Amanda Bath Advance Practitioner RPS IRMER , WHY? Amanda Bath Advance Practitioner RPS Introduce myself Experience May 2014

RPS- Radiation Protection Supervisor RPA- Radiation Protection Advisor CMPE- Christies Medical Physics and Engineering

Topics Ionising radiation and effects. Risks Legislation How does it effect our practice

Sources of Ionising Radiation UK Ionising radiation is around us all of the time. Air we breathe It is in the food we eat (e.g. bananas contain radioactive potassium, brazil nuts. Radon gas from the ground, -geographical, gamma from certain rocks in the ground, Cosmic: high energy particles from space (increases with height so there is more radiation when travelling in a plane, and pilots need to be careful about the dose) , Small piece of pie 0.6% other man made IR such as nuclear industry , man made products, occupational. Ionising radiation can come from a number of different sources. shows the average individual background radiation dose in the UK. Note that around 50% of the dose comes from radon, although this varies across the country. The term internal radiation is used when a radioactive isotope is inside the body. Medical 15%

Effects of Ionising Radiation

somatic effects stochastic deterministic Effects which occur in the irradiated individual are called somatic effects. The cellular interactions and damage can be categorised into two types: stochastic and deterministic effects.

Stochastic Effects Stochastic effects are ones where the chance of the effect happening increases with radiation dose. There is no threshold dose at which they will definitely occur. Stochastic effects may occur for diagnostic procedures although the probability is very small. Stochastic effects may not appear for years or decades, making it impossible to determine what caused the damage. An example of this is lung cancer, which can be caused by smoking, radon gas, or ionising radiations and which does not appear for about 15 years after the damage has occurred. These effects are known as stochastic as they are completely random. It is like the lottery, the fewer tickets you buy, the lower the chance of winning.

Deterministic Effects These occur when high radiation doses are received. This damage is a consequence of cell death and the effects can show immediately or after several cell divisions. The damage can be directly linked to that exposure. There is a threshold below which no deterministic effects occur. These deterministic doses are well above the doses received during diagnostic radiology and nuclear medicine examinations.

Risks Annual Risk of death: Smoking 10 cigarettes a day – 1 in 200 Road accident – 1 in 5,000 Natural radiation – 1 in 9,000 Accidents at work – 1 in 20,000 Medical radiation – 1 in 53,000 Put things into perspective life time risk of death

Legislation

The United Nations 1953 Dwight D.Eisenhower “Chance for Peace”. IAEA- International Atomic Energy Agency WHO- World Health Organisation. UNSCEAR- United Nations Scientific Committee on the Effects of Atomic Radiation. Dwight D. Eisenhower April 16th 1953 .Chance for Peace speech to UN general assembly because of fear of Russia's atomic power. United Nations legislation-Influences/reasons started was because of Started in 1950’s after Hiroshima and Nagasaki when The International Atomic Energy Agency (IAEA) - the nuclear watchdog of the United Nations - promotes the peaceful use of atomic energy while trying to make sure that the technology is not used for military purposes. WHO- world health organisation, interested in health of populations, human orientated. Unscear- Levels of radioactivity in the environment that will effect said environment and subsequently onto humans- animal, vegetable, mineral.

International Commission for Radiological Protection (ICRP) Independent advisory body founded in 1928 , registered charity. Three fundamental principles of radiation protection Justification Optimisation Dose limits Established to advance for the public benefit the science of Radiological Protection , in particular by providing recommendations and guidance on all aspects of radiation protection. The ICRP regularly reviews current knowledge about radiation risks and publishes recommendations based on the consensus of opinion of international experts in the field. These are then adopted by the EU in the form of directives, and interpreted in law by national governments. specific recommendations about the whole range of uses of ionising radiation including medical exposures which it defines as 'radiological practices in medicine'.  

European Union/Commission European Atomic Energy Community (EURATOM) Peaceful use of Nuclear Energy . Protection of patients exposed in medical practice Issued directives that led to IR99 and IRMER.

United nations – with WHO and Unscear plus recommendations from IRCP lead to EU directives and the forming of UK legislation. UK Legislation

IRR99 is UK law and is enforced by the HSE. The Health and Safety Executive (HSE)- Work with Ionising Radiation , which includes: The Ionising Radiations Regulations 1999 (IRR99) An approved Code of Practice Guidance notes IRR99 is UK law and is enforced by the HSE. HSE published work with ionising radiation. Any workers with any source of ionising radiation.

IRR99 The employer has the responsibility for complying with the regulations but will not be able to fully discharge his responsibility without the cooperation of his employees. It is therefore important that you are aware of the key points of the legislation.

IRR99 As Low As Reasonably Practicable ALARP “Every radiation employer shall…take all necessary steps to restrict as far as reasonably practicable the extent to which his employees or other persons are exposed to ionising radiation.” Irr99 what does it mean to us as employees? Important part of the legislation. All employers have a duty to follow this principle.

IRR99- Requirements Appropriate training Register of staff “engaged “ in work. Staff uniquely identified . Training dates and refresher dates recorded. Training of staff engaged in working in radiation- importance of complying with regulations. Not cleaners etc who are just directly concerned- given adequate training and aware of local rules.

The Ionising Radiation (Medical Exposure) Regulations 2000 IR(ME)R Employers are required to provide written procedures and protocols to cover medical exposures for which they are responsible. IR(ME)R 2000 is UK law and is currently enforced by the Care Quality Commission.(CQC)

IR(ME)R 4 duty holders in the administering of ionising radiation Employer-radiological installation and risk assessments. (advice from RPA) Referrer- registered medical practitioner/health professional. Practitioner- registered medical practitioner/health professional. Justifies the exposure. Operator- person who carries out the exposure. No role is specific to any profession Employer-A person who carries out (other than as an employee), or engages others to carry out medical exposures. Provide a framework under which processes take place. E.G. The Trust .Referrer-A registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with employer’s procedures to refer individuals for medical exposure to a practitioner. E.g. Clinician, Radiologist, Radiographer, Nurse Practitioner . The referrer is responsible for supplying the practitioner with sufficient medical data relevant to the medical exposure. Practitioner-A registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with employer’s procedures to take responsibility for an individual medical exposure/ Justifies the exposure. E.g. Radiologist and Radiographers Operator-Any person who is entitled in accordance with employer’s procedures to carry out practical aspects of the exposure and any supporting aspects e.g. Q.A.

IR(ME)R- Operators An operator is any person who is entitled, in accordance with the Employer’s procedures, to carry out practical aspects of the exposure allocated to them by the employer or practitioner. This includes identification of the patient! patient could be client/ family history screening. Includes QA equipment testing. Again working under a written framework and local rules. Practical aspects include the physical conduct of the exposure and other supporting aspects that have an influence on radiation dose to the patient. Written guidelines for the operator to follow , know your own limits. Check the patient information carefully and ensure what they say is what you are expecting-clinical info , dob, address .

IR(ME)R-Requirements Adequate training. Continuing education and training with up to date records/register. Assistant practitioners- work-based training , e-learning , within scope of qualification you have completed. Competence matrix- individual training profiles. No practitioner or operator shall carry out an exposure without adequate training. Use of any new techniques and radiation protection requirements records should be up to date and show nature of training. Assistant practitioners without professional qualifications. Duties under Irmer indicated , date and nature of training recorded.

How does this effect our practice?

X-ray set and wet developing! 1988

How practice changes. Incidents- Paper to electronic systems. Film screen to full field digital mammography. Talk about 2 incidents that occurred in our dept. They made us reflect and change our practice.

1.Electronic Requesting No mammograms repeated within 6 months of previous mammogram. (exceptional circumstances). Previous paperwork not available, no method of recording information. Client had a mammogram 2 months earlier. Dept policy no mammograms within 2 months, no longer film packet available or paperwork. Complete electronic requesting, where do you justify exposure , operators details, amount of films uused , room no ect..

Outcome New protocol in place. Check on PACS system for previous imaging Record on ‘Q’ page of RIS system. Result- fewer incidents. RPA happy that systems are in place. Wasn’t reportable to CQC. Careful with identification and questioning. No problem if follow protocol.

Electronic page to show justification, operators initials/code and in comments box date of last mammogram. Final ID check still rests with operator.

2.FFD Mammography Flat field test The parameters are set automatically ie. large focal spot, Mo/Mo, 26kV and 200 mAs. Ensure that the operating parameters are returned to Standard and Auto Describe briefly the test, all set automatically in QA window on GE machine. 4 patients on 1 morning all had to have mammos repeated because radiological unreportable/inadequate. Extra dose of unnecessary radiation.

2.FFD Mammography Once back to browser window still set on 26Kv and 200 mAs. patients x-rayed before realised , several staff members. All 4 images for each lady had to be repeated as images were technically inadequate. RPA informed and extra probable dose calculated.

Outcome New protocol in place. Sign to say have returned to “auto” and “auto”. All staff informed of incidents. Not happened since. Change to practice, all staff informed. Not a blame game but any incidents need to be reported!!

Regulatory Changes 2007 EU process of revision Influenced by IRCP and IAEA recommendations. The Department of Energy and Climate Change. Audit- Identification and justification. EC reviewing and consolidating radiation directives into one new basic safety standards directive. Influenced by the bodies we recommended prev. Under the hat of the dept of energy and climate change. De of E and CC overall uk responsibility for revision of these standards.

Audit Audited the ‘Q’ page. April 2013- 179 out of 196, (91%) of examinations were justified, from a target of 100%. Dec 2013-199 out of 200 examinations (99.5%) were justified and had the operator recorded. Electronic requesting April 2012. April 2013 audited selection of examinations from last 12 mths . Reviewed data, compliance 91% needs improving -To comply with legislation, each ionising radiation exposure within the department has to be justified and the operator (technician’s code) identified. By recording operators initials, filling in date of last mammo assuming operator has correctly id client. Audit results fed back to staff – repeated audit Dec 2013, larger numbers included all examinations even SN biopsies. Completion of data improved to 99.5%. Still not 100% but v.close. Audit does work!

Summary Legislation is LAW. Necessary to keep up to date with training. Recording of evidence. Resources. IRR 99 and Irmer 2000 are law-legal requirement that we adhere to these regulations and keep up to date with our training. Laws are evolving and changing as our ways of working with radiation changes- digital mammography, paperless systems. All evidence –including evidence of training and competencies must be recorded. Report any incidents to RPS, supervisor. If in doubt don,t press the button.

Health education England Programme in partnership with the NHS and professional bodies. Useful tool, very informative and interesting, back to basics approach but very comprehensive. www.e-lfh.org.uk

References www.hse.gov.uk/radiation/ionising www.christie.nhs.uk/the-foundation-trust/treatments-and-clinical-services/christie-medical-physics-and-engineering-(cmpe).aspx www.e-lfh.org.uk Amanda.bath@uhsm.nhs.uk