radiation safety manual · 2016-05-18 · 1-3 general information radiation safety committee...

THE UNIVERSITY OF TEXAS MEDICAL BRANCH

RADIATION SAFETY MANUAL

ENVIRONMENTAL HEALTH AND SAFETY

Revised: April, 2016

RADIATION SAFETY MANUAL

Table of Contents

Chapter 1 : General Information ................................................................................................................ 1-1

Radiation Emergency Information ......................................................................................................... 1-1

Use and Distribution of the Radiation Safety Manual ........................................................................... 1-2

Radiation Safety Committee .................................................................................................................. 1-3

Radiation Safety Officer and Staff .......................................................................................................... 1-4

Chapter 2 : Licensing Radioactive Material for Use ................................................................................... 2-5

Authorized Users .................................................................................................................................... 2-5

Permit to Use Radioactive Material ....................................................................................................... 2-9

Ordering Radioactive Material ............................................................................................................. 2-11

Receipt and Documentation of Radioactive Material ......................................................................... 2-12

Transferring Radioactive Material ....................................................................................................... 2-14

Training Requirements for Personnel Who Work With Radioactive Materials ................................... 2-16

Personnel Monitoring .......................................................................................................................... 2-18

Record Keeping .................................................................................................................................... 2-21

Chapter 3 : General Rules and Guidelines for Handling RAM .................................................................. 3-22

Routine Laboratory Procedures ........................................................................................................... 3-22

Emergency Procedures ........................................................................................................................ 3-25

Emergency Weather Procedures ......................................................................................................... 3-27

Disposal of Radioactive Materials ........................................................................................................ 3-30

Use of Radioactive Materials in Animals ............................................................................................. 3-39

Guidelines for Area Contamination Surveys ........................................................................................ 3-40

Chapter 4 : Bioassay Program .................................................................................................................. 4-43

Guidelines for Individuals Working With I-125 and I-131 .................................................................... 4-43

Guidelines for Individuals Working With H-3 ...................................................................................... 4-47

Chapter 5 : Management of Patients Undergoing Brachytherapy .......................................................... 5-48

Introduction ......................................................................................................................................... 5-48

Radiation Safety Staff Responsibilities ................................................................................................. 5-49

Radiation Oncology Department Staff Responsibilities ....................................................................... 5-50

Nursing Instructions ............................................................................................................................. 5-58

Chapter 6 : Management of Patients Receiving Therapeutic Amounts of Radionuclides ....................... 6-61

Introduction ......................................................................................................................................... 6-61

General Information ............................................................................................................................ 6-62

Radiation Safety Programs ................................................................................................................... 6-66

Nuclear Medicine Staff Responsibilities .............................................................................................. 6-67

Nursing Service Staff Responsibilities .................................................................................................. 6-72

Environmental Services and Dietary Services Staff Responsibilities ................................................... 6-75

Chapter 7 : General Instructions for Auxiliary Personnel ........................................................................ 7-76

Instructions for Maintenance Personnel ............................................................................................. 7-76

Instructions for Smoke Detector Disposal ........................................................................................... 7-78

Instructions for University Police ......................................................................................................... 7-79

Instructions for Environmental Services Personnel ............................................................................. 7-82

Instructions for Pathologists Dealing with Radioactive Body Tissues .................................................. 7-84

APPENDIX A: EXAMPLES OF SIGNS AND LABELS ...................................................................................... 7-86

APPENDIX B: GLOSSARY ........................................................................................................................... 7-89

1-1

CHAPTER 1 : GENERAL INFORMATION

Radiation Emergency Information

Telephone ENVIRONMENTAL HEALTH AND SAFETY

Directory

Luz Cheng, Senior Director DAY (409) 772-2279

Radiation & Biosafety Programs & NIGHT (409) 772-1011

Radiation Safety Officer (UTMB Operator)

DAY (409) 772-2279

EHS On-Call NIGHT (409) 772-1011

(UTMB Operator)

RADIOACTIVE WASTE PICK-UP QUESTIONS

DAY 70515

DIVISION OF RADIATION ONCOLOGY DAY 22531

DIVISION OF NUCLEAR MEDICINE DAY 28016

CAMPUS POLICE DAY 21111

NIGHT (409)772-1111

CAMPUS FIRE DEPARTMENT DAY 21211

NIGHT (409)772-1211

How to

Report

An Emergency

STEP PROCEDURE

1

2

3

4

Give your name

Give your location: room and building

Give the phone number you are using

Describe the nature of the emergency:

Is there a personal injury? Is there a threat of injury?

1-2

General Information

Use and Distribution of the Radiation Safety Manual

Who Needs The Radiation Safety Manual is issued through the Radiation Safety Program. It is

available to:

all personnel at UTMB who use, supervise, or control the use of radioactive

materials or radiation -producing machinery (such as X-ray machines)

personnel who might have reason to enter areas where sources of radiation are

present

Location of Manuals should be located in:

Manuals

Every laboratory authorized to use radioactive materials

Areas where radiation producing machines are present

Certain nursing stations

Certain department offices (e.g., Environmental Services, Facilities Operations

and Management, i.e. University Police)

Accountability Manuals are numbered for purposes of inventory and updating. Individuals to whom

manuals are issued are asked to return their manuals if they terminate employment at

UTMB. Individuals who have possession of manuals issued to particular departments,

divisions, offices, work stations, etc., should pass these on to their successors or return

them to Radiation Safety when they terminate employment at UTMB.

Updates to the

Manual Changes and corrections to this manual will be issued by Radiation Safety when needed.

Such updates will be distributed to all individuals who possess a copy of the manual.

Upon receipt of the update, make changes in accordance with instructions accompanying

the update and notify all individuals.

1-3

General Information

Radiation Safety Committee

Purpose The Radiation Safety Committee (RSC), established in 1968 as the Committee on

Ionizing Radiation, is responsible for ensuring that radioactive materials and radiation –

producing devices are used safely and in accordance with State and Federal regulations.

Responsibilities The RSC is responsible for:

Formulating general policy governing the use of radiation-producing equipment and

radioactive materials

Reviewing and approving all requests for the use of radiation-producing machines

and radioactive material at the University

Determining that all individuals authorized to use radiation-producing machines and

radioactive materials have sufficient training and experience to enable them to

perform their duties safely

Establishing a program to ensure that all individuals whose duties may require them

to work in the vicinity of radioactive material or radiation-producing machines are

properly instructed about all appropriate health and safety matters

Conducting an annual review of the Radiation Safety Program to determine that all

activities are being conducted safely and in accordance with Texas Regulations for

Control of Radiation and the University’s license

Function The Committee meets at least quarterly. Members include:

A representative of the Administration

The Radiation Safety Officer

A representative of the nursing staff

Physicians with expertise in the use of radioactive materials and radiation-producing

machines for diagnosis and therapy

Individuals with expertise in the use of radioactive materials for non-human research

Other members shall be appointed at the discretion of the University President.

1-4

General Information

Radiation Safety Officer and Staff

Radiation Safety Officer The Radiation Safety Officer is appointed by the President of UTMB.

Radiation Safety The Radiation Safety staff of Environmental Health and Safety:

Staff

Assists in the development of general policies for control of radiation

Collects and disseminates information relative to radiation protection

Evaluates equipment and physical facilities

Evaluates operational techniques and procedures

Provides radiation safety training

Conducts an inspection program to assure that laboratory facilities and

procedures are in accordance with UTMB policies and 25 TAC 289

Conducts testing programs for containment systems

Provides advice on decontamination of facilities and equipment following

spills or prior to remodeling or modification of facilities

Responds to emergencies and investigates accidental exposures

Aids in completion of the “Application for Permit to Use Radioactive

Material” either as a new permit, an amendment to an existing permit, or a

renewal of an existing permit

Conducts a program of weekly and monthly wipe tests in the laboratory

areas where the radioactive materials are handled

Conducts a bioassay program for internal deposition of radionuclides

Issues personnel dosimetry devices

Receives and inspects packages containing radioactive materials

Maintains and updates an inventory of radioactive materials and radiation

producing machines

Processes outgoing shipments of radioactive materials in accordance with

present federal and state regulations

Calibrates portable radiation survey instruments

Surveys microwave ovens, x-ray cabinets and electron microscopes for

radiation leakage

Maintains records necessary to comply with 25 TAC 289

2-5

CHAPTER 2 : LICENSING RADIOACTIVE MATERIAL FOR USE Authorized Users

Introduction A license to possess and use radioactive materials has been issued to The University of

Texas Medical Branch by the Texas Department of State Health Services. The license is

called a “Specific License of Broad Scope” because it permits the flexibility that is

required for patient care and research in a dynamic medical center. At the same time, it

requires UTMB to maintain a well-managed and documented program to ensure that

radioactive materials are used safely.

Under the terms of this license, the Radiation Safety Committee is delegated the

responsibility for authorizing qualified individuals to use radioactive materials.

Use of The use of radioactive material at UTMB requires authorization from the UTMB

Radioactive Radiation Safety Committee. Only those individuals who, by virtue of their

Material training and experience have been designated as Authorized Users by the Radiation

Safety Committee or those individuals supervised by Authorized Users (referred to as

Technical Staff) may use radioactive materials at UTMB.

Definition of Those faculty members who, because of their training and experience, have been

Faculty designated by the Radiation Safety Committee as being qualified to use

Authorized Users radioactive material at UTMB are referred to as FACULTY AUTHORIZED USERS.

Authorized Users are directly responsible for all aspects of radiation safety associated

with his/her possession and use of radioactive material and the use by the Technical Staff

that they supervise.

The UTMB Radiation Safety Officer, by virtue of their appointment to the office by the

UTMB Administration, shall be designated as a Faculty Authorized User regardless of

their actual faculty status.

Non-Faculty In some circumstances, individuals who hold a doctorate level degree and are

Authorized Users qualified by virtue of training and experience to use radioactive material, but are not

members of the UTMB faculty (e.g. research fellows), may be designated “Non-Faculty

Authorized Users.” These individuals may use radioactive material only in conjunction

with a Faculty Authorized User who is willing to be accountable for the radioactive

material and to ensure that all UTMB policies are followed.

Permit In those situations where two or more Authorized Users are using the same

Administrators facilities for the use of radioactive materials, only one permit will be issued for the area.

The Committee will ask that one of the Faculty Authorized Users be designated as the

PERMIT ADMINISTRATOR. The Permit Administrator serves as a point of contact for

all correspondence regarding activities under the Permit.

The UTMB Radiation Safety Officer shall be designated as the Permit Administrator for

the permit issued to the Radiation Safety Office by the Radiation Safety Committee.

Technical Staff Those individuals who use radioactive materials under the supervision of an Authorized

User and have met the training requirements set forth by the UTMB Radiation Safety

Committee (see “TRAINING REQUIREMENTS FOR PERSONNEL WHO WORK

WITH RADIOACTIVE MATERIALS” in the UTMB Radiation Safety Manual.)

Time Limit for All faculty members who use radioactive material at UTMB are required to

Becoming an make application to the Radiation Safety Committee and become “Authorized Users” as

Authorized User soon as possible.

2-6

Licensing Radioactive Material for Use

Authorized Users (continued)

Using Radionuclides The Radiation Safety Committee recognizes that there are certain circumstances when a

Prior to Receiving faculty member may need to use radioactive material before the Committee has granted

Authorized User Authorized User status. When these circumstances arise, the faculty member

Status can use radionuclides on an existing Radioactive Materials Use Permit as “Technical

Staff,” providing:

The faculty member complies with the “Training Requirements for Personnel Who

Work with Radioactive Materials” section of the Radiation Safety Manual

The administrator of the permit is willing to take responsibility for the faculty

member’s use of the radioactive material

A faculty member, who is in the process of making application to become an Authorized

User and wishes to start using radioactive material in the interim, may do so for a

maximum of six months under this provision.

A faculty member whose application has been denied by the Committee due to

insufficient training and/or experience may use radioactive materials under this provision

with the condition that the training and experience requirements be completed within six

months of the Committee’s decision or by the end of the next training course presented

by Radiation Safety that is designed to meet the training requirement.

If a faculty member fails to meet the time constraints set forth in this policy, the Permit

Administrator of the permit under which the faculty member has been using radioactive

materials will be informed by the Radiation Safety Committee to disallow the faculty

member’s continued use of radioactive material.

Responsibilities The Authorized User is directly responsible for all aspects of radiation safety associated

with his possession and use of radioactive materials. This responsibility includes:

Complying with 25 TAC 289

Complying with conditions of the UTMB Radioactive Materials License

Complying with the conditions of their permit

Complying with the UTMB Radiation Safety Manual and Policies of the Radiation

Safety Committee

Providing instructions on safe and proper radiation practices to all persons working

within the facilities of the Authorized User

Maintaining adequate control of the radioactive material to ensure that areas beyond

the Authorized User’s control are not adversely affected by its use

Providing necessary equipment for safe work with radioactive material

Properly labeling all radiation sources and areas

Notifying Radiation Safety of any accident or abnormal incident involving or

suspected of involving radioactive material

Informing Radiation Safety of any changes in personnel and any significant changes

in lab design or procedures

2-7



Absence of IF THE AUTHORIZED USER IS TO BE ABSENT FROM THE CAMPUS

Authorized User FOR AN INTERVAL OF TIME

Greater Than Three Three Weeks or Less:

Weeks:

Either Suspend the use of the Ensure that the use of the

radioactive material and radioactive material will

ensure its safe storage for be under the supervision

the duration of the of a qualified technical

absence staff member (see

“Training Requirements”)

Or Submit to Radiation Comply with rules for

Safety the name of a absence greater than three

qualified individual who weeks

will assume

responsibility for the safe

use of the radioactive

material. (This individual

must be approved as an

Authorized User by the

Radiation Safety

Committee and must

submit a signed statement

of intent to Radiation Safety.)

Authorized Users leaving UTMB for a visiting professorship at another institution and

desiring to have radioactive materials transferred there should refer to “Transfer of

Radioactive Materials.”

2-8

Licensing Radioactive Material For Use


Resignation of

Authorized User

Upon completion of all of these procedures, the Radiation Safety Program will provide a

clearance signature on the “School of Medicine Faculty Release Form.”

STEP PROCEDURE

1 Notify Radiation Safety at least two weeks in advance of the

departure.

2 Complete and return to Radiation Safety all Radionuclide Data

Forms for any radioactive waste or materials.

3 Ensure that all equipment and facilities used for handling

radionuclides are free of radioactive contamination. NOTE: This

includes both equipment being taken to the new location and

equipment remaining at UTMB.

If you were the sole Authorized User on the permit for the facilities

being vacated, contact Radiation Safety to have final wipe tests

performed after all radioactive materials have been removed; and,

upon being notified by Radiation Safety that the facility is free of

radioactive contamination, remove all signs and tape indicating

radionuclide use.

4 Return to Radiation Safety all Radiation Safety Manuals issued to

the Authorized User.

5 Return any personnel dosimetry devices issued to the Authorized

User.

6 Ensure proper disposition of radioactive material:

IF… THEN

Radioactive materials are not to

be used again

Dispose of all of them by

following routine disposal

procedures and call for pickup

by the Environmental

Protection Management.

Radioactive materials are going to

another UTMB Authorized User

Transfer them. (See “Transfer

of Radionuclides)

Radioactive materials are going to

the User’s new location

Bring them to Radiation Safety

for future delivery (Call

Radiation Safety to arrange

this.)

7 Have a post operational bioassay performed by EHS if you are

participating in bioassay program.

2-9


Permit to Use Radioactive Material

Radioactive A Permit is issued by the UTMB Radiation Safety Committee to identify a location (e.g.

Material Use a laboratory or group of laboratories) where the use of radioactive materials is permitted,

Permit the Authorized User or Users responsible for the radioactive material specified on the

(a.k.a. Permit) Permit, the Permit Administrator, the radionuclides permitted to be used, the maximum

on hand limit per nuclide and other conditions or restrictions for radioactive material use.

Where more than one Authorized User is listed on the Permit, each is jointly and

severally responsible.

Application Any qualified faculty member who wishes to become an Authorized User of radioactive

Permits materials must submit an application to the Radiation Safety Committee describing:

Training and experience

Facilities

Radiation measuring equipment

Special safety devices

Procedures for control of radioactive material and radiation

Emergency procedures

Waste disposal methods

To obtain a permit to use radioactive materials:

STEP PROCEDURE

1 Complete an application.

2 Have your facility inspected by the Radiation Safety staff.

3 The completed application and staff recommendation will be presented to the

Radiation Safety Committee for approval at its next regularly scheduled

meeting.

4 If the application is approved by the RSC, a permit will be issued.

The permit will list the Authorized Users, the radionuclides, the physical form, the

amounts authorized for use, the type of use, and any special conditions imposed by the

Radiation Safety Committee. Permits are valid for three years.

Application for permits and a guide for completing them are available from the Radiation

Safety Program’s office. Call Radiation Safety to have a copy sent to you. The

Radiation Safety Staff will assist all applicants in completing the forms.

Amendment of Requests for relatively minor changes in a permit may be submitted in memo form to

Permits Radiation Safety. If the requests involve the addition of a new Authorized User, new

procedures, new radioactive materials, or a change in hazard level, supportive

information will be requested. An application to amend the permit must be submitted to

the Radiation Safety Committee for approval.

Revised 5/18/04

2-10


Permit To Use Radioactive Material (continued)

Renewal of Radioactive Material Use Permits expire on the last day of the month indicated on the

Permits permit. Prior to that date, Radiation Safety will send a completed renewal application for

the Permit Administrator to review, sign, and return. Applications for renewal of permits

must be submitted to Radiation Safety by the close of business on the last day of the

month prior to the expiration month.

If the permit is not to be renewed, the application form is to be returned with a memo

stating the Permit Administrator’s intent to let the permit expire.

Authorized Users who do not submit renewals or respond to a request for additional

information within the time limits specified will be asked to deliver their radioactive

material to Radiation Safety for disposal.

Compliance Radiation Safety Program staff conducts semi-annual surveys for permit compliance in

Inspection all areas authorized for storage and use of radioactive material.

Of Permits

The Permit Administrator is notified a week before the inspection. Results are mailed

within seven (7) working days. Actions that are required to bring a permit back into

compliance are to be completed within seven (7) working days of receipt of the

deficiency notification.

Inactive Status of If an Authorized User has not used radioactive materials or keep radioactive materials in

Authorized Users inventory for a period of 1 year or more, the Radiation Safety Program will recommend

to the Authorized User to request to place the permit in an “Inactive Status”.

Once the permit is “Inactive”, the Authorized User is no longer directly responsible for

all aspects of radiation safety associated with his possession and use of radioactive

materials as listed on page 2-6 of the Radiation Safety Manual.

If at some point, the Authorized User determines that he will need to use radioactive materials, he must contact

Radiation Safety and submit a written request to put the permit back to the “Active Status”. Permits are in effect for

3 years. If the request is made within the 3 years, the approval can be done administratively by the Radiation Safety

Program and reported to the Radiation Safety Committee. If it is made after the permit expires, a complete renewal

application must be submitted to the Radiation Safety Committee for approval.

2-11


Ordering Radioactive Material

Purchasing Purchases of radioactive material must be approved by Radiation Safety prior to the

ordering of the material. Purchase requests are prepared electronically in PeopleSoft.

Radiation Safety will approve order three times daily during normal working hours.

STEP PROCEDURE

1 An Authorized User or the Authorized User’s designee may submit orders

to Radiation Safety. This delegation must be made in writing to Radiation

Safety.

2 Prepare a purchase request in PeopleSoft indicating that the order is

radioactive and the permit number for the Authorized User.

3 The description of the material to be ordered must have:

Radionuclide

Chemical form

Activity in mCi

Vendor

4 The delivery code for the shipment must be L12198.

5 Following the approval, Radiation Safety will electronically forward the

requisition number to the purchasing department or back to the submitter

for ordering.

Free Samples If you expect to receive free samples or evaluation kits containing radioactive

Evaluation material, contact the Radiation Safety Office for further instructions.

Kits

2-12


Receipt and Documentation of Radioactive Material

Receiving When radioactive material is received in Radiation Safety, the staff will:

Check the package for damage and/or contamination and then remove the inner

container

Place a Radioactive Material Control (RMC) number on each container

Prepare a Radionuclide Data Form (original and duplicate) for each RMC number

assigned

Notify the Authorized User or his/her representative that the shipment has arrived

Transfer the receiving report and the Radionuclide Data Form with the radioactive

material to the Authorized User

The Authorized User or his representative will:

Pick up the radioactive material within 1 working day after notification by Radiation

Safety

Verify the type and quantity of radioactive material

Sign and date the Radionuclide Data Form

Obtain receiving report and Radionuclide Data Form

Return directly to the laboratory with the radioactive material

NOTE: Any radioactive material packages delivered directly to the lab are to be taken to

Radiation Safety for processing.

Radionuclide The Radionuclide Data Form accompanies any radioactive material that is processed

Data Form through Radiation Safety. The form should be completed according to these guidelines:

Radiation Safety staff will:

Enter requisition number in space provided

Enter the Radioactive Material Control number assigned to this particular shipment

in the space marked “RMC #” and on the containers used for storage of the material

Complete the “Receipt Survey” section

Enter the following information in the spaces provided in the “Identification”

section:

o Nuclide

o Chemical form

o Total mCi

o Vendor

The Authorized User or his representative will:

Sign and print one’s name and date the form on the space provided at the time of

receipt.

Complete those parts of the IDENTIFICATION section not used by Radiation

Safety (optional).

Complete the “USAGE” section as appropriate (see Disposal of Radioactive

Materials”).

2-13


Receipt And Documentation Of Radioactive Material (cont.)

Radionuclide

Data Form

(continued)

Complete the “DISPOSAL” section as appropriate (see “Disposal of Radioactive

Materials”).

Return the original (white) copy to Radiation Safety when all of the material has been

disposed

2-14


Transferring Radioactive Material

Introduction Radioactive material shall not be transferred to or from anyone else, either on campus or

off campus, without prior approval by Radiation Safety. This approval can be obtained

by telephone or e-mail.

Transfer The Authorized User from whom the material will be transferred will:

Within UTMB

Obtain authorization from Radiation Safety to transfer the material

Obtain a new RMC # for the material being transferred

Enter the date, activity and the new RMC # assigned by Radiation Safety on the

original Radionuclide Data Form in the DISPOSAL section (e.g. 2/10/02, 1.0 mCi

transfer to ABC-123)

Mark the container of the material being transferred with the new RMC #

Retain the forms issued to him/her for this material (the recipient will be issued a

new Radionuclide Data Form corresponding to the new RMC # for the amount

transferred to him/her)

The Authorized User receiving the material will:

Contact Radiation Safety within two working days if the new Radionuclide Data

Form is not received in the mail

Maintain a record of the use and disposal of the transferred material on the form

provided

Radiation Safety will:

Approve or deny the transfer request based on recipient’s permit and current

inventory

Assign a new RMC # for the recipient

Enter transfer on recipients computer inventory record

Issue a Radionuclide Data Form to the recipient for the transferred material

Transfers The recipient (UTMB Authorized User) will:

to UTMB From

Off Campus

Inform Radiation Safety of what they intend to have transferred

Remind the sender to contact their own Radiation Safety Officer for further

instructions

Provide Radiation Safety with the name and telephone number of the sender’s

Radiation Safety Officer


Contact shipper’s Radiation Safety Officer

Send copy of UTMB license to shipper’s Radiation Safety Officer

Instruct the sender to ship the material, UTMB Health & Safety Services,

Radiation Safety Program, 301University, Galveston, TX 77555-1111

2-15


Transferring Radioactive Material (continued)

Transfers The sender (UTMB Authorized User) will:

From UTMB to

Off-Campus

Notify Radiation Safety at least 5 days before the transfer date

Provide EHS with the name and telephone number of the recipient’s Radiation

Safety Officer

Make arrangements for actual transportation to the recipient’s Radiation Safety

Officer


Provide assistance in preparing the radioactive material for shipment (i.e. packaging,

labeling and documentation)

Contact the recipient’s Radiation Safety Officer to obtain a copy of that institution’s

license and other shipping instructions

2-16


Training Requirements for Personnel Who Work With Radioactive Materials

Introduction Appropriate training for any individuals who work with or in the vicinity of radioactive

material or radiation-producing machines is an essential part of any radiation safety

program. This includes all individuals who work with radioactive materials at UTMB

laboratories, regardless of employment classification (e.g., family member, post-doctoral

fellow, graduate student, research associate, laboratory technical assistant). The

University has an obligation to its employees and students to provide them with:

A safe working environment

An awareness of the hazards to which they may be exposed

Training in methods to protect themselves against those hazards

This training is required by the Texas Regulations for Control of Radiation (TRCR). It

must be a joint effort between Radiation Safety and the individuals authorized to use

radioactive material or radiation-producing machines.

All individuals who work with or in the vicinity of radioactive material must be

knowledgeable about the potential health hazards associated with the use of radioactive

materials, methods and procedures to minimize exposure to radiation, and their rights and

responsibilities under the TRCR and the UTMB Radiation Safety Program.

UTMB In order to ensure that adequate training is obtained, Environmental Health and Safety

Instruction conducts a training course titled “Basic Radiation Safety in the Laboratory.” All

individuals who work with radioactive material must successfully complete the course at

one of the two sessions immediately following commencement of their work with

radioactive material. Successful completion of this course is a requisite for working with

radioactive materials at this University. In some instances faculty members desiring to

work with radioactive materials in large quantities will be required to attend the

“Radiation Protection in Research” course.

Training Exemptions will be granted on an individual basis to:

Exemptions

Individuals who can document comparable training at another institution

Authorized Users who are exempt by virtue of the acceptance of their training and

experience by the Radiation Safety Committee for Authorized User status

Individuals who have had comparable training but have no documentation may be

granted an exemption upon passing a written exam encompassing the type of

material covered in the course

All other exemptions will be determined on an individual basis by Radiation Safety.

2-17


Training Requirements For Personnel Who Work With Radioactive Materials (continued)

Note Prior to successful completion of the course, or receiving an exemption, individuals may

work with radioactive material only under the direct supervision and in the physical

presence of another individual who has been appropriately trained.

This policy does not exempt Authorized Users from their responsibility to provide in-

service training for personnel working in their laboratory.

Annual Radiation All technical staff who will be working in the laboratory with unsealed radioactive

Safety Training materials shall receive radiation safety training before the individual begins working in

the laboratory and annually thereafter. Each individual should know:

The type and quantities of radioactive materials or radiation producing machines that

are used or stored in each laboratory area

The nature of the hazard associated with each type of radioactive material or

radiation-producing machine

Laboratory safety procedures designed to protect the worker against harmful effects

of radiation

The proper use of protective equipment (e.g., syringe shields, lead aprons, remote

handling devices, etc.)

Procedures to follow in case of a spill or other accidents involving radioactive

material or radiation producing machines

Training may be provided by an Authorized User approved by the UTMB Radiation

Safety Committee. Alternatively, a one-hour radiation safety refresher course is provided

by Radiation Safety to all individuals working with radioactive material in the laboratory.

The training is offered once a month. The refresher may be substituted for the annual in-

service training required of Authorized Users to provide to their technical staff.

Authorized users not handling radioactive material are exempt from the requirement to

complete annual radiation safety training.

Documentation All radiation safety-related training or education that employees receive, whether from

Radiation Safety or within the laboratory, shall be properly documented and maintained

on file for review. Radiation Safety will provide assistance in design of in-service

training programs upon request.

2-18


Personnel Monitoring

Criteria for The Texas Regulations for Control of Radiation requires that anyone who is likely to

Monitoring receive a dose in excess of 10 percent of the maximum permissible occupational dose in

any calendar year must wear a personnel monitoring device. The RSC has determined

that personnel monitoring devices shall be worn at UTMB by anyone in the following

categories:

Personnel working with x-ray producing devices with the exception of electron

microscopes, cabinet x-ray units and dental units (excludes medical students)

Personnel who work in the vicinity of radioactive material or radiation-producing

machines in the Department of Radiation Oncology

Personnel who work in the vicinity of radioactive material in the Division of Nuclear

Medicine

Personnel working with radionuclides that emit beta particles with energies greater

than 1 MeV or gamma rays when these radionuclides are used in quantities

exceeding 5 mCi of activity

Any persons required to enter a posted high radiation area

Requests for personnel monitoring devices for special uses will be evaluated on an

individual basis and the approval of Radiation Safety will be required.

Pregnant Females Radiation Safety provides monitoring for a “Declared Pregnant Female.” A Declared

Pregnant Female is a woman who has voluntarily declared her pregnancy in writing to the

Radiation Safety Officer. In addition, Radiation Safety provides a consultation service to

discuss working safely with radioactive materials and radiation producing machines

during a pregnancy.

Monitoring Currently, UTMB uses Optically Stimulated Luminescent dosimeters (OSL) for whole

Devices body, fetal and environmental monitoring and thermoluminescent dosimeters (TLDs) for

extremity monitoring. Only NVLAP accredited dosimetry services are used. These and

other monitoring devices are outlined below.

DEVICE ASSIGNED TO… EXCHANGE SCHEDULE

Ring Badge Individuals in higher-risk

areas for hand exposures

TLD ring dosimeters are

exchanged monthly or

quarterly depending on the

area’s level of risk

POCKET

DOSIMETERS

(pocket ion

chambers)

Personnel for a one-time

only use (obtained by

special request)

Are to be returned to

Radiation Safety upon

completion of use

OSL Individuals in both “high-

risk” and “low-risk” areas

OSL dosimeter packets are

exchanged monthly or

quarterly depending on the

area’s level of risk

Revised 4/25/16

2-19


Personnel Monitoring (continued)

Monitoring Reports All personnel dosimeters are processed commercially. The exposure reports are sent to

Radiation Safety and reviewed by the staff. Any exposures that exceed the maximum

permissible limits or are much higher than average are discussed with the individual and

the individual’s supervisor and appropriate steps are taken to prevent reoccurrence. Any

individual may receive a copy of his/her exposure history by requesting it in writing from

Radiation Safety.

Purpose The sole purpose of the personnel dosimeter is to record a radiation exposure. IT DOES

NOT PROTECT AGAINST RADIATION!

In-service Training The Radiation Safety Program provides a training program on the care and use of

personnel dosimeters. Attendance is required prior to the issuance of a dosimeter. The

training class is held twice weekly.

Proper Use and Personnel dosimeters must be properly used and cared for in order to give an accurate

Care of Badges reading. The following guidelines outline proper care:

Attach the badge near the collar of your upper garment (or at the waist) and wear at

all times while on duty. If you are wearing a lead apron, the badge should be worn at

the collar outside the apron.

Note: Individuals who wear an apron, thyroid shield and eye shield of at least 0.25

mm lead equivalent (0.5 mm for individuals working around fluoroscopic machines

lacking lead drapes) may request in writing a variance to be permitted to wear their

badge under their apron.

Leave the badge in a safe place when you are not on duty. Make sure it is away from

all sources of radiation. Personnel dosimeters should not be taken off campus.

Never wear a badge issued to another person or allow anyone else to wear yours.

Take care not to send the badge to the laundry with the uniform or lab coat.

Make sure to return the badge at the proper time to exchange for a new one. This is

your responsibility.

Do not puncture or remove the dosimeter from the holder.

2-20


Personnel Monitoring (continued)

Care of Badges

(continued)

If you lose or damage your dosimeter, a replacement must be obtained from Radiation

Safety immediately. A “Lost or Damaged Personnel Dosimeter” report must also be

obtained from Radiation Safety. Upon completion of this form, an exposure will be

assessed for the time period of the lost dosimeter and added to your exposure history.

Report any other incident relative to the wearing of the badge (such as possible

accidental exposure when the badge is not worn) to Radiation Safety.

Do not wear your badge during any medical procedure that involves radiation or

radioactive material in which you are the patient.

Return of Return your personnel dosimeters to Radiation Safety by the 7th

working day of the new

Personnel wear period. If you do not, you will receive a “Lost and Damaged Personnel Dosimeter

Dosimeter Report” form and be instructed to return either the completed form or the dosimeter by

the 21st working day of the new wear period.

Consequences of

Failure to

Return Dosimeter

Exemptions Exemptions regarding the deadline for returning the dosimeter or form will be granted on

an individual basis for individuals on vacation, sick leave, etc.

Individuals who work with

radionuclides:

If either the dosimeter or the form is not

returned by the 21st working day, Radiation

Safety will not approve purchase or receipt of

radionuclides for the Radioactive Materials

Use Permit under which you work until the

dosimeter or the form is returned.

Individuals who work with

radiation-producing machines:

If either the dosimeter or the form is not

returned by the 21st working day, Radiation

Safety will notify your Department Chairman

that you are not permitted to operate radiation-

producing equipment until the dosimeter or the

form is returned.

2-21

Licensing Radioactive Material For Use

Record Keeping

Required Records The following duplicate records maintained by the Permit Administrator shall be

kept until the next audit by Radiation Safety:

Radionuclide Data Forms (2 years from date of final disposal of material)

Radioactive Waste Disposal Forms (2 years from date of final disposal of

material)

Radiation Safety Surveys

Survey Meter Calibration

Wipe test (see below)

Original records of activities performed by the Permit Administrator or his staff

shall be maintained as stated below:

In-service training of laboratory personnel (indefinitely)

Calibration of Dose Calibrators (5 years)

Wipe test records of surveys not performed by Radiation Safety

(indefinitely)

These records shall be transferred to Radiation Safety upon termination of the

permit.

3-22

CHAPTER 3 : GENERAL RULES AND GUIDELINES FOR HANDLING RAM

Routine Laboratory Procedures

Introduction A set of written procedures is required for each laboratory or area where radioactive

materials are used. These procedures must describe specific rules applicable to that area.

The location of these procedures shall be known and accessible to all individuals who

work in the area.

The following general rules apply to all personnel who use radioactive material and

should be incorporated into each laboratory’s written procedures.

Signs and Notices Areas where radioactive materials are used must be posted in accordance with the Texas

Regulations for Control of Radiation. The following signs will be conspicuously posted

and replaced if defaced.

“Caution Radioactive Materials” signs on all doors to laboratories and storage areas

“Notice to Employees” BRC Form 203-1

Regulation Card (indicating where copies of 25 TAC 289 and other documents are

located)

“Emergency Procedures”

Personnel For your health and safety, it is imperative that you follow the rules concerning

Protection radioactive materials. If you have any questions about the following procedures, ask

your supervisor or call Radiation Safety.

When required by Radiation Safety, wear personnel dosimeters and finger dosimeters.

Wear lab coats or other protective clothing as an outer garment at all times while in

the laboratory.

Maintain good hygiene by:

o Keeping fingernails short and clean

o Thoroughly washing hands and arms before handling any object that goes

into the mouth, nose or eyes

o Not handling radioactive material if there is a break in the skin below the

wrist or by wearing 2 pairs of gloves when handling the material

Keep the laboratory neat and clean.

Label permanent areas used for radioactive work (including sinks and equipment)

with “Caution Radioactive Material” tape.

The following activities are prohibited anywhere in a laboratory or in any other

location in which radioactive materials are stored or used: eating, drinking, smoking,

chewing gum, etc., or otherwise placing items in the mouth, applying cosmetics,

storing or preparing food or drink for human consumption, storing items or utensils

used for human food or drink preparations or consumption.

NOTE: A specific exception to this rule will be allowed upon written request as it relates

solely to the preparation or consumption of food or drink by research subjects or

patients involved in approved human research protocol, or human diagnostic or

therapeutic medical procedures involving the consumption of radioactive material.

3-23

General Rules and Guidelines for Handling Radioactive Materials

Routine Laboratory Procedures (continued)

Storage of Keep radioactive material in a leak-proof container.

Radioactive

Materials Label all radioactive material containers with an appropriate label stating:

- The radionuclide

- The amount of activity

- The date

Label refrigerators or freezers with a “Caution – Radioactive Material” sign and do not

store food or beverages for human consumption in them.

Secure and lock storage areas when materials are left unattended.

Handling of Wear disposable gloves when handling unsealed radioactive materials. In some

Radioactive uses, remote handling devices may be required by Radiation Safety.

Materials

Never pipette radioactive materials (or any other materials while working with

radioactive material) by mouth.

Use absorbent padding or other material in areas where radioactive material is handled.

Perform iodinations and use volatile radioactive material only in a fume hood specifically

approved for such use by Radiation Safety. If you do not have an approved hood, contact

Radiation Safety to arrange for the use of a suitable hood.

Surveys Laboratory personnel will routinely survey the laboratory for contamination. See section

entitled “Area Contamination Surveys” on page 3-40 for guidelines.

Bioassays Laboratory personnel must comply with the policies of Radiation Safety and RSC for

bioassays or other personnel surveillance operations. (See “Bioassay Program,”

page 4-43)

Radioactive Waste Place radioactive waste only in specially marked receptacles. Disposal of limited

Materials quantities of radioactive liquid waste into specifically designated sinks may be permitted

by Radiation Safety.

For further information on disposal, refer to “Disposal of Radioactive Material” on page

3-30.

3-24


Routine Laboratory Procedures (continued)

Incident Notify Radiation Safety immediately by telephone of all incidents involving:

Reporting

Radioactive contamination (external or internal) of personnel

Radioactive contamination of a large area or that you are unable to manage with the

resources readily available to you

Release of radioactive material to the environment

Loss of radioactive material (including radioactive waste)

Known or suspected excess radiation exposure to general public or lab personnel

Loss or damage to personnel dosimeters

Notify Radiation Safety within one week of incidents involving radioactive material or

other sources of radiation that are less severe than those listed above.

Equipment Repair Notify Radiation Safety prior to the repair or removal of any equipment that may be

contaminated with radioactive material or that contains a source of radiation.

3-25


Emergency Procedures

Introduction During the course of routine operations, radioactive material may be spilled, causing

contamination of lab areas, personnel, or equipment. Correct action taken during such an

emergency can prevent spread of the contamination.

Written A set of written procedures describing the specific steps to be taken in the event

Instruction of a spill of radioactive material shall be posted in a prominent location in each

laboratory or area where radioactive materials are stored or used. These procedures shall

be established on an individual basis applicable to the particular area, according to the

type and quantity of material used. They should include:

Specific location of radioactive waste containers

Specific type and location of survey meters

Emergency telephone numbers

Minor MINOR SPILLS can be generally considered as those that do contaminate small areas of

Spills laboratory surfaces or equipment, but do not result in:

External or internal contamination of personnel

Excessive external radiation exposure to personnel

Serious delay in work procedures

The following steps should be taken in case of minor spills:

STEP PROCEDURE

1 Notify all persons in the area that a spill has occurred.

2 Cover the spill with absorbent paper.

3 Using disposable gloves carefully fold the absorbent paper and pad;

insert it in a plastic bag and dispose of it in a radioactive waste

container. In another container, dispose of all other contaminated

material such as disposable gloves.

4 With a window GM survey meter, check the area around the spill, and

your hands and clothing for contamination. Perform follow-up wipe

tests and decontaminate as necessary.

5 Report the incident to Radiation Safety.

3-26


Emergency Procedures (continued)

Major Spills MAJOR SPILLS may result in any or all of the following:

Contamination of large surface areas

Internal or external contamination of personnel

Excessive external radiation exposure to personnel

Serious delay in work procedure

The following steps should be taken in case of major spills:

STEP PROCEDURE

1 Notify all persons not involved in the spill to vacate the room.

2 Cover the spill with absorbent pads, but do not attempt to clean it up.

Confine the movement of all potentially contaminated personnel to

prevent the further spread of contamination. Prevent personnel from

entering the contaminated area.

3 If possible, return stock vials to their shields, but only if it can be

done without further contamination or without significantly

increasing your radiation exposure.

4 Notify Radiation Safety and the laboratory supervisor.

5 Remove and store contaminated clothing for further evaluation by

Radiation Safety. If the spill is on the skin, flush thoroughly and

wash with mild soap and lukewarm water.

3-27


Emergency Weather Procedures

Introduction High water flooding and hurricane force winds can cause damage to laboratories that

could result in spread of radioactive contamination. This emergency procedure is

designed to minimize the potential for the spread of contamination. The specific

response will depend upon the existing and expected weather conditions.

Pre-Planning Emergency weather preparedness begins long before the threat of inclement weather

exists. The following measures will make it easier to prepare the lab should the

emergency weather plan actually be implemented.

Keep radioactive materials in your inventory at a minimum. Get rid of old materials

in storage.

Do not allow radioactive waste to accumulate in your lab.

If your lab has outside windows, identify secure areas within the lab for storage, such

as inside refrigerators or built-in cabinets with doors that stay shut.

Keep all emergency telephone numbers posted in the lab updated.

Keep plastic or other waterproof containers at hand. You may need them to store

your materials.

Keep a supply of “Radioactive” tape or labels on hand.

3-28


Emergency Weather Procedures (continued)

Emergency In the event of a weather emergency, you should take the following minimum

actions:

AREA

Areas susceptible

to flooding

(basement and

ground floor labs)

Areas susceptible

to damage from

high winds (labs

with windows)

INSTRUCTIONS

Weather permitting, Radiation Safety staff will instruct

you to take radioactive waste to the designated waste

facility for disposal. NOTE: Due to limited space, only

waste from flood prone areas will be accepted.

Weather not permitting, or if Radiation Safety’s waste

facility has been secured, move your radioactive waste

to designated areas above the first floor for temporary

storage.

Move radioactive materials (other than waste) to

designated areas above the first floor for temporary

storage (call Radiation Safety for the location at the

designated temporary storage area for your lab).

If possible, place radioactive materials, in waterproof or

plastic containers.

Securely close all radioactive material containers so that

they will not lose their contents should they be upset

Clearly mark all radioactive material containers as

“Radioactive” and note their contents (radionuclide,

activity, and RMC #).

Move radioactive materials and wastes to secure

locations, such as:

- Refrigerators

- Storage cabinets with doors

-Storage closets

- Rooms not susceptible to damage from high winds or

- Flying debris

Tape shut all storage cabinets containing radioactive

material that do not have secure latches.

Close all radioactive waste containers and get them off

the floor.

Check the lab area to be sure no radioactive material has

been left out on an open lab bench.

3-29


Emergency Weather Procedures (continued)

Emergency

Actions

(continued)

Areas susceptible to

damage from high

winds (labs with

windows)

Label all storage locations not already so marked

with “Caution Radioactive Material” labels (labels

on temporary storage locations must be removed

after the radioactive materials are returned to their

normal location).

Lock all areas where radioactive materials are

stored (e.g. laboratory doors, refrigerators in

corridors, etc.).

3-30


Disposal of Radioactive Materials

Introduction Each authorized user is responsible for ensuring that the material under his permit is

disposed of properly. No radioactive materials shall be disposed of except in the

following ways:

Release into the sanitary sewage system

Segregation and disposal

Administration to According to the 25 TAC 289 once radioactive

a Patient material is administered to a patient, no further account of its disposal is required.

However, if excreta are collected from a patient receiving a large therapeutic dose of

radioactive material, the excreta should be stored for decay prior to actual disposal.

Release into the To release radioactive material into the sanitary sewage system, the following criteria

Sanitary Sewage must be observed. (Information about the maximum activity of a radionuclide that may

System be disposed of per day may be obtained from Radiation Safety):

UTMB policy #8.1.6 “Disposal of Hazardous waste” states regulations and

conditions of the UTMB license be followed

Only material that is soluble or dispersible in water and is not prohibited from

sewage disposal because of its chemical or biological nature will be disposed of in

this manner

The Radionuclide Data Form must reflect the activity (in millicuries) that is disposed

Disposal may be made only via sinks specifically approved for that purpose by

Radiation Safety

Material being disposed must be flushed with copious amounts of water to ensure

proper dilution

Liquid scintillation cocktail including “environmentally safe” cocktails must not be

disposed of via the sanitary sewage system

3-31


Disposal Of Radioactive Materials (continued)

Segregation All radioactive material that is not administered to a patient or released into the sanitary

and Disposal sewage system must be segregated in the following categories (do not mix waste

categories within a waste container):

CATEGORY DESCRIPTION

Dry Solid

Waste, half-

life greater

than 300 days:

Non-liquid items such as gloves, pipets, pipet tips, test tubes,

petri dishes, paper towels, diapers, chux, containers of needles,

etc. (NOTE: All wastes must be non-pathogenic. See

“Radioactive Pathogenic Wastes). NO LS VIALS

CONTAINING LIQUID MAY BE PLACED IN DRY SOLID

WASTE BOXES.

“Dry Solid

Waste, half-

life less than

300 days:

Non-liquid items such as gloves, pipets, pipet tips, test tubes,

petri dishes, paper towels, diapers, chux, containers of needles,

etc. (NOTE: All wastes must be non-pathogenic. See

“Radioactive Pathogenic Wastes”). NO LS VIALS

CONTAINING LIQUID MAY BE PLACED IN DRY SOLID

WASTE BOXES. ALL RADIOACTIVE LABELS MUST BE

OBLITERATED PRIOR TO DISPOSAL.

Sharps: Place in an approved puncture resistant container (sharps

container), solidify and then place in the appropriate dry solid

waste box. This includes needles, Pasteur pipets, broken glass,

etc.

L.S. Vials: Use only the small size (1 cubic foot) boxes supplied by

Environmental Protection Management. NO GLOVES,

PIPETS, STOCK VIALS, BACTEC VIALS, PAPER

TOWELS, AQUEOUS NON-SCINTILLATION VIALS,

ETC. MAY BE PLACED IN THE LS VIAL BOXES.

Segregate vials in the appropriate box as follows:

a) H-3, C-14

b) P-32, P-33 only

c) S-35 only

Call Radiation Safety, ext. 22279, if your radionuclide is not

listed in any category.

Stock Vials: Collect stock vials separately from other waste. Short-lived

materials must be separated from long-lived ones.

Bulk Liquid: Liquids collected because they are not permitted to be disposed of

via sanitary sewage system. (i.e., toxic or not miscible with

water). Collect in quantities of 1 gallon or less in a tightly sealed

container. Each container must have a Radioactive Waste

Disposal Form.

Waste from

RIA kits:

If the kits contain C-14, H-3, or I-125, call Radiation Safety for

disposal instructions. If the kit contains other nuclides, the waste

may be disposed of as Dry, Solid waste.

Animals/

Bedding:

Radioactive animals and contaminated bedding must be collected

separately from other radioactive wastes. Animals must be triple

bagged, labeled with tape marked radioactive and stored in a

freezer designated for radioactive material use. For animals

treated with pathogenic agents, call Radiation Safety for

instructions.

3-32



Segregation Radioactive waste containers for proper segregation of waste (with the exception of bulk

And Disposal liquids and stock vials) will be provided to each lab by Environmental Protection

(continued) Management. Information on where to obtain shields for waste containers is provided by

Radiation Safety.

Documentation Proper documentation of the use and disposal of radioactive material is the responsibility

Of Use and Disposal of the Authorized Users. Radiation Safety will supply forms for this purpose.

Radionuclide The Radionuclide Data Form is used to track each shipment of radioactive material from

Data Form receipt by Radiation Safety through disposal by the Authorized User and his staff (see

“RECEIPT AND DOCUMENTATION OF RADIOACTIVE MATERIAL” section).

At the time of use – an entry should be made in the “USAGE” section indicating:

who used it, amount of material used, the type of experiment and date used.

At the time of disposal – an entry shall be made in the “DISPOSAL” section

indicating: date disposed, method of disposal and the activity in mCi

When all of the radioactive material has been disposed, total the activity for each disposal

method in the space provided at the bottom of the “DISPOSAL” section. All of the

activity shown in the “IDENTIFICATION” section must be accounted for in the

“DISPOSAL” section.

After completion, the original (white) copy is returned to Radiation Safety. The duplicate

copy (generally pink or yellow) is kept by the Permit Administrator.

Example of See sample on page 3-34.

Properly Completed

“Radionuclide Data

Form”

3-33



How to Complete The “Radioactive Waste Disposal Form” is used to identify the contents of each waste

A “Radioactive container and must accompany each radioactive waste container that has been filled and

Waste Disposal is ready for removal from the laboratory. It must be completed and attached to each

Form waste container. (Exceptions: as many as seven small bulk liquid containers, less than

one gallon each, containing the same chemical constituents, may be listed on one form.)

Below are instructions for filling out each section properly

SECTION WHAT INFORMATION IS NEEDED

Physical/

Chemical

Description

Must be an actual description of the contents (e.g., plastic LS

vials, test tubes, gloves, diapers, etc.) The words “Trash” or

“Garbage” will not suffice. For bulk liquids list the chemical

names, concentrations and total volume in each container. For

animals list total weight in grams.

RMC # The Radioactive Material Control number that corresponds to the

source of activity must be listed for each entry.

Activity Use millicurie (mCi) units only

Radionuclide Chemical element and mass number (e.g., I-125) that corresponds

to the RMC #).

Type Properly identify the material category.

Certification An Authorized User must sign the form or someone designated in

writing to Radiation Safety by an Authorized User. Because of

legal requirements, there can be no exceptions.

Each entry on the waste disposal form MUST be completed. If one form is not enough to

list container contents, attach additional forms numbered consecutively. Each form must

be signed. If you have any questions, call Radiation Safety.

Example of properly completed “Radioactive Waste Disposal Form” see sample on page

3-34.

3-34



Example of Properly Completed “Radionuclide Data Form”

3-35



Example of a Properly Completed Radioactive Waste Disposal Form

3-36



Pick-Up When requesting a pick-up of radioactive material, the following rules should be

Procedures observed:

Environmental Protection Management picks up radioactive waste only on Tuesday

or Thursday. Be sure to contact EPM at least 24 hours in advance of the desired

pick-up day.

Log on to http://www.utmb.edu/bof/epm/RADInput.asp to request a radioactive

waste pick-up and provide the appropriate information (type of waste, number of

boxes, number of stock vials, type of animal, etc.)

Refusal of Waste Improperly documented or segregated waste will not be accepted by Environmental

Protection Management. If evidence of improper segregation or documentation is

discovered by Environmental Protection Management after waste has been removed from

the lab, the waste container and its contents will be returned to the lab for proper

segregation and documentation as necessary.

If waste has been refused for pick-up, the lab will be issued a “Notice of Attempted Pick-

up (see sample page 3-16) stating the reason for the refusal. Radiation Safety will assist

the lab with resolving the problem.

After the deficiency is corrected, the lab must call in to request another waste pick-up.

Special Rules Some specific guidelines for the handling and disposal of stock vials are listed below:

for Stock Vials

Stock vials are not to be disposed of via any radioactive waste container in the lab.

Environmental Protection Management will pick them up as separate items.

As many as eight stock vials may be listed on one Radioactive Waste Disposal

Form.

Special Rules Some specific guidelines for the handling and disposal of bulk liquids are listed below:

for Bulk Liquids

Bulk liquid waste must be collected in closable containers.

Container size should not exceed 1 gal (4 liters) for ease of handling.

The Radioactive Waste Disposal Form for each container shall list the contents by

chemical name, concentration and total volume, in the “Physical/Chemical

Description” section.

Container type (glass or plastics) should be compatible with chemicals disposed.

http://www.utmb.edu/bof/epm/RADInput.asp

3-37


Example of “Notice of Attempted Pick-up Form”

3-38



Disposal of Environmental Protection Management and Radiation Safety will pick up and dispose of

Radioactive radioactive animals. For disposal of other animals, call the Animal Resources Center.

Animals Some specific guidelines for radioactive animal disposal are listed below:

Animals shall be double-bagged in plastic bags (large animals shall be triple-bagged

and labeled with tape marked “RADIOACTIVE.”) Care must be taken to keep the

outside of the bag free from blood.

Prior to pick-up, store your animal carcasses and beddings in freezers designated for

radioactive use.

A properly completed Radioactive Waste Disposal Form (see section titled

“DISPOSAL OF RADIOACTIVE MATERIALS”) must accompany each bag.

Ensure that the form does not get contaminated with blood making it unreadable.

Animal excreta can either be disposed of through sewage as liquid radioactive waste

or mixed with the bedding and carcasses.

3-39


Use of Radioactive Materials in Animals

Introduction All use of radioactive material in animals must be specifically authorized by the

Radiation Safety Committee and the Animal Care and Use Committee.

Application for Individuals desiring to use radioactive materials in animals must, as part of their

Authorization to application for or amendment to a Radioactive Material Use Permit, describe the

Use Radioactive precautions and procedures to be used in handling and care of animals. Radiation Safety

Materials in will assist in writing these procedures. The information provided should address the

Animals following areas:

TOPIC INFORMATION NEEDED

Facilities for

injecting

radioactive

material into

animals

Describe procedures for restraining animals during injection and

the method for containing any radioactive material lost during

injection. For small animals, a tray lined with absorbent

material should be used. For large animals, some other method

may be required.

Labeling of

cages for the

injected animals

The label should include the type of radionuclide, quantity of

material injected per animal, date of injection, and the

Authorized User. (Cage labeling is especially important for

animals that are not sacrificed within a short period of time after

injection.)

Type of cage

used to contain

the animal

What type of cage will be used? If contamination is likely to be

a problem, a metabolic-type cage should be considered.

Monitoring and

decontamination

of cages

If animal cages are to be returned to Animal Resources Center

after use, describe procedures for decontaminating and

monitoring cages. Records of radiation levels and wipe tests

should be maintained.

Segregation of

the injected

animals from

other animals

Are long-term retention studies being conducted? If so, this

information is especially important.

Disposal of

animal excreta

Describe the methods to be used for disposal, e.g., through

sewage as liquid waste, or mixed with saw dust and wood

shavings and incinerated.

Ventilation Will the radioactive material to be administered be volatile?

Will it be excreted in respiratory air, or in a volatile form? If so,

special consideration must be given to ventilation. If it is

excreted in urine or feces, dust-free bedding should be used.

Instructions of

animal handlers

Describe the indoctrination of animal handlers that you will

provide. This should include dose levels, time limitation and

special handling requirements that you specify for your animals

and/or their excreta. In general, once injected with radioactive

material, animals should be housed in the laboratory. They are

not to be returned to the central animal care facilities without

specific approval of Radiation Safety and the Director of the

Animal Resources Center.

3-40


Guidelines for Area Contamination Surveys

Frequency of The required frequency for area surveys depends on the procedures performed and the

Surveys quantities of radionuclide used.

DAILY: Perform a survey of all areas where radioactive material for human

used is eluted, prepared, or injected. Perform surveys either before or

after operations, with a low-range, thin-window GM survey meter and

decontaminate if necessary.

WEEKLY: Perform wipe test surveys in laboratory areas where radioactive

materials are used daily or monthly.

MONTHLY: Perform wipe test surveys in laboratory areas were radioactive

materials are used in amounts less than 1 millicurie per experiment.

Maintain a record of all survey results as specified by the UTMB Radioactive Material

License. If desired, Radiation Safety will perform these required (weekly and monthly

only) wipe tests and maintain the appropriate records free of charge.

Using Survey The purpose of survey instruments is to reveal the presence of unsuspected loose

Instruments or fixed contamination and also to measure general area radiation levels to ensure that

they are not excessive. The use of a survey instrument for contamination survey does not

eliminate the requirement to perform scheduled wipe tests, but should be used to ensure

that contamination is not present in other areas of the laboratory, on personnel or

equipment.

A survey instrument should be available in any laboratory where radioactive material is

sufficient to produce significant radiation levels or contamination. As a general rule, a

survey instrument should be available if the quantities used exceed 1 mCi (except for

weak beta emitters such as H-3). Usually, survey instruments are purchased by the

principal investigator or individual authorized to use the radioactive material (they are not

provided by Radiation Safety).

Instrumentation Radiation Safety calibrates all survey instruments on at least an annual basis.

Calibration

Instrument Instrument selection should be based on the following criteria:

Selection

Survey instruments should normally be of the Geiger-Mueller (GM) type. If levels

exceed 10 mR/hr, then both an ionization chamber and GM detector should be

available.

Survey instruments should be lightweight, readily portable, and easily handled by

laboratory personnel.

The instrument should be simple to operate and the scale should read in both mR/hr

and counts per minute.

3-41


Guidelines For Area Contamination Surveys (continued)

Instrument

Selection

(continued)

The Geiger-Mueller detector should be a thin-window type to permit detection of

surface contamination by such low-energy emitters as Carbon-14 and Sulfur-35.

Instruments should be easy to calibrate.

Even though a laboratory may be working with only one radionuclide, a nuclide-

specific instrument should not be obtained unless the principal investigator knows

with certainty that no other nuclides will be added at later date. This consideration is

important in order to reduce subsequent cost factors for purchase of new equipment.

Instruments should be accurate within 10% on a full scale.

Radiation Safety should be notified when a laboratory purchases a new meter.

Radiation Safety can also provide recommendations for purchasing the proper

instrument.

Instructions for Surveys for contamination using a GM Survey meter should be conducted in the

Conducting following manner. (This procedure is applicable for thin-window detectors only

Contamination and only for gross amounts of contamination. It is not a substitute for wipe

Surveys Using GM tests).

Survey Meters

STEP PROCEDURE

1 Turn survey instrument on and check for proper operation. A battery check

is important.

2 Select several radioactive material work areas in the laboratory and several

areas where work with radioactive materials does not occur, but where

contamination might be spread.

3 Low-background Radiation Areas: Move the probe very slowly over the

surfaces to be checked. The probe should be perpendicular to and within

¼ inch of the surface.

High-background Radiation Areas: Take wipe tests of selected areas and

count by holding wipes within ¼ inch of the thin-window with the detector

located in a low-background area.

Note: Low-background Radiation Area means that, in general, the average

meter reading due to ambient background radiation does not exceed 200

CPM (approx. 0.05 mR/hr).

4 If the instrument meter reading is 100 CPM above background,

contamination is present.

5 Decontaminate and perform follow-up wipe tests.

6 After performing wipe tests, go over these areas with the survey instrument.

3-42


Guide-Lines For Area Contamination Surveys (continued)

Important Significant meter readings after decontamination and negative wipe tests may indicate

fixed contamination.

CONTACT RADIATION SAFETY IMMEDIATELY FOR ASSISTANCE!

Instruction for Area wipe tests should be conducted in the following manner:

Area Wipe Tests

STEP PROCEDURE

1 Put on disposable gloves if you are handling potentially contaminated items

or if you are directly handling the wipe medium. (Gloves are not required

if you use hemostats to hold the cotton used for wiping.) Note: If you

suspect contamination on the floor, wear shoe covers also.

2 Using filter paper, cotton or another suitable wipe medium, wipe an area of

100 cm2 of a large surface. (Wipe an entire surface if only a small item is

being tested).

3 Code the wipes or the counting vials and survey map information of the

area wiped.

4 Count the wipes in an appropriate counter for one minute each. (If the

same wipe is to be counted for gamma radiation in a sodium iodide counter

and beta radiation in a liquid scintillation counter, be sure to do the gamma

count before adding the liquid scintillation cocktail.

5 Convert counts per minute (CPM) to Ci or dpm.

6 Record this information and retain it for inspection purposes for two years.

Contamination If wipes indicate 100 pCi/100 cm2 or greater above background, the area wiped

Action Levels shall be considered contaminated. Decontaminate, re-wipe and determine new

contamination level. Record this data. Repeat this cycle until wipes indicate less than

100 pCi/cm2.

4-43

CHAPTER 4 : BIOASSAY PROGRAM

Guidelines for Individuals Working With I-125 and I-131

Introduction Radioiodinated solutions and compounds undergo decomposition that may result in the

volatilization of radioiodine. If this occurs, individuals working with these materials

have a potential for accidental uptake of radioactive iodine. Once inside the body, the

iodine concentrates in the thyroid and irradiates that organ. This bioassay program will

enable the Radiation Safety staff to determine the radioiodine burden in an individual’s

thyroid and calculate the radiation dose to the thyroid. In addition, the program will

monitor the effectiveness of radionuclide handling procedures.

This program is designed to meet Texas Department of State Health Services

requirements for bioassay of I-125 and I-131.

Program All individuals who handle unsealed I-125 and I-131 in quantities exceeding

Participation those listed in the following table and those who work nearby (within a few meters) shall

participate in this bioassay program. The quantities in the table apply to that amount

handled either in a single usage or the total amount handled over a period of three

consecutive months.

Individual Authorized Users are responsible for supplying Radiation Safety with the

names of those who meet the criteria for inclusion in the bioassay program. Authorized

Users shall not permit anyone who meets any of the criteria to work with or near

radioiodine until they have undergone a baseline bioassay.

Levels Requiring ACTIVITY LEVELS ABOVE WHICH BIOASSAY FOR I-125 OR I-131

Bioassay IS REQUIRED:

TYPE OF OPERATION ACTIVITY HANDLED IN UNSEALED FORM

Volatile/Dispersible Bound to Non-Volatile Agent

Processes in open room or

bench, with possible escape of

iodine from process vessels

0.1 mCi

1 mCi

Processes with possible escape

of iodine carried out within a

fume hood of adequate design,

face velocity and performance

reliability

1 mCi

10 mCi

Processes carried out with

glove boxes, ordinarily closed,

but with possible release of

iodine with occasional

exposure to contaminated

box/box leakage

10 mCi

100 mCi

4-44

Bioassay Program

Guidelines For Individuals Working With I-125 And I-131 (continued)

Frequency

TYPE OF BIOASSAY NECESSARY WHEN… HOW OFTEN?

Baseline or Preoperational

Bioassay

Beginning work with I-125 or I-131 in

quantities necessitating participation in

the bioassay program

Once, prior to beginning work with

radioiodine

Routine Working with quantities of radioiodine

that necessitate participation in the

bioassay program, to be done within 72

(but not less than 6 hours) of working

with radioiodine

Biweekly (After three months of

routine biweekly bioassays, the

frequency may be reduced to

quarterly, upon approval of the

Radiation Safety Officer). For those

who work under conditions, which

present a high potential for uptake,

routine bioassay may be done more

often

Diagnostic An individual has exceeded action level As determined by the Radiation

Safety Officer

Emergency There is a possibility that an individual

has received an uptake in excess of 0.5

Ci of I-125 or 0.14 Ci of I-131, to be

done as soon as possible following the

incident

Each time it is suspected that an

individual has received an excessive

uptake

Post-operational Work with radionuclides is terminated, to

be done within three days (but not less

than 6 hours) after discontinuing

operations with radionuclides

Once, before the individual leaves

the University

4-45

Bioassay Program


Action Levels The thyroid burden at the time of measurement should not exceed:

0.12 Ci of I-125

0.04 Ci of I-131

A corresponding appropriate amount of a mixture of these two isotopes

Corresponding Whenever the above Action Levels are exceeded the following actions shall be

Actions taken:

Radiation Safety shall conduct an investigation of radioiodine handling procedures,

and, if it is determined that continuation of current operations would cause further

uptake, use of radioiodine shall be discontinued until further corrective actions can

be implemented.

The affected individual will be restricted from further work with radioiodine until the

thyroid burden is less than the Action Levels.

Diagnostic bioassays will be performed on the affected individual at biweekly

intervals until the thyroid burden is less than the Action Levels.

Radiation Safety staff will calculate the committed thyroid dose, make exposure

record entries and notify the TDSHS as appropriate.

If the affected individual or others working in the same area are on a quarterly

bioassay schedule at the time Action Levels are exceeded, reinstate the biweekly

schedule until it can be demonstrated that further work with radioiodine will not

cause the Action Levels to be exceeded.

In addition to the above actions, whenever the thyroid burden exceeds 0.5 Ci I-125, 0.14

Ci I-131, or a corresponding appropriate amount of a mixture of these two isotopes:

Refer the case to appropriate medical consultation, and Radiation Safety office

Perform diagnostic bioassays at weekly intervals until the thyroid burden is less than

the values stated above

4-46

Bioassay Program


Bioassay The procedure for bioassay testing involves the following:

Testing

Procedure Based on information provided by the Authorized User, Radiation Safety shall contact

those individuals involved and schedule a baseline bioassay.

Individuals participating in the program shall notify Radiation Safety following their

initial contact with radioiodine to schedule the first routine bioassay (to be performed

within 6-72 hours). Upon completion of this first bioassay, a schedule shall be

established for further testing.

Any individual involved in a radiological incident who may have exceeded the limits

of 0.5 Ci I-125 or 0.14 Ci I-131 shall notify Radiation Safety immediately.

Any individual who is participating in this program shall notify Radiation Safety

prior to leaving this University.

Bioassays shall be performed by individuals designated by the Radiation Safety

Officer and shall be conducted in accordance with the detailed procedure contained

in the Radiation Safety Program Standard Operating Procedures Manual.

4-47

Bioassay Program

Guidelines for Individuals Working With H-3

Introduction Tritium does not present an external exposure hazard because the low energy beta

particle emitted cannot penetrate the outer dead layer of skin. The hazard to personnel is

through internal contamination. The critical organ for tritium uptake is the whole body

water. Three to four hours after intake, tritiated water is uniformly distributed in all body

water.

Program All individuals who handle unsealed H-3 in quantities exceeding 80 mCi shall

Participation participate in this bioassay program.

Bioassay The procedure for bioassay testing involves the following:

Testing

Procedure

At least one day prior to working with quantities of H-3 in excess of 80 mCi, contact

Radiation Safety to arrange for a baseline bioassay.

On the day of the experiment, go to Radiation Safety to pick up a urine specimen cup

and instructions on urine collection.

On the first working day after the experiment, bring the specimen to Radiation

Safety. If a H-3 uptake is detected in the sample, a schedule shall be established for

further testing. The Radiation Safety Officer shall determine if any other actions are

necessary.

If you have participated in this bioassay program and plan to leave UTMB or no

longer work with H-3, notify Radiation Safety for a post-operational bioassay.

5-48

CHAPTER 5 : MANAGEMENT OF PATIENTS UNDERGOING BRACHYTHERAPY

Introduction

Overview The University of Texas Medical Branch utilizes ionizing radiation:

In medical research

As a diagnostic agent

As a therapeutic agent

This chapter deals with the use of radioactive material in sealed sources inserted into

body cavities or surgically implanted for the treatment of cancer. All personnel involved

in the treatment or care of these patients should be familiar with the recommendations in

this section.

Note All patients undergoing brachytherapy will be located in a private room as designated by

Radiation Safety.

5-49

Management of Patients Undergoing Brachytherapy

Radiation Safety Staff Responsibilities

Training Design The Radiation Safety Officer will determine the needs for training and establish

a system to provide training consistent with the recommendations of:

National Council on Radiation Protection and Measurements

The Joint Commission

Training will be provided to various medical personnel to include:

Nursing Services

Environmental Services

Food and Nutrition Services Staff

Physicians

Regulation In order to guarantee compliance with recommendations of the NCRP, TJC

Compliance and the 25 TAC 289, Radiation Safety will conduct spot checks of radiation therapy

activities such as:

Posting of signs and labels

Source accountability

Staff awareness

Record keeping Radiation Safety will maintain the records necessary to show compliance with the

regulations of various responsible agencies.

5-50


Radiation Oncology Department Staff Responsibilities

Consent Form The Radiation Oncology Department must discuss with the patient the hazards and risks

involved with brachytherapy and obtain a signed consent form.

Notification of Prior to source implantation, Radiation Safety must be notified of the following

Radiation Safety information:

Date of insertion

Estimated length of treatment

Radionuclide used

Radionuclide activity

Hospital and room in which the patient is housed

Briefing All attendant staff will be briefed on the course of treatment planned, to include:

Attendant Staff

Approximate dose rates

Estimated length of treatment

Reminder of rules and precautions for visitors and staff

After Insertion After insertion of radiation sources, the Radiation Oncology Department must:

Post a warning sign on or by the patient’s door

Place warning tag on laundry and trash bags in the patient’s room

Place yellow wristband on patient

Place a warning sign on patient’s chart

Complete the form “Nursing Instructions for Patients Treated with Brachytherapy

Sources” and place it in the patient’s chart

Perform radiation level survey

5-51


Radiation Oncology Department Staff Responsibilities (continued)

Example of This is an example of the warning sign that is to be placed on or by the door of a

Warning Sign brachytherapy patient’s room:

5-52



Example of This is an example of the warning sign that is to be placed on the outside of the

Warning Sign for patient’s chart:

Outside of

the Patient’s Chart

5-53



Example of This yellow wristband is to be placed on a patient’s wrist.

Wristband

Example of This is an example of the tag that is to be placed on the laundry and trash bags

Laundry/Trash that are located in the room of the brachytherapy patient.

Tag

Caution: Contents May Be

Radioactive. Do not Remove From

This Room.

PRECAUCION: Contenious

Pueden Ser Radioactivos. No

Vaya A Remover De Este Cuarto

5-54



Example of This is an example of the Nursing Instruction Form that is to be completed for

Nursing radiation therapy patients with permanent implants.

Instruction Form

PERMANENT IMPLANT

CAUTION

PATIENT CONTAINS RADIOACTIVE MATERIAL

NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES

Patient’s Name:_____________________________ UH # ______________________________________________________

Room Number: ________________ Physician’s Name:_________________________________________________________

Radionuclide: _______________ Activity: _____________ Number of Sources:_____________________________________

Date and Time of Administration:___________________________________________________________________________

Date and Time Sources Are To Be Removed:__________________________________________________________________

Exposure Rate at: 1 meter from Patient: ___________________________________________ mR/hr.

Exposure Rate at Adjacent Room Closest to Patient: _________________________________ mR/hr.

Exposure rate at: Hallway at Point Closest to Patient: ________________________________ mR/hr.

Instrument Model: ___________________ SN:________________________________________________________________

Date and Time Sources Removed:___________________________________________________________________________

Number of Sources Removed: _________________________________ By: _________________________________________

Surveys After Source Removal Performed By:_________________________________________________________________

(RETURN THIS SHEET TO RADIATION SAFETY, RT. 1111, UPON COMPLETION OF THERAPY)

1. Do not spend any more time in patient’s room than is necessary to care for patient. In particular, time at patient’s

bedside should be kept to a minimum.

2. Place laundry in linen bag and save until surveyed and released by Radiation Oncology or Radiation Safety.

3. Housekeeping staff may not enter the room unless escorted by a nurse. Only essential cleaning should be done.

4. Visitors must be 18 years or older.

5. Patient may not have pregnant visitors.

6. Visitors should remain at least 6 feet from the patients and should not stay more than 2 hours per day.

7. A dismissal survey must be performed before patient is discharged.

IN CASE OF EMERGENCY CALL: On-Duty Off-Duty

Dr.:_________________________ ________ Pager # ____________

Dr.: ________________________ ________ ____________

Dr. Steve Morrill 22531 Pager # (409) 645-8437

Home # (409) 925-3804

Radiation Safety Office 22279 University Operator x21011

5-55



Example of This is an example of the Nursing Instruction Form that is to be completed for

Nursing radiation oncology patients with temporary implants.

Instruction Form

TEMPORARY IMPLANT

CAUTION

PATIENT CONTAINS RADIOACTIVE MATERIAL

NURSING INSTRUCTIONS FOR PATIENTS TREATED WITH BRACHYTHERAPY SOURCES

Patient’s Name:_____________________________ UH # ______________________________________________________

Room Number: ________________ Physician’s Name:_________________________________________________________

Radionuclide: _______________ Activity: _____________ Number of Sources:_____________________________________

Date and Time of Administration:___________________________________________________________________________

Date and Time Sources Are To Be Removed:__________________________________________________________________

Exposure Rate at: 1 meter from Patient: ___________________________________________ mR/hr.

Exposure Rate at Adjacent Room Closest to Patient: _________________________________ mR/hr.

Exposure rate at: Hallway at Point Closest to Patient: ________________________________ mR/hr.

Instrument Model: ___________________ SN:________________________________________________________________

Date and Time Sources Removed:___________________________________________________________________________

Number of Sources Removed: _________________________________ By: _________________________________________

Surveys After Source Removal Performed By:_________________________________________________________________

(RETURN THIS SHEET TO RADIATION SAFETY, RT. 1111, UPON COMPLETION OF THERAPY)

1. Do not spend any more time in patient’s room than is necessary to care for patient. In particular, time at patient’s

bedside should be kept to a minimum.

2. Place laundry in linen bag and save until surveyed and released by Radiation Oncology or Radiation Safety.

3. Housekeeping staff may not enter the room unless escorted by a nurse. Only essential cleaning should be done.

4. Visitors must be 18 years or older.

5. Patient may not have pregnant visitors.

6. Visitors should remain at least 6 feet from the patients and should not stay more than 2 hours per day.

7. A dismissal survey must be performed before patient is discharged.

IN CASE OF EMERGENCY CALL: On-Duty Off-Duty

Dr.:_________________________ ________ Pager # ____________

Dr.: ________________________ ________ ____________

Dr. Steve Morrill 22531 Pager # (409) 645-8437

Home # (409) 925-3804

Radiation Safety Office 22279 University Operator x21011

5-56



Radiation The patient’s room and all surrounding areas will be surveyed as soon as

Level Surveys possible after the sources have been implanted. The exposure rate measurement will be

recorded on the nursing instruction sheet:

In the patient’s room, one meter from the patient

In the hallway at the nearest point to the patient

In all adjacent rooms along the wall common to the patient’s room

Radiation Radiation levels in unrestricted areas will be maintained at less than the limits

Levels specified in the 25 TAC 289 and the UTMB license (5 mrem/hr in stairways, restrooms,

hallways and other fleetingly occupied areas, and 2 mrem/hr in adjacent rooms

containing patients or hospital personnel). If radiation levels cannot be maintained less

than these limits, notify Radiation Safety immediately.

Conclusion of

Treatment

IMPLANT TYPE PROCEDURE

Temporary At the time of removal, conduct a physical inventory of

sources removed, record on Nursing Instruction Sheet and

compare against number of sources implanted for

verification.

Using a suitable instrument, survey the patient to guarantee

that all radiation sources have been removed.

Survey the patient’s room and surrounding area to ensure

no source of radiation is left behind.

If all sources are accounted for and there is no evidence of

sources left behind in the room or in the patient, remove all

radiation signs and labels, complete the entries required on

the Nursing Instruction Sheet and return it to Radiation

Safety; if not, notify the Radiation Safety Officer

immediately.

Permanent (Au-198

I-125 seeds) Do not release patients from hospital without authority of

the Radiation Safety Officer until the implanted activity is

calculated to be less than 30 mCi.

Using an ion chamber type instrument, measure the

exposure rate 1 meter from the umbilicus with the patient

standing. Do not release patients without the authority of

the Radiation Safety Officer if the exposure rate exceeds 5

mR/hr.

Record the calculated activity and 1 meter exposure rate on

Nursing Instruction Sheet.

5-57



Conclusion of

Treatment

Inventory of A physical inventory of the number of sources removed will be conducted at the time of

Sources removal and compared against the number implanted for verification.

IMPLANT TYPE PROCEDURE

Permanent (Au-128

And I-125 seeds) Instruct the patient and/or family members

regarding special radiation safety precautions to be

followed after release from hospital.

Survey the patient’s room and surrounding area to

ensure that no source of radiation is left behind.

Remove all radiation signs and labels, complete the

Nursing Instruction Sheet and return it to Radiation

Safety.

5-58


Nursing Instructions

Questions Nursing personnel are encouraged to contact the Radiation Oncology Department with

any questions about patient care. Contact Radiation Safety in regard to radiation safety

precautions.

Personnel Dosimeters For additional instructions see the section titled “Personnel Monitoring” in this Manual.

Specific Patient The physician’s order sheet may contain special instructions for nursing care. All nurses

Care Guidelines should read these instructions before caring for the patient. Some of the basic guidelines

for specific patient care are the following:

No patient should receive a bed bath while radiation sources are in place.

Perineal care is not given during gynecologic treatment. The perineal pad may be

changed when necessary, unless orders to the contrary are on the sheet.

Special orders will be written for oral hygiene for patients with oral implants.

If a patient’s bed has been moved away from the wall, do not move it. (It has been

moved in order to reduce radiation levels in adjacent areas).

Exposure Time Nurses should spend only the minimum time near the patient in order to perform routine

nursing care.

Pregnant No nurse, visitor, or attendant who is pregnant is allowed in the room of a brachytherapy

Women patient while sources are implanted. Female visitors should be asked whether they are

pregnant.

Environmental A member of the nursing staff must accompany housekeeping staff into patient rooms.

Services Staff Only essential cleaning should be done. Trash and laundry should not be removed from

the patient’s room unless cleared by the Radiation Oncology Department or Radiation

Safety.

Hospital Staff In general, unless specific instructions to the contrary are written, hospital staff not

directly associated with the treatment of the patient should not be permitted to enter the

patient’s room. If in doubt, call the Radiation Oncology Department or Radiation Safety.

5-59


Nursing Instructions (continued)

Loose Radioactive Nurses must never touch:

Sources

Needles

Capsules

Containers holding brachytherapy sources

If a source becomes dislodged, use long forceps to put it in the shielded container

provided. After the source has been secured, immediately refer to the Nursing Instruction

Sheet for emergency phone numbers.

Dressing Changes Surgical dressings and bandages used to cover the area of source insertion may only be

changed by the attending physician or radiation oncologist. Dressings may not be

discarded until directed by the therapist. Dressings should be kept in a basin until

checked.

Bed Linens All bed linens must be surveyed before being removed from the patient’s room. It is

important to guarantee that no dislodged radiation sources are accidentally removed with

the bed linen.

Activities of Brachytherapy patients are confined to bed unless an order to the contrary is written.

Patients All patients will remain in their assigned rooms during the treatment period.

Visitors Visitors must be 18 years old or older, unless other instructions are given on the

Physician’s Order Sheet in the patient’s chart. Visitors should:

Sit or stand at least six feet from the patient

Remain no longer than two hours per day (unless otherwise instructed)

No pregnant visitors shall be allowed to visit patients receiving brachytherapy.

Emergency IF the patient dies or requires emergency surgery …

Procedures

THEN refer to Nurses’ Instruction Sheet in the chart for emergency phone numbers.

IF a source becomes dislodged …

THEN, using long-handled tongs or forceps, quickly place source in the shield provided,

then refer to Nurses’ Instruction Sheet for emergency phone numbers.

IF the patient must be moved due to fire or other emergency …

THEN follow standard evacuation procedures with the exception that these patients must

remain at least six feet from other patients and staff once relocated.

5-60


Nursing Instructions (continued)

Conclusion of At the conclusion of treatment, call the Radiation Oncology Department to:

Treatment

Survey the patient and room

Count the radiation sources to ensure that all temporary implants have been removed

prior to discharging the patient.

After the room has been surveyed and declared free of sources of radiation, all signs and

labels will be removed from the room and chart. Until then, treat the room as a radiation

area even if the patient is no longer present.

6-61

CHAPTER 6 : MANAGEMENT OF PATIENTS RECEIVING THERAPEUTIC

AMOUNTS OF RADIONUCLIDES

Introduction

Overview This chapter will list the responsibilities of the various healthcare personnel involved

with or in support of the administration of non-sealed sources of radionuclides in

therapeutic amounts. The healthcare personnel addressed in this section include:

Nuclear Medicine

Radiation Safety

Physician, Nursing, Environmental Services and Dietary Staff

Forms of Non-sealed sources are used in different forms such as:

Radionuclides

Solutions

Colloidal suspensions

Micro spheres

Etc.

A variety of radionuclides may be employed, such as those listed in Table 6.1:

Written Directives A written directive shall be dated and signed by an Authorized User (human-use) prior to

administration of any therapeutic dosage of unsealed radioactive material. Written

directives shall include the treated individual’s name, radiopharmaceutical, dosage, and

route of administration. Written directives shall be retained for three (3) years.

Source of The information presented in this section is based on the recommendations of the

Information National Council on Radiation Protection and Measurements Report No. 37 entitled,

“Precautions in the Management of Patients Who Have Received Therapeutic Amounts

of Radionuclides.”; USNRC REG GUIDE 8.39 (April 1997); and 25 TAC 289.256

6-62

Management of Patients Receiving Therapeutic Amounts of Radionuclides

General Information

Precautions Individuals (patients or research subjects) treated with quantities of radionuclides such

that the Total Effective Dose Equivalent (TEDE) to any other individual from exposure

to the treated individual is likely to exceed 0.5 rem will be placed in a private room with

a bathroom.

Release of Individuals who have been treated with radionuclides may be released if the TEDE

Individuals to any other individual from exposure to the treated individual is not likely to exceed

Containing 0.5rem. Individuals containing the radionuclides listed in Table 6.1 may be considered

Radionuclides to not likely expose other individuals to greater than 0.5 rem if the activity remaining

at time of release is at or below the value in Column 1; or, the highest dose rate at one

meter (1 m) from the treated individual is at or below the value in Column 2. The values

in Column 1 do not include consideration of the dose to a breast-feeding infant or child

from ingestion of radiopharmaceuticals contained in the treated individual’s breast milk.

(See Table 6.2 for radiopharmaceuticals and activities that could result in TEDE greater

than 0.5 rem should breast-feeding not be interrupted or discontinued.) For

radionuclides not listed in Table 6.1, calculations will be performed in accordance with

methods listed in USNRC REGULATORY GUIDE 8.39 (April 1997) to determine when

the individual may be released. Copies of such calculations will be retained for three (3)

years after date of release of the individual.

Instructions to The treated individual, their parent or guardian shall be provided with written instructions

Released on recommended actions to follow to maintain doses to other individuals As Low As

Individuals Reasonably Achievable (ALARA) if the TEDE to any other individual is likely to exceed

0.1 rem. Individuals containing the radionuclides listed in Table 6.1 may be considered

to likely expose other individuals to greater than 0.1rem if the activity remaining at time

of release is at or above the value in Column 3 or the highest dose rate at one meter (1 m)

from the treated individual is at or above the value in Column 4. The values in Column 3

do not include consideration of the dose to a breast-feeding infant or child from ingestion

of radiopharmaceuticals contained in the treated individual’s breast milk. (See Table 6.2

for radiopharmaceuticals and activities that could result in TEDE greater than 0.1 rem

should breast-feeding not be interrupted or discontinued.) For radionuclides not listed in

Table 6.1, calculations will be performed in accordance with methods listed in USNRC

REGULATORY GUIDE 8.39 (April 1997) to determine when the individual may be

released without required instructions. Copies of such calculations will be retained for

three (3) years after date of release of the individual.

6-63


General Information (continued)

TABLE 6.1 : Activities and Dose Rates for Authorizing Release of Individuals Treated

with Radionuclides and for Required Written Instructions

Column 1 Column 2 Column 3 Column 4

Radionuclide (mCi) (mrem/hr) (mCi) (mrem/hr)

Ag 111

520 8 100 2

Au 198

93 21 19 4

Cr 51

130 2 26 0.4

Cu 64

230 27 45 5

Cu 67

390 22 77 4

Ga 67

240 18 47 4

I 123

160 26 33 5

I 125

7 1 1 0.2

I 131

33 7 7 2

In 111

64 20 13 4

P 32

** ** ** **

Re 186

770 15 150 3

Re 188

790 20 160 4

Sc 47

310 17 62 3

Se 75

2 0.5 0.5 0.1

Sm 153

700 30 140 6

Sn 117m

29 4 6 0.9

Sr 89

** ** ** **

Tc 99m

760 58 150 12

Tl 201

430 19 85 4

Y 90

** ** ** **

Yb 169

10 2 2 0.4

** activity and dose rate limits are not applicable in the case of these radionuclides

because of the minimal exposures to members of the public resulting from activities

normally administered for diagnostic or therapeutic purposes.

Individuals who Treated individuals who could be breast-feeding an infant or child and contain

Could Be radiopharmaceuticals above the activity values listed in Table 6.2, Column 1, could

Breast-feeding expose the infant or child to a TEDE greater than 0.5 rem if there is no interruption or

After Release cessation of breast-feeding. Treated individuals who could be breast-feeding an

infant or child and contain radiopharmaceuticals above the activity values listed in

Table 6.2, Column 2, could expose the infant or child to a TEDE greater than 0.1 rem if

there is no interruption or cessation of breast-feeding. Treated individuals containing

radiopharmaceuticals in amounts above those in Table 6.2 may be released provided that

the following conditions are met:

The treated individual, their parent or guardian is provided with written instructions

on the discontinuation or interruption of breast-feeding;

The consequences of failing to follow the instructions are provided in writing to the

treated individual, their parent or guardian;

Other instructions for maintaining doses to others ALARA are provided; and

The treated individual does not exceed the values in Table 6.1, Column 1.

6-64



If a radiopharmaceutical not listed in Table 6.2 is administered to a patient who could be

breast-feeding, a determination shall be made whether a breast-feeding infant or child

could exceed a TEDE of either 0.1 rem or 0.5 rem and written instructions shall be

provided accordingly.

TABLE 6.2 : Activities and Pharmaceuticals Resulting in Doses to Breast-feeding Infants

and Children in Excess of 0.5 rem and 0.1 rem

Column 1 Column 2

Radiopharmaceutical (mCi) (mCi)

(results in (results in

>0.5 rem) >0.1 rem)

I 131

NaI 0.002 0.0004

I 123

NaI 3 0.5

I 123

OIH 20 4

I 123

mIBG 10 2

I 125

OIH 0.4 0.08

I 131

OIH 1.5 0.3

Tc 99m

DTPA 150 30

Tc 99m

MAA 6.5 1.3

Tc 99m

Pertechnetate 15 3

Tc 99m

DISIDA 150 30

Tc 99m

Glucoheptonate 170 30

Tc 99m

HAM 50 10

Tc 99m

MIBI 150 30

Tc 99m

MDP 150 30

Tc 99m

PYP 120 25

Tc 99m

Red Blood Cells

In-vivo Labeling 50 10

Tc 99m

Red Blood Cells

In-vitro Labeling 150 10

Tc 99m

Sulphur Colloid 35 7

Tc 99m

DTPA Aerosol 150 30

Tc 99m

MAG3 150 30

Tc 99m

White Blood Cells 15 4

Ga 67

Citrate 0.2 0.04

Cr 51

EDTA 8 1.6

In 111

White Blood Cells 1 0.2

Tl 201

Chloride 5 1

6-65



Release A record shall be maintain for each treated individual released that shall include the

Documentation basis for authorizing the release of the individual and the instructions provided to

individuals who could be breast-feeding infants or children after release that could result

in a TEDE exceeding 0.5 rem to the infant or child. Such records shall be retained for

three (3) years after date of release of the individual.

Contaminated Patients treated for thyroid carcinoma with Iodine-131 may contaminate areas of their

Areas hospital room through perspiration, urine, feces, or vomit. Any area that is likely to

become contaminated will be covered with protective material appropriate for the

amounts of contamination expected.

I-131 Patients The following procedures should be followed for disposal of contaminated items for

Removal of Iodine-131 patients:

Contaminated

Items

ITEM PROCEDURE

LINENS Nuclear Medicine will survey all linens for contamination

before removal from the patient’s room and, if necessary,

hold them for decay.

DISPOSABLE

ITEMS

Disposable plates, cups, eating utensils, tissues, surgical

dressings, and other waste items will be placed in a specially

designated container. The material will be collected,

checked for contamination, and disposed of as normal or

radioactive waste as appropriate.

NON-DISPOSABLE

ITEMS

Non-disposable items such as watches, sphygmomanometers

and other patient care equipment will be held in the patient’s

room and checked for contamination by Nuclear Machine.

These items will be returned to normal use, held for decay, or

decontaminated as appropriate for the level of contamination.

6-66

Management of Patients Receiving Therapeutic Amounts at Radionuclides

Radiation Safety Programs

Training Design The Radiation Safety Officer will determine the needs for training and establish a system

to provide training consistent with the recommendations of:

National Council on Radiation Protection and Measurements

Joint Commission on the Accreditation of Healthcare Organizations

Other appropriate agencies and organizations

Training will be provided to various medical personnel, to include:

Nursing Services

Environmental Services

Dietary Staff

Physicians

Management of Radiation Safety will assist in the clearance and release of the patient’s room

Patient Rooms and contents. The staff will inform the Nuclear Medicine staff concerning acceptable

levels of contamination remaining in the patient’s room upon release. Nuclear Medicine

staff will decontaminate if necessary.

Regulation Radiation Safety is responsible for ensuring compliance with the recommendations

Compliance of the NCRP, TJC and Texas Regulations for Control of Radiation and will maintain

documentation to show compliance with these regulations unless the requirement for

maintenance of documentation is otherwise specified.

6-67

Management at Patients Receiving Therapeutic Amounts of Radionuclides

Nuclear Medicine Staff Responsibilities

Administration Nuclear Medicine shall ensure that a written directive has been properly executed

and Release of for the administration of the radiopharmaceutical; and that the written directive is

Individuals maintained for a period of three (3) years from the date of administration.

Receiving

Radionuclide Nuclear Medicine shall determine:

Treatment

if the quantity of radiopharmaceutical administered to the treated individual is likely

to expose others to a TEDE greater than 0.5 rem (if so, the individual will not be

released from UTMB until they meet the release criteria);

when the treated individual can be released from UTMB control; and

if the treated individual is likely to be breast-feeding infants or children after release,

and if so, what the potential TEDE to the exposed infant or child would be.

Upon release, Nuclear Medicine shall provide the treated individual, their parent or

guardian with written instructions on recommended actions to follow to maintain doses to

other ALARA if the treated individual is likely to expose others to a TEDE greater than

0.1 rem,

Nuclear Medicine shall maintain a record for each treated individual released that

includes:

the basis for authorizing the release of the individual; and

the instructions provided to individuals who could be breast-feeding infants or

children after release that could result in a TEDE exceeding 0.5 rem to the infant or

child.

Nuclear Medicine shall ensure that such records are retained for three (3) years after the

date of release of the individual.

Procedures Whenever an individual is admitted to the hospital who is to receive, or has received,

for Hospitalized radionuclide treatment that:

Individuals

would likely expose other individuals to greater than 0.1rem, or

would likely result in significant radioactive contamination of a patient room,

Nuclear Medicine shall adhere to the following procedure:

6-68

Management at Patients Receiving Therapeutic Amounts of Radionuclides

Nuclear Medicine Staff Responsibilities (continued)

* Note: Radiation levels in unrestricted areas will be maintained at less than the limits

specified in the Texas Regulations for Control of Radiation and the UTMB license.

These limits are: 5 mrem/hr in stairways, restrooms, hallways, and other fleetingly

occupied areas; 2 mrem/hr in adjacent rooms containing patients or hospital personnel.

STEP PROCEDURE

1 Notify Radiation Safety before the administration of radiopharmaceuticals or

immediately upon admission if the radionuclide has already been administered.

2 Meet with the patient to:

Discuss the purpose of treatment

Describe the risks associated with treatment

Obtain a signed consent form from patient

Discuss steps to be taken by patient to prevent spread of contamination

and/or to minimize radiation exposure of others

3 Inform the nursing staff about details of the treatment:

Approximate dose

Estimated dose rate

Reminder of visitors’ rules

Precautions for nurses

4 If radioactive contamination is a serious potential

Prepare the patient room prior to the treatment as necessary;

Provide a supply of disposable gloves and shoe covers for persons entering

the room.

5 Post appropriate radiation/contamination notices:

Warning sign on or by the patient’s door

Warning tags on trash/linen bags in patient’s room as necessary if

radioactive contamination is a serious potential

Warning sign on patient’s chart

Physician’s Order Sheet for radionuclide therapy in the patient’s chart

6 Place yellow wristband on patient.

7 Administer the radiopharmaceutical to patient.

8 Measure the exposure rate at one meter from the patient immediately after

administration, and then on a daily basis thereafter. Record these rates under

progress notes in patient’s chart.

9 Measure the exposure rate in all surrounding areas along the walls common to

the patient’s room. Notify Radiation Safety immediately if the levels cannot be

maintained within specified limits. * Record results in patient’s chart.

10 Notify the Radiation Safety Office prior to patient discharge.

11 After the patient is discharged, survey the room for contamination. If

radioactive contamination is found in the room above acceptable levels as

established by the Radiation Safety Program, decontaminate the room to the

acceptable levels.

6-69



Example of This warning sign is to be placed on the door to a patient’s room that is

Warning Sign receiving radiotherapy.

For Door to

Patient’s Room

6-70



Example of This tag is to be placed on bags used to collect laundry or trash in the room

Tag for of a patient receiving radiotherapy.

Trash/Laundry

Example of Sign This warning sign is to be placed on the cover of the patient’s chart.

for Patient’s Chart

Example of This yellow wristband is to be placed on a patient’s wrist.

Wristband

Caution: Contents May Be

Radioactive. Do not Remove From This Room. PRECAUCION: Contenious Pueden Ser Radioactivos. No

Vaya A Remover De Este Cuarto.

6-71



Physician’s Order The Physician’s Order Sheet for individuals covered by the above procedure shall

Sheet at a minimum contain the following information:

Patient identifying information

Radiopharmaceutical and activity administered

Any restrictions on patient movement out of their room

Total time per day staff or visitors may remain in the patient’ room and at what

distance

Exclusion of pregnant women from entering the room

Requirements for wearing personal protective equipment while attending to the

patient

Restrictions on removing items from the room

Names and phone numbers of Nuclear Medicine faculty and staff to call in case of a

problem or question

Phone number for Radiation Safety Office

Restrictions on cleaning the room or admitting another patient until the room has

been cleared by either Nuclear Medicine or Radiation Safety Office

6-72


Nursing Service Staff Responsibilities

Knowledge All nursing staff working with radiotherapy patients are responsible for understanding

Of Procedure and following all procedures and instructions. Personal safety and the safety of patients

will depend on the use of proper techniques in the care of patients receiving

radiopharmaceuticals.

Exposure Time Nurses should spend only the time required for ordinary nursing care near the patient.

Precautions for Visitors must:

Visitors

Be 18 years old or older (unless other instructions are noted in the physician’s orders

on the patient’s chart)

Remain at least six feet from the patient except for a brief exchange of greetings or

to say goodbye

Visitors must not:

Remain in the patient’s room for more than the length of time per day specified in

the Physicians Orders

Be pregnant (All female visitors should be asked if they are or might be pregnant.

No pregnant visitor will be allowed in the patient’s room).

Precautions for In general, unless specific instructions to the contrary are written, hospital staff and

Hospital Staff employees not directly associated with the treatment of the patient should not be

And Employees permitted to enter the patient’s room. If in doubt, call Nuclear Medicine or Radiation

Safety.

Activity Patients shall be confined to their rooms except as approved by Nuclear Medicine.

Of Patients

6-73


Nursing Service Staff Responsibilities (continued)

Special For those patients undergoing therapy involving Iodine-131 there are several special

Instructions for precautions required, as outlined in the table below.

I-131 Patients

ITEM PROCEDURE

URINE Urine is not routinely collected. If orders are written to collect

urine, special containers will be provided by Nuclear Medicine.

The patient should collect his/her own urine in the container. If the

patient is bedridden, a separate urinal or bedpan should be provided

and flushed several times in a designated sink with hot soapy water

after use. Handle the urinal or bedpan with double disposable

gloves on. After flushing, nurses should wash their hands with

gloves on and again with the gloves off. Dispose of gloves in the

designated radioactive waste container.

FECES Feces need not be routinely saved, unless ordered by Nuclear

Medicine. If the nurse collects the excreta, disposable gloves

should be worn. After assisting the patient, nurses should wash

their hands with gloves on and again with gloves off. The gloves

should be placed in the designated radioactive waste container for

disposal.

MEAL

UTENSILS

Patients who are treated with Iodine-131 in excess of 33 mCi will

use disposable plates, cups and eating utensils.

VOMIT All vomit must also be kept in the patient’s room for disposal. Call

Nuclear Medicine if the patient should vomit.

Blood and Routine blood and urine samples are not to be obtained while the patient is undergoing

Urine Samples this therapy unless specifically authorized by a Nuclear Medicine physician and

Radiation Safety.

Use of Gloves All staff should wear disposable gloves when handling bed linens, urinals, bedpans,

basins, or other containers having any material obtained from the body of the patient.

The gloves do not need to be sterile or surgical gloves. After use, these gloves should be

left in the patient’s room in the designated waste container. Hands should be washed

thoroughly with soap and water.

Dressing Changes Surgical dressings should be changed only as directed by the physician. Such dressings

should not be discarded but should be collected in plastic bags and labeled as radioactive

waste. Handle these dressings only with tongs or tweezers. The tongs or tweezers should

be placed in a separate plastic bag to be checked for radioactive contamination by

Nuclear Medicine. Staff handling these dressings should wear disposable gloves.

Disposable Items Disposable items should be used in the care of these patients whenever possible. After

use, these items should be placed in the designated waste container. Contact Nuclear

Medicine for proper disposal of the contents of the container.

Non-Disposable All non-disposable items such as watches, books, etc., should be placed in a plastic bag

Items and should be left in the patient’s room to be checked before discharge by Nuclear

Medicine.

6-74


Nursing Staff Responsibilities (continued)

Clothes and Linens All clothes, towels and bed linens used by the patient should be placed in the laundry bag

provided and should be left in the patient’s room to be checked by Nuclear Medicine.

Bed linens will not normally be changed since the period for radiation safety precautions

is usually only 2-3 days.

In Case of Spillage Exercise care to ensure that no urine or vomit is spilled on the bed or floor. If there is

suspected contamination from the patient’s excreta or vomit, spillage or other causes:

Notify Nuclear Medicine and Radiation Safety immediately.

Take the necessary precautions until a representative from Nuclear Medicine or

Radiation Safety arrives. SEE: Precautions after a Suspected Contamination.

Suspected If a nurse, attendant or anyone else knows or suspects that his or her skin or clothing

Personnel is contaminated then:

Contamination

Notify either Nuclear Medicine or Radiation Safety.

Remain in the area near the patient’s room and do not walk about the hospital.

If your hands have become contaminated, wash them immediately with soap and

water.

Precautions

After a

Suspected

Contamination

After a suspected contamination, follow these guidelines:

Mark off the entire area of potential contamination. This must be done to prevent

further spread of personnel contamination.

Control access to and from the area.

Make sure that personnel inside the area or those who have entered the area remain

for monitoring.

Use absorbent material such as paper towels or diapers to contain the spill and

prevent further contamination. Do not remove the materials until the Health

Physicist from Radiation Safety or a Nuclear Medicine representative arrives.

Emergencies If a radiotherapy patient should need emergency surgery or should die, notify Nuclear

Medicine or Radiation Safety immediately (refer to the physician’s order sheet for

emergency numbers). Patient resuscitation and stabilization should be pursued

immediately.

Discharge of When a patient is discharged, call Nuclear Medicine and request that the room be

Patient surveyed for contamination before remaking the room. Nuclear Medicine will contact

Radiation Safety for a follow up survey. After the room has been surveyed and declared

free of contamination, all signs and labels will be removed from the room and chart.

Until then, treat the room as a radiation area even if the patient is no longer present.

6-75


Environmental Services and Dietary Services Staff Responsibilities

Environmental Environmental Services staff will:

Services

Responsibilities

Enter the patient’s room only when accompanied by a nurse.

Remove trash for disposal only after it is cleared by Nuclear Medicine or Radiation

Safety.

Remove linens or other materials only after they are cleared by Nuclear Medicine or

Radiation Safety.

Upon discharge of the patient, clean the room only after it has been cleared by

Nuclear Medicine or Radiation Safety.

Dietary Staff The Dietary staff will:

Responsibilities

Provide disposable utensils for patients being treated for thyroid carcinoma.

Not remove any items from the patient’s room without prior approval of Nuclear

Medicine or Radiation Safety.

7-76

CHAPTER 7 : GENERAL INSTRUCTIONS FOR AUXILIARY PERSONNEL

Instructions for Maintenance Personnel

Introduction Radioactive materials and radiation-producing machines are found in many locations on

the UTMB campus. Some general guidelines for specific areas are outlined below.

Radiation Area Do not enter any of these areas without specific permission to do so either from someone

Or High-Radiation in authority in that area or from Radiation Safety.

Area Instructions

When specifically authorized to enter such an area:

Follow instructions

Do work required

Leave – do not waste time

Rooms Marked

“Radioactive

Material”

STEP PROCEDURE

1 Enter room unless specific signs say “Keep Out.”

2 Seek someone who works in the room and explain the work that is to

be done.

3 Before you begin work, have laboratory personnel check by

instrument survey or a wipe test, to make certain that the work area

is free of contamination.

4 If you cannot find someone in the area to check with, leave the room

and ask at the department office for assistance locating someone who

works in that room.

5 If it is an emergency repair job and you cannot get help at the

department office, call Radiation Safety.

6 If the area is free of contamination, proceed with the job. While in

the area:

Do not smoke, eat, drink, or apply cosmetics

Do not enter other areas marked off as radioactive material areas

Watch for signs of possible contamination, such as broken

labeled bottles or vials, or liquid pooled in an area

7-77

General Instructions for Auxiliary Personnel

Instructions For Maintenance Personnel (continued)

Equipment

Marked

“Radioactive

Material”

For sinks, hoods, or other equipment marked “Radioactive Material”:

Have lab personnel check by wipe test or instrument survey to ensure that there is

no contamination.

If equipment must be taken back to shop, or there are any questions, call Radiation

Safety for supervision.

Call Radiation Safety to have a hood exhaust duct surveyed.

Call Radiation Safety for assistance with clearance and decontamination of

equipment that is to be moved.

Important Call Environmental Health and Safety, ext. 22279, at any time if in doubt about any

procedures for handling anything marked “radioactive material.”

7-78


Instructions for Smoke Detector Disposal

Introduction Non-functioning smoke detectors containing radioactive sources that are removed from

UTMB facilities by Business Operations & Facilities (BOF) will be disposed of as

radioactive waste. This policy outlines the responsibilities of both BOF and Radiation

Safety.

Radiation Safety Radiation Safety will:

Responsibilities

Provide a container for BOF to use as a waste receptacle for the smoke detectors and

forms for documentation at disposal

Pick up the waste when requested

Repackage the detectors if required by the commercial radioactive waste contractor

BOF BOF will:

Responsibilities

Dispose of the detector intact, without disassembling the unit, in the waste container

provided by Radiation Safety

For each detector in the waste container, record the radionuclide and activity on the

“Radioactive Waste Disposal” form provided by Radiation Safety

Log on to http://www.utmb.edu/bof/epm/RADInput.asp to request a radioactive

waste pick-up

Example of a Properly Completed “Radioactive Waste Disposal Form”

http://www.utmb.edu/bof/epm/RADInput.asp

7-79


Instructions for University Police

Access to Radioactive material and radiation-producing devices are found in many locations

Radiation Areas on the UTMB campus. This poses little or no hazard to security personnel if the

guidelines below are followed:

A location labeled “High Radiation Area” should not be entered without calling

Radiation Safety personnel first, unless the situation is life threatening

A location labeled, “Radiation Area” can be entered for a short time to protect life or

property. For routine matters, contact Radiation Safety personnel first

A location labeled “Radioactive Material” will be safe to enter unless specifically

marked “Do Not Enter.” While in the area:

o Do not handle containers labeled with radioactive material symbols

o Do not smoke, eat or drink in these areas

o Be wary of evidence of spills of radioactive material

When to Notify You should notify Radiation Safety:

Radiation Safety

Before entering a high radiation or radiation area (with the exceptions noted above)

If any container labeled “Radioactive Material” is found broken, crushed or leaking

In case of fire in any room labeled “Radioactive Material”

When in doubt, call Radiation Safety! (However, there is no need to contact Radiation

Safety for alarms or lights on refrigerators, cold rooms, incubators, etc. Instead, notify

the department responsible for the laboratory in which the item is located).

Package Delivery Carrier services making delivery of radioactive material packages to UTMB or Shriners

Burns Institute after normal working hours will be directed to the security station at the

emergency room entrance on Strand Street. The procedure for accepting these deliveries

is outlined on the next page.

7-80


Instructions For University Police (continued)

Package

Delivery

* Whenever possible, personnel should remain at least three feet away from packages

bearing a DOT Type III Label. An example of this label is on the next page.

STEP PROCEDURE

1 The Dispatcher shall visually inspect all packages at the time of

delivery. If the package is DAMAGED (wet, crushed, open, etc.) then:

IF… Then…

Damaged (wet, crushed, open,

etc.)

1. Do not handle package.

2. Ask the carrier to stay until

Radiation Safety personnel have

been contacted.

3. Phone Radiation Safety at the

after-hours Hospital Operator,

ext. 21011.

Intact 1. Check to be sure that package(s)

are addressed to UTMB or

Shriners Burns Institute.

2. Sign for package.

3. Notify the Sergeant or other

Commissioned Officer as soon

as possible.

2 The Sergeant or Commissioned Officer contacted shall ensure

expeditious transport of the package(s) as follows:

If… Then…

Package is addressed to

NUCLEAR MEDICINE

It should be taken to Room 2.476,

Clinical Science Building and placed

behind the lead shield on the right

side of the workbench along the back

wall. Large boxes may be placed on

the floor in front of the shield.

Package is addressed to ANY

OTHER UTMB

DEPARTMENT OR

SHRINERS BURNS

Contact Radiation Safety at the after-

hours hospital operator. If it needs

refrigeration, place it in the white

refrigerator labeled “Radioactive

Material” in the back of the

laboratory.

7-81


Instructions For University Police (continued)

Example of

DOT Type III

Label

7-82


Instructions for Environmental Services Personnel

Introduction In order to prevent the spread of radioactive contamination or the improper disposal of

radioactive waste, it is important that housekeeping personnel are aware of the proper

way to conduct themselves in areas where radioactive materials are used. There are two

separate areas of concern:

Laboratories

Hospital rooms

Conduct in Follow these guidelines in laboratories:

Laboratories

Note the “Caution – Radioactive Material” sign at entrance to the area

Look for and obey any other special instructions at entrances, such as “Do Not

Enter.” If there are no special instructions, enter the room.

Do not smoke, eat, drink, or apply cosmetics while in these areas.

Do required work as quickly as possible, and then leave the area.

Watch for problems:

o If you see a tape-labeled container that has spilled or leaked, leave the area

and contact your supervisor.

o If you have stepped in something that you think is radioactive leave your

shoes inside the door to the room, and contact your supervisor.

If you do not understand what to do, do not enter the area.

Lock the door to the room when you leave.

Instructions for WHAT TO DO WITH ITEMS MARKED “RADIOACTIVE MATERIAL”

Specific Areas

ITEM/AREA INSTRUCTIONS

Bench tops labeled with

tape

Do not:

Lean on or against it

Put anything down on it

Handle anything that is on it

Floor area labeled with

tape

Do not:

Walk in this area

Clean the floor in this area

Lab equipment labeled

with tape

Do not:

Touch this equipment.

7-83


Instructions For Environmental Services Personnel (continued)

Instructions for WHAT TO DO WITH ITEMS MARKED “RADIOACTIVE MATERIALS”

Specific Areas

(continued)

Conduct in

Hospital Rooms

D

o

n

D

Do not clean areas where radioactive material is spilled unless you are supervised by

Nuclear Medicine or Radiation Safety. If there are any questions or problems, contact

Radiation Safety at ext. 22279 or through the hospital operator.

ITEM/AREA INSTRUCTIONS

Refrigerators

labeled with tape

Do not open.

Trash bags or cans

labeled with tape

Do not empty this trash. If there is any doubt whether or not it is

radioactive, do not empty it.

Sinks labeled with

tape or signs

Do not use this sink to get water or dispose of water.

STEP PROCEDURE

1 Note the “Caution – Radiation Area” sign at entrance to

a patient’s room, and do not enter the room.

2

Go to nursing station on floor.

3 Tell a nurse what you need to do in the patient’s room.

4 Enter the patient’s room only with a nurse present.

5 Do only what the nurse instructs you to do.

7-84


Instructions for Pathologists Dealing with Radioactive Body Tissues

Post-Mortem Bodies of patients containing administered radioactive material shall not be removed

Procedure from the patient area without notification of Radiation Safety and the physician in charge

of the case. Radiation Safety will determine whether or not a radiation hazard exists in

handling the body and will issue instructions accordingly.

If… Then…

Patient has received

BRACHYTHERAPY

The attending physician is responsible for the removal of

brachytherapy sources and brachytherapy applicators from

patients before the body leaves the patient area. (Once these

sealed sources are removed, there is no further radiation

problem.)

In all other cases, residual radioactive material may still be found in body tissue.

Radionuclides may be concentrated in an organ or tumor, or may be distributed through

all body tissues or fluids.

There is to be an

AUTOPSY on the

body, or if the body is

to be EMBALMED

Radiation Safety should indicate what issues or body fluids

are to be removed promptly (at autopsy), and what special

precautions should be taken.

There are

RADIOACTIVE

FLUIDS PRESENT

IN THE BODY

Every effort should be made to see that they are properly

discharged down the drain without spilling on the floor or

splashing neighborhood areas.

There are any

RADIOACTIVE

TISSUES TO BE

RETAINED

They should immediately be placed in appropriately shielded

vessels for storage or for disposal according to procedures

approved by Radiation Safety. Each container needs to be

labeled with:

Date

Name and hospital number of patient

Radionuclide and activity

Date when radiation level will be below permissible level

for disposal or handling without precautions

Radioactive material tape

INJURY OCCURS

during an autopsy

(where gloves being

worn are cut or torn)

Radioactive material may be introduced into the wound. In

addition to ordinary treatment of the wound, Radiation Safety

needs to be consulted with regard to any possible radiation

hazard.

Accidental In case of accidental overflow, the fluid should be taken up immediately, as

Overflow completely as possible, with absorbent paper and pad held in tongs or forceps and

Procedure promptly put into a plastic bag and labeled as radioactive waste. Special care should be

taken to prevent the floor of the morgue from being contaminated. Such contamination

can be transferred to the shoes and so be spread through the institution.

7-85


Instructions For Pathologists Dealing With Radioactive Body Tissues (continued)

Accidental In addition, the floors of such rooms are often of rough concrete or other material

Overflow that is difficult to decontaminate, and flushing them or scrubbing them with water

Procedure may only spread the contamination. To avoid this, tape a large sheet of absorbent

material, underlaid with plastic, to the floor before beginning the autopsy, to provide a

working region easy to decontaminate.

Protective shoe covers should be worn by all personnel in this region and removed before

they leave the work area. Wearing plastic aprons and gloves prevents contamination of

clothing and skin. Care should be taken in removing protective clothing so as not to

contaminate the skin of radionuclide-free areas.

7-86

APPENDIX A: EXAMPLES OF SIGNS AND LABELS

Examples of Sign Used at Entrance to Patient Room Where Radioactive Material is Used

7-87

APPENDIX A: EXAMPLES OF SIGNS AND LABELS (CONTINUED)

Example of Sign Used at Entrance of Laboratories Where Radioactive Materials Are Used or Stored

7-88

APPENDIX A: EXAMPLES OF SIGNS AND LABELS (CONTINUED)

Example of Tape Used to Label Area and Equipment Used for Working With Radioactive Material

7-89

APPENDIX B: GLOSSARY

Activity: The number of nuclear disintegrations occurring per unit time in a given quantity of

material. The unit is the Curie.

Alpha Particle: A strongly ionizing particle emitted from the nucleus during radioactive decay consisting

of 2 protons and 2 neutrons with a double positive charge.

Attenuation: The process by which a beam of radiation is reduced in intensity when passing through

some material. It is the combination of absorption and scattering processes.

Background Radiation: Radiation arising from sources other than the one under consideration. Background

radiation, due to cosmic ray and natural radioactivity, is always present. There may also

be background radiation due to the presence of radionuclide substances in other parts of

the building, in the building material itself, etc.

Becquerel (Bq): Amount of activity equal to one nuclear disintegration per second.

(NOTE: 1 Bq= 2.7E-11 Ci)

Beta Particle: Charged particle emitted from the nucleus of an atom, having a mass and charge equal to

magnitude to that of an electron.

Biological Half-Life: The time required for the body to eliminate ½ of the administered doses of any substance

by regular processes of elimination. This time is approximately the same for both stable

and radioactive isotopes of a particular element.

Contamination: Radioactive material in undesirable location. Two types:

1. Fixed – not readily removed

2. Removable – that which can be easily removed

Count: The external indication of a device designed to enumerate ionizing events. It may refer to

a single detected event or to the total registered in a given period of time.

Cumulative Dose: The total dose resulting from repeated exposures to radiation to the same region or the

whole body.

Curie: The amount of activity, equal to 3.7 E10 disintegrations per second (DPS) (2.22 E12

dpm). (Note: 1 Curie – 3.7 E10 Bq)

Cutie Pie: A radiation survey meter of the ion chamber type used to determine exposure rate.

Decay: Disintegration of the nucleus of a unstable nuclide by the spontaneous emission of

particles and/or photons.

Declared Pregnant A woman who has voluntarily declared her pregnancy in writing to the Radiation

Female: Safety Office.

Decontamination: Removal of radioactive contamination from where it is deposited. Soap and water is a

good decontamination agent.

7-90

APPENDIX B Glossary (continued)

Detector: Material or device that is sensitive to radiation and can produce a signal suitable for

measurement or analysis.

Dose Equivalent: A quantity used in radiation protection expressing all radiation on a common scale for

calculating the effective absorbed dose. The unit of dose equivalent is the rem, which is

numerically equal to the absorbed dose in rads multiplied by the quality factor.

Dose Rate: Radiation dose received per unit time.

Dosimeter: Instrument used to detect and measure an accumulated dosage of radiation.

Effective Half-Life: Time required for a radioactive nuclide in a system to be diminished 50 percent as a

result of the combined action of radioactive decay and biological elimination.

Efficiency: A measure of the probability that a count will be recorded when radiation is incident on a

detector.

Exposure: A measure of the ionization produced in air by x-ray or gamma radiation.

External Radiation: Exposure to ionizing radiation when the radiation source is located outside of the body.

Gamma Ray: Very penetrating electromagnetic radiation of nuclear origin. Except for origin, gamma

rays are identical to x-ray.

Geiger-Mueller (GM) Highly sensitive gas-filled detector and associated circuitry used for radiation detection\

Counter: and measurement.

Gray (Gy): Unit of absorbed dose equal to 1 Joule/kg of any material.

Half-Life: The length of time required for half of the radioactive atoms present to decay.

Health Physics: That branch of radiological science dealing with the protection of personnel from harmful

effects of ionizing radiation.

Human Use: Internal or external administration of radioactive materials or ionizing radiation to human

beings.

Internal Radiation: Exposure to ionizing radiation when the radiation source is within the body as a result of

deposition of radionuclides in the body tissues.

Ionization: The process by which a neutral atom or molecule acquires either a positive or a negative

charge.

Ionization Chamber An instrument designed to measure the quantity of ionizing radiation in terms of the

(Ion Chamber): charge of electricity associated with ions produced within a defined volume.

Ionizing Radiation: Radiation that interacts with matter to form ion pairs.

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Isotopes: Nuclides having the same number of protons (i.e., same atomic number and chemical

symbol).

Labeled compound: A compound consisting of molecules which have one or more constituent radioactive

atoms. Used to follow physical, chemical or biological processes.

Maximum Permissible Maximum dose of radiation that may be received by persons working with ionizing

Dose: radiation and which produce no detectable damage over the normal life span.

MilliRoentgen: A submultiple of the roentgen equal to one one-thousandth (1/1000th) of a roentgen.

(See Roentgen).

Monitoring, Periodic or continuous determination of the amount of ionizing radiation or radioactive

Radiological: contamination present in an occupied region as a safety measure for purposes of health

protection.

Area Monitoring: Routine monitoring of the level of radiation or of radioactive contamination of any

particular area, building, room or equipment.

Personnel Monitoring: Monitoring any part of an individual, his breath, excretions, or any part of his clothing.

(See Radiological Survey).

Non-Ionizing Radiation that does not form ions when interacting with matter (i.e., microwaves, heat,

Radiation: light (lasers), UV, IR).

Nuclide: A species of atom characterized by the constituents of its nucleus, capable of existing

for a measurable length of time.

Photon: A quantity of electromagnetic energy (E) whose value in Joules is the product of its

frequency (v) in hertz and Planck constant (h). The equation is: E=h.

Quality Factor: The linear-energy-transfer-dependent factor by which absorbed doses are multiplied to

obtain (for radiation protection purposes) a quantity that expresses, on a common scale

for all ionizing radiations, the effectiveness of the absorbed dose.

Rad: The unit of absorbed dose and equal to 100 ergs/gram of any material or 0.01

Joules/Kg.

Radiation: 1. The emission and propagation of energy through space or through a material medium

in the form of waves; for instance, the emission and propagation of electromagnetic

waves, or of sound and elastic waves. 2. The energy propagated through a material

medium as waves: for example, energy in the form of electromagnetic waves. The

term “radiation” or “radiant energy,” when unqualified, usually refers to

electromagnetic radiation. Such radiation commonly is classified according to

frequency as Hertzian, infrared, visible (light), ultra-violet, x-ray, and gamma ray.

3. By extension, corpuscular emissions, such as alpha and beta radiation, or rays of

mixed or unknown type, as cosmic radiation.

Radioactivity: The spontaneous transformation of nuclei from a higher energy state to a lower energy

state (can be thought of as a transformation from an unfavorable neutron to proton ratio

to a more favorable one).

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Radioisotope: The unstable isotope of an element that decays or disintegrates spontaneously, emitting

radiation. A radioactive isotope.

Radiological Survey: Evaluation of the radiation hazards incident to the production, use or existence of

radioactive materials or other sources of radiation under a specific set of conditions.

Such evaluations customarily include a physical survey of the disposition of materials

and equipment, measurements or estimates of the levels of radiation that may be

involved, and a sufficient knowledge of processes using or affecting these materials to

predict hazards resulting from expected or possible changes in materials or equipment.

Radionuclide: An unstable nuclide, one that decays or disintegrates spontaneously.

Radiotoxicity: Term referring to the potential of an isotope to cause damage to living tissue by

absorption of energy from the disintegration of the radioactive material introduced into

the body.

Rem: The special unit of dose equivalent. The dose equivalent in rem is numerically equal to

the absorbed dose in rad multiplied by the quality factor.

Restricted Area: Any area access which is controlled by the licensee or registrant for purposes of

protection of individual from exposure to radiation and radioactive material. “Restricted

area” shall not include any areas used for residential quarters, although a separate room

or rooms in a residential building may be set apart as a restricted area.

Roentgen: The special unit of exposure equal to 2.58 E-04 coulombs/Kg of air.

Scattered Radiation: Radiation that during passage through matter has been deviated in direction.

Scintillation Counter: A counter in which light flashes produced in a scintillator by ionizing radiation is

converted into electrical pulses by a photomultiplier tube.

Shielding Material: Any material, which is used to absorb radiation and thus effectively reduces the intensity

of radiation, and in some cases eliminate it. Lead concrete, aluminum, water, and plastic

are examples of commonly used shielding material.

Seivert (Sv): Unit of dose equivalent numerically equal to the absorbed dose in Grays multiplied by the

quality factor.

Smear: A procedure in which a swab, e.g., a circle of filter paper, is rubbed on a surface and its

radioactivity measured to determine if the surface is contaminated with loose radioactive

material.

Specific Activity: Total radioactivity of a given nuclide per gram of a compound, element, or radioactive

nuclide.

Survey Meter: A handheld, portable radiation detection instrument designed for surveying or monitoring

an area for the presence of radioactive material or radiation.

Thermoluminescent A dosimeter made of certain crystalline material which is capable of both storing a

Dosimeter (TLD): fraction of absorbed ionizing radiation and releasing this energy in the form of visible

light when heated. The amount of light released can be used as a measure of radiation

exposure to those crystals.

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Unrestricted Area: The licensee or registrant for purposes of protection of individuals from exposure to

radiation and radioactive material does not control any area access to which, and any area

used for residential quarters.

Wipe Test: Refer to “Smear”

X-Ray: Penetrating electromagnetic radiation having wavelengths shorter than those of visible

light. Bombarding a metallic target with fast electrons in a high vacuum usually

produces them. In nuclear reactions it is customary to refer to photon originating in the

nucleus as gamma rays, and those originating in the nucleus of the atom as x-rays.

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