure that employers protect their employees from detrimental exposure to artificial optical radiation (i.e. optical radiation other than that from the sun) by carrying out workplace evaluations/assessments and providing any necessary safety equipment or training. The Directive will have a significant impact on employees working in a wide variety of areas within the hospital environment - from hospital staff working in operating theatres to those working in phototherapy units, even office lighting and the optical radiation from computer screens are included. NWMP intend to keep Trusts up-to-date on developments and will help implementation of the legislation over the coming years. Laser Safety Guidelines Recently the MDA document, ‘Guidance on the Safe Use of Lasers in Medical and Dental Practice’ DoH 1995, has been replaced with the MHRA document, ‘Guidance on the safe use of lasers, intense light source systems and LEDs in medical, surgical, dental and aesthetic practices’ DB2008(03) April 2008. NWMP will be reviewing this document in the near future and will inform Trusts should there be any relevant guidance changes. Incidents involving Radioactivity In 2004, the Department of Health updated its advice to all Accident and Emergency departments concerning plans for dealing with incidents involving radiation casualties (see http://www.dh.gov.uk/assetRoot/04/12/37/80/04123780.pdf). The plans must include identifying a local medical physics department to provide specialist advice in the event of an incident. NWMP provides such advice on request. Trusts are encouraged to phone to discuss their requirements and any queries with the RPA (contact Brian Murby – 0161 446 3951, Jennie Prince – 0161 446 3906 or Pravin Patel – 0161 446 3970). In June 2005, the Department of Health's Emergency Planning Division provided all accident and emergency departments with RAM-GENE radiation monitors so that A&E staff could determine whether or not a casualty attending for treatment is contaminated with radioactive materials. NWMP is prepared to check these monitors annually as part of the existing medical physics contract as long as the transport costs are met by the hospital. Pennine RPA Report 2009.doc Page 10 of 13 Jan 2009 Andy Shaw on behalf of North Western Medical Physics, Radiation Protection Adviser to Pennine Acute Hospitals NHS Trust 22 January 2008 Pennine Acute Hospitals NHS Trust RPC Report - UV Radiation The UV equipment known to NWMP has not changed in the past year and is: North Manchester General Hospital One Verre et Quartz Dixwell UVB whole-body cabinet located in the Dermatology Department. Clinical use of this unit was understood to have been suspended since early 2006, so our calibration checks have likewise been suspended. If plans develop to restart patient treatments with this unit, it would be helpful to know this in good time so that all necessary calibration and hazard assessment measurements can be made before first clinical use. Royal Oldham Hospital One Waldmann UV7001 UVB whole-body cabinet located in the Dermatology Department. UV phototherapy has been overseen by Dr R D Ead, Consultant Dermatologist until his retirement earlier in 2008. SpN S Armstrong continues in charge of the day-to-day use of the equipment. Our most recent visit to this department was in February 2008 to perform a full annual survey of the equipment. We have no concerns about this equipment or its use at present. Fairfield General Hospital One Waldmann UV7001K UVB whole-body cabinet located in the Dermatology Department. UV phototherapy continues to be overseen by Dr D Fitzgerald, Consultant Dermatologist. SpN E Shaw continues in charge of the day-to-day use of the equipment. Our most recent visit to this department was in November 2008 to perform a full annual survey of the equipment. We have no concerns about this equipment or its use at present. Rochdale Infirmary We continue to understand that there is a Waldmann UV7001 UVB whole-body cabinet on this site, but that it has never been commissioned for service. If plans develop to commence patient treatments with this unit, it would be helpful to know this in good time so that all necessary calibration and hazard assessment measurements can be made before first clinical use. D Allan 31 December 2008 Pennine RPA Report 2009.doc Page 11 of 13 Jan 2009 Royal Oldham Hospital MR Unit, Pennine Acute Hospitals NHS Trust Report of the Magnetic Resonance Advisor An Annual Safety Review was performed on 6th November 2008 by Andrew Green, Superintendent Radiographer of the MR Unit and Judith Kilgallon and Neil Davis, on behalf of North Western Medical Physics (NWMP), Magnetic Resonance Advisor to the Pennine Acute Hospitals NHS Trust. A written report was prepared by Neil Davis, a copy of which has been provided to the MR department. The review looked at the Local Rules and identified a number of amendments; these changes have been incorporated and the Local Rules reissued by NWMP. There have been no MR safety incidents in the period November 2007 to November 2008. This indicates that the MR safety policy is working well and does not need further review at this time. MR safety training for personnel working in the department is up-to-date. It was mentioned in previous reviews that radiographers should receive training to enable them to request and interpret IOFB X-rays. Radiographers are now able to request IOFB X-rays, but the training to enable them to interpret the X-rays is still pending. In light of a recent situation when the use of a pulse oximeter would have been beneficial, finance has been obtained in order to purchase one, though this has not yet been done. Following the incidence of a magnet quench at another hospital, Philips have conducted their own safety review. As a result of this, the position of the quench pipe has been altered (as illustrated below), and this change has been approved by Philips. As part of the same review, in light of the inward opening door in to the scan room Paul Fenton has sanctioned the use of a hammer to break the window in case of increased pressure due to quenching, though the hammer has not yet been sourced. The scanning of patients with aneurysm clips has recently been suggested, discussed, and rejected, remaining in line with policies of other district general hospitals. MR safety training will be required for staff involved with the central booking system when it is introduced, and it has also been suggested that MR safety training is included as part of the Trust General Induction Day. It is anticipated that within the next year the local rules will be updated in order to comply with the recommendations of the 2007 MHRA Device Bulletin “Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use” as far as is reasonably workable and practicable. PENNINE RPA REPORT 2009.DOC PAGE 12 of 13 Jan 08 Dr J E Kilgallon On behalf of North Western Medical Physics PENNINE RPA REPORT 2009.DOC PAGE 13 of 13 Jan 08