Category Archives: Radiology

Patient Fluoro Dose Tracking and Follow-up Policy

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The Conference of Radiation Control Program Directors (CRCPD) has published guidance on the tracking of dose in fluoroscopy. Both a brief outline and a more descriptive white paper are available.

Basically, any patient who experienced fluoro time in excess of one hour should be notified and tracked for post-procedure erythema.  Facilities should follow up by telephone approximately 3 weeks after the procedure to ascertain whether there is any evidence of a radiation induced injury. This will assure that prompt medical care will be delivered if necessary.

Other threshold criteria besides simple fluoro time are also discussed.  The linked documentation in the above paragraph should be of great assistance in crafting a facility-specific policy to address this important issue.

Authorized Operation of Fluoroscopic Machines for Medical Use

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Thanks to Julie Kralis, Director of Imaging Services at Sherman Hospital in Elgin, IL for the following article concerning fines imposed by IEMA on two nurses and a registrant for unauthorized use of fluoroscopic machines.

32 Ill. Adm. Code Part 360.30 “General Requirements and Administrative Controls” Section a) 3) states that the registrant shall,

Verify that each individual required to be accredited by 32 Ill. Adm. Code 401 to apply x-rays for either diagnostic or therapeutic purposes is properly accredited with the Agency prior to allowing the individual to apply medical radiation procedures on human beings;

360.30 a) 4) continues,

[The registrant shall] permit operation of the x-ray systems only by individuals who are licensed in accordance with State law (see Section 360.10(a) of this Part), or who are accredited by the Agency pursuant to 32 Ill. Adm. Code 401 or who are exempt from such requirements in accordance with the provisions of 32 Ill. Adm. Code 401.

Be sure to check out our previous article on the requirement for licensed radiographic technologist participation during fluoroscopic procedures.

Retention of Records

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IEMA Instructional Set 52.2 Appendix A describes the retention of documents for permanent nuclear medicine job sites.  For radiographic installations, the requirements for record retention are found in 32 Ill. Adm. Code Part 360.

One of the items not listed in Part 360, however, is the requirement for CT QA record retention.  Based on a discussion with a senior IEMA CT inspector, the minimum retention period for CT QA testing records is one year, or for the period since the last inspection, whichever is longer.

IEMA further recommends that facilities keep all of the previous year’s data while the facility’s technologists collect the current year’s data.  This would help prevent inadvertent disposal of records, and provide some overlap to ensure that there is no gap in the CT QA history.

Fluoroscopy Procedures and the Requirement for a Licensed RT

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Old Fluoroscope

1950's Fluoroscope

Regulations do not specifically address the issue of allowing non-licensed radiologic technologists (RT) to pan the table and move the fluoroscopy unit in cath lab procedures. In an April, 2001 letter to Diagnostic Imaging Specialists (DIS), the IEMA Division of Electronic Products disseminated guidelines that expanded upon the basic licensing requirements for individuals who apply ionizing radiation to human beings.

In the letter, the Division of Electronic Products states that,

“Provided that a licensed physician and an accredited technologist are physically present and actively participating in the fluoroscopic procedure, the following tasks may be performed by individuals other than accredited radiologic technologists: 

  • Moving or positioning the patient; 
  • Moving or positioning of the x-ray unit; and 
  • Resetting the fluoroscopic timer.
However, the adjusting or setting of technique factors for the x-ray exposure, and the activating of the exposure switch must still be performed by a licensed practitioner or accredited technologist.

 

For more information on the accreditation requirements for any individual who applies ionizing radiation to human beings, please visit 32 Ill. Adm. Code 401.

Use of Bismuth Shields in CT

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CT scan of brain

Computer tomography of human brain, from base of the skull to top. Taken with intravenous contrast medium.

The debate over the use of bismuth shields during CT procedures continues.  In May of this year, the Radiological Society of North America (RSNA) published an article prefacing the American Association of Physicists in Medicine (AAPM) position statement on this issue. The RSNA article outlines the benefits and possible shortcomings of using bismuth shields to reduce dose to the patient in CT.

Many facilities do not have standardized procedures for use of bismuth shields.  At the University of California at San Francisco Hospital for example, their policy only states that, “Bismuth or lead shields are applied to breasts, thyroid, gonads, and eyes whenever possible, especially in pediatric patients, to minimize their exposure to radiation.”

In the 2008 edition of the book, MDCT: From Protocols to Practice by M.K. Kalra et al., the authors write,

“Recently, thinly layered bismuth-impregnated radioprotective latex shields have been used to reduce the surface dose to the breast, thyroid, and lens when these structures lie in the area of interest.  However, the use of gonadal shielding during CT examinations is controversial. A testis capsule (shield) can reduce the absorbed dose to the testes in abdominal CT, whereas a lead apron is not appropriate for dose reduction to the ovaries (due to their frequently irregular position).”

The authors go on to say,

“Recent studies suggested that although the use of in-plane bismuth shields can reduce exposure to important parts of the body, such as thyroid, breasts, and lens, they also lead to changes in the image noise and CT attenuation values or Hounsfield units [1]. Geleijns et al. therefore recommended that the use of these shields should be avoided by achieving dose reduction with tube-current reduction [1].”

We are not aware of any hospitals that have a written policy on the use of bismuth shields, and it may be prudent to wait to develop one until the AAPM releases their position statement on the use of bismuth shields in CT.  A recent presentation by Dr. McCollough, Director of the CT Clinical Innovation Center at the Mayo Clinic, adds more data to the growing body of research.

IEMA regulations do not comment on the use of bismuth shields, but only on the use of lead shields, as in 32 Ill. Adm. Code 360.40 m) “Gonadal Shielding. Except for cases in which it would interfere with the diagnostic procedure, gonadal shielding of not less than 0.5 millimeter of lead equivalent shall be used for patients (who have not passed the reproductive age) during those radiographic procedures in which the gonads are in the useful beam.”

This linked article in the American Journal of Roentgenology discusses the use of lead in shielding the male gonads during CT.

References:

[1] Geleijns J, Salvado Artells M, Veldkamp WJ et al (2006) Quantitative assessment of selective in-plane shielding tissues in computed tomography through evaluation of absorbed dose and image quality. Eur Radio 16:2334-40 52.