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Vanderbilt University Online Radiation Safety Policies & Procedures Manual
Table of Contents

Section 7: Responsibilities and Rules for Radiotherapy Treatments

A. Brachytherapy

1. Radiation Oncology Responsibilities

1. Insertion and removal of sealed sources in patients shall only be performed by physicians specifically authorized by the RSC or by physicians operating under their direct supervision.
    
2. All patients with temporary implants must be hospitalized in a private room approved by the RSC.
   
   Patients with permanently implanted sources must be hospitalized in a private room approved by the RSC. VEHS or Radiation Oncology will evaluate each case to determine if the patient may be discharged without restriction or treated as an outpatient.
   
   Application must be made to the RSC for authorization to use hospital rooms for brachytherapy patients, on a form 7A available on the VEHS web site www.safety.vanderbilt.edu. VEHS maintains a list of rooms authorized for use with brachytherapy patients.
    
3. Visitors, nursing staff, and others must observe radiation precautions, when the patient's room is posted with a radiation warning sign. These precautions are given in part C of this section. Precautions are also summarized on the posted patient warning signs.
    
4. Exposure rates in unrestricted areas (hallway and adjacent patient rooms) must not exceed 2 mrem (0.02 mSv) in any one hour or 100 mrem (1 mSv) in a year. This may require the use of bedside lead shields in some cases or having adjacent rooms vacated while radiation sources are present.
    
5. A radiotherapy patient warning sign must be posted on the door of the patient's room when radiation precautions are required. If isolation rooms are used, the ante room door must also be posted if the exposure rate exceeds 2mrem/hour (0.02 mSv/hour) in the ante room. State regulations require that the number of sources used, the activity, date, and radiation level at one meter be recorded on this sign. The radiation level may be determined by measurement with a survey meter or by calculation.
   
   Relatively high exposure rates may be expected from 137Cs, or 192Ir patients. Before sources have been loaded in the patient, VEHS must be notified so they may make the required measurements and post the warning sign.
   
   Radiation levels are much lower for 125I patients. Radiation Oncology is responsible for the survey and posting requirements for these patients.
    
6. During hospitalization, radiation precautions must be observed until VEHS removes the radiation warning sign. 125I patients may be released from the hospital if the shielded exposure rate at one meter is less than 0.2 mR/hour, as determined by VEHS measurements.
   
   Prior to release of the patient and the room, VEHS staff will measure the radiation exposure rate of the patient and make a final survey of the patient's room to check for lost sources. Removal of the warning sign from the patient's door signifies that the room has been cleared for unrestricted occupancy.
    
7. When radiation sources are implanted in surgery, it is the responsibility of the radiation oncologist to instruct other participating personnel in radiation precautions.
    
8. Radiation exposure to other patients in the recovery room must not exceed 2mrem (0.02 mSv) in any hour or 100 mrem (1 mSv) to an individual in a year. Recovery room personnel must be notified sufficiently in advance to make arrangements for the patients.
    
9. An accountability log tracking use from storage to return to storage of all sealed sources must be maintained for inspection by the Tennessee Division of Radiological Health. The record shall include the following information:
   1. date and number of sealed sources removed from storage, and quantity of material in each sealed source
   2. location of use or patient name
   3. date of return, and indication that all sources are accounted for
   4. signature of individual removing or returning sources.
       
10. All persons who regularly handle brachytherapy sources must wear whole body and ring dosimeters. The user must make full use of protective devices such as remote handling tools, L-blocks, etc.
     
11. Transport of brachytherapy sources shall be in adequately shielded containers. Shielded containers should be left on the floor (usually in the patient's room) for use in event of an emergency. Return all unused sources to the storage room immediately after the implant procedure is completed.

2. VEHS Responsibilities

1. After a patient has been loaded with 137Cs or 192Ir, VEHS will post radiation warning signs and measure radiation levels from the patient and in adjacent unrestricted areas.
   
   When radiation sources are implanted in surgery, VEHS must assure that no radiation sources remain in the room after surgery. Sources of very small dimensions such as 125I seeds are very difficult to locate without a survey meter. Therefore, it is the responsibility of VEHS to perform a radiation survey when this type of source is implanted.
    
2. VEHS will perform the closing survey in the patient's room to verify that no sources remain after 125I sources have been implanted. VEHS will also make measurements of all patients released from the hospital that contain radioactive implants to verify that radiation exposure rates are within required limits.
    
3. VEHS will maintain the list of hospital rooms approved by the RSC for use with brachytherapy patients.
    
4. Records of the surveys made for each patient will be collected by VEHS and maintained for inspection by regulatory limits.
    
5. VEHS will test all sealed sources for contamination at intervals not to exceed six months.
    
6. VEHS will conduct a physical inventory of all sealed sources at quarterly intervals.
    
7. VEHS will be available for radiation emergencies.
    
8. VEHS must conduct a source count and a radiation survey of the patient to confirm that no sources remain. This must be documented on the back of the door sign.

B. Therapeutic Quantities of Radiopharmaceuticals

1. Nuclear Medicine Responsibilities

1. Radiopharmaceuticals for therapeutic purposes shall be administered by, or under the supervision of, physicians authorized by the RSC.
2. The radiation precautions given below must be followed whenever a hospitalized patient does not meet release criteria. Once a patient falls below the release criteria, the radiation precautions are no longer required.
3. Inpatient admitting must be notified when a patient is to receive therapeutic quantities of radioactive material. The patient must be assigned to a room approved for this purpose by the RSC. The nursing staff must be informed whenever radiation precautions are required for a patient.
4. Prior to the administration of therapeutic quantities of 131I, the room must be prepared to avoid subsequent contamination problems. The floor, bathroom and major surfaces in the room that are likely to become contaminated must be covered with protective material, as appropriate to the amounts of contamination expected.
5. If a patient will be administered therapeutic quantities of a radiopharmaceutical, notify VEHS of the time and location of the administration so they may post required signs and make radiation measurements. Exposure rates in unrestricted areas (hallway and adjacent patient rooms) must not exceed 2 mrem (0.02 mSv) in any one hour or 100 mrem (1 mSv) to an individual in one year.
6. Whenever possible, large therapeutic doses should be administered in the patient's room.
7. Patient care instructions, nursing procedures and visitor restrictions are given in part C of this section and are also summarized on the warning sign posted on the patient's door.
8. Radioactive tissue specimens, blood, ascetic fluid, excreta, or cadavers may be delivered to laboratory pathology services. All specimens from these patients that are sent to a laboratory must be labeled "Radioactive". If possible, specimens should be taken before administration of radioactive material.
9. The patient may be released from the hospital when the administered radioactivity falls the release criteria. If the patient remains hospitalized, the radiation precautions may not be removed until the patient meets release criteria. VEHS will be responsible for determining when the activity in a patient has reached these levels.
10. When a patient containing residual activity leaves the hospital, the physician is responsible for providing any necessary instructions to the patient and family concerning the nature and hazard of the treatment and any further precautions that may be necessary.
11. Upon discharge of the patient or removal of the radiation precautions, the room and contents must be surveyed to ensure that radiation and contamination levels must meet requirements for unrestricted use. VEHS will decontaminate the room and will maintain monitoring records.

2. VEHS Responsibilities

1. Radiation warning signs must be posted whenever the administered activity exceeds release criteria. These signs will be posted and removed by VEHS.
2. After the administration of radiopharmaceuticals, VEHS will perform the radiation surveys required by State regulations.
3. VEHS will determine when a patient may be released from the hospital or radiation precautions may be removed.
4. Bags of radioactive waste generated by radiotherapy patients will be collected and disposed by VEHS.
5. Before a therapy patient's room can be reassigned to another patient, the room must be surveyed for contamination. When surveys indicate that no contamination exists above allowable limits, the room warning sign will be removed. Removal of this sign signifies that another patient may occupy the room.
6. VEHS will maintain all survey records for inspection by the State regulatory agency.
7. VEHS is available for routine consultation and for any emergency situation. The VEHS telephone number is listed on the radiation warning sign.

C. General Staff and Visitor Precautions

1. Patients who have received a tracer dose of radioactive materials for diagnostic tests or who have received small amounts for minor therapies present no special hazard. However, patients containing appreciable therapeutic quantities of radioactive materials may constitute a significant radiation source. Guidelines designed to maintain radiation exposure at safe levels have been established for dealing with these patients. Patients must usually be in a private room. A radiation warning sign posted on the room door can identify these patients.
    
2. Hazards from radioactive materials arise from:
   1. Radiation emitted by radioactive materials located external to your body, such as the radioactivity in the patient's body.
   2. Contamination of skin with radioactive materials. This could occur, for example, when handling radioactive excreta from the patient.
   3. Inhalation or ingestion of radioactive materials.

   For unsealed sources (radioiodine, or radioactive phosphorus) all three hazard types usually exist.

   For sealed sources (cesium, iridium seeds, or 125I seeds) there is no possibility of contamination, inhalation or ingestion of radioactive material, provided these sources are not damaged, but there is an external radiation hazard. VEHS tests these sources for leakage on a regular basis to assure that they are safe.
    

3. The attitude of the attendant toward the patient is important. Good nursing care involves relieving anxiety, and since many people have a fear of radiation, the attitude of the hospital personnel can do much to temper this fear. Nurses should not act as if they are afraid of the patient or have any anxiety about being in the patient's room. There is no reason to be more concerned about caring for a patient containing radioactive material than for a patient with an infectious disease.
    
4. Radiation precautions will be in effect during the entire period that the radiation warning signs are posted. Removal of the signs signifies that the radiation precautions are no longer necessary.
    
5.  If there are any special instructions for a particular patient they will be noted on the patient's chart or on the posted signs.
    
6. Always provide adequate care for the patient but work efficiently and quickly. Patients should be encouraged to care for themselves and to be as self-sufficient as possible, thus reducing the need for contact with hospital personnel.
    
7. Pregnant staff should not be responsible for the routine care of radiotherapy patients.
    
8. VEHS will perform surveys of the therapy patient's room, remove all radioactive waste, and will be available to answer questions concerning the hazards or the precautions needed for a particular procedure.
    
9. Release of the room for another patient:
   
   For temporary implants, VEHS will verify that no sources have been left in the room and will remove the sign from the patient's door.
   
   For radioiodine therapies, VEHS will survey the room before it is reassigned to another patient. VEHS will remove the warning signs at this time to signify that the room is ready for the next patient.
    
10. Radiation monitoring badges will be issued to nurses administering care to therapy patients.

D. Radiation Precautions regarding Patients receiving Temporary Implants

1. The radioactive material is contained in metal tubes, needles or ribbons and is inserted into a body cavity (vagina, nasopharynx) or directly into tissue. The material is not dispersed within the patient's body and fluid excreted from the patient is not radioactive. These sources are temporary implants and no residual radiation remains in the room or patient after removal of the sources.
   
   The tubes or needles emit gamma radiation and the exposure rates encountered are considerable a few feet from the patient. Hence all individuals should maintain as much distance as possible from the patient.
   
   The restrictions given below are to remain in effect until the sources are removed.
    
2. Temporary brachytherapy implant patients must be confined to a private room. The patient must remain in bed unless orders to the contrary are written.
    
3. Visitors should stay at least 6 feet from the patient and should limit their visit to one hour per day. There should be no visitors who are pregnant or under age 18.
    
4. Nursing and other hospital staff should minimize time spent in the room and near the patient, consistent with the provision of all necessary care. No special precautions are needed for vomit, urine, eating utensils, etc.
   
   Bed baths given by a nurse should be omitted while the sources are in place. Personal care should not be given gynecological patients during the treatment period. The perineal pad may be changed when necessary unless orders to the contrary have been given.
   
   Only the attending physician or radiation oncologist may change any dressings or bandages used to cover an area of insertion.
   
   All linens, gowns, dressings, equipment and trash containers must remain in the room until Radiation Oncology and VEHS have accounted for all sources and the release the room.
   
   Nurses who are pregnant should not be assigned to these patients.
    
5. If the implanted source becomes loose or separated from the patient, or if the patient requires emergency surgery, contact the attending Radiation Oncologist immediately. Never touch needles, capsules or applicators containing radium or cesium. If a source becomes dislodged, use long forceps and put it in the shielded cart or the corner of the room.
    
6. At the conclusion of the treatment VEHS will verify that no sources remain in either the patient or the room. After verification, the radiation warning sign is to be removed. Removal of the sign signifies that the room is available for occupancy for the next patient.

E. Radiation Precautions regarding Patients receiving Permanent Implants

1. Radioactive material in tiny containers is inserted into tumors and left there permanently, ultimately becoming inactive through radioactive decay. The radioactive material is contained within metallic seeds and is not dispersed within the patient's body. Fluids excreted from the patient are not radioactive. No special precautions are needed for urine or vomit.
   
   VEHS will measure the radiation levels emitted by each patient. The radiation precautions given below may be removed after a specific length of time since the radiation levels are continually decreasing due to radioactive decay. The date at which these precautions can be removed will be given on the caution sign placed on the patient's door. In some cases, radiation precautions may not be required at all due to the very low amounts of radioactivity used.
    
2. Patients should remain in their private rooms until the date at which the radiation precautions are removed.
    
3. Visiting time is normally restricted to one hour per day, and visitors should stay at least 6 feet from the patient. There should be no visitors who are pregnant or under age 18.
    
4. Nursing and other hospital staff should minimize time spent in the room and near the patient, consistent with the provision of all necessary care. Bed baths given by a nurse should be omitted while radiation precautions are in effect.
   
   Any dressing or bandages used to cover an area of insertion may be changed only be the attending physician or radiation oncologist.
   
   All linens, gowns, dressings, equipment and trash containers must remain in the room until VEHS has accounted for all sources and the release the room.
   
   Pregnant nurses should not be assigned to these patients.
    
5. Call Radiation Oncology should you locate any loose metallic seeds in the patient's room. Do not handle seeds with bare hands. If a source becomes dislodged, use long forceps and put it in the shielded cart or the corner of the room.
    
6. At the conclusion of the treatment, VEHS will verify that no sources remain in the room. After verification, the radiation warning sign will be removed. Removal of the sign signifies that the room is available for occupancy by the next patient.

F. Radiation Precautions regarding Patients receiving Radioiodine

1. The radioactive iodine (131I) is administered orally to the patient. The iodine concentrates in the patient's thyroid. However, most of it will be eliminated from the patient via the urine within the first 48 hours. Radioiodine will also be present in perspiration and other body excreta. Radioactivity remaining in the body after 48 hours is located primarily in the patient's thyroid and is eliminated slowly.
   
   Fluids from the patient's body will contaminate linen, bed clothes, and practically anything the patient touches. Thus, the patient and room should be handled as one would handle a surgical procedure (for example, a gown, shoe covers, and gloves must be worn).
   
   The primary hazard to attending personnel is the possible intake of radioactive material that has been released from the patient's body. Major routes of potential intake are passage through skin and ingestion. For example, if you were to touch a surface contaminated with radioactivity, your fingers could transfer radioactivity to your mouth when eating, smoking, or applying cosmetics.
   
   A secondary hazard is the radiation emitted by the patient's body or from collections of urine. Personnel should minimize time spent in the vicinity of these sources and maintain as much distance as possible while delivering the required medical care.
    
2. Patients receiving the 131I therapy must be assigned to a room with a toilet. The floor and any objects the patient is likely to touch must be covered with plastic or other protective material to prevent contamination. The Paint Shop will prepare the room prior to the administration of the radioiodine. A strict isolation setup needs to be ordered for the patient. In addition, shoe covers and a waterproof mattress cover should be ordered.
    
3. The patients will receive the following instructions:
   1. You are restricted to your room.
   2. You must use disposable eating utensils. These utensils should be placed in the special waste container after use.
   3. You should wear gloves when handling items that are not protected by coverings, such as personal items the patient may wish to take home.
   4.  You should flush the toilet two or three times after each use. This will insure that all radioactive urine is washed from the toilet bowl.
   5. You should avoid physical contact with visitors.
       
4. Visitors have the following restrictions:
   1. Visits should be limited to 1 hour per day. No pregnant women or persons under age 18 should visit the patient without special permission from VEHS.
   2. Visitors should remain at least 6 feet from the patient.
   3. Visitors must be protected with gowns, shoe covers, and gloves. Visitors should not handle any items in the room.
   4. Visitors must not smoke, eat, or drink while in the patient's room.
       
5. Nursing Care
   1. Nursing and other hospital staff should minimize time spent in the room and near the patient, consistent with the provision of all necessary care.
   2. Attending personnel must wear disposable gloves when handling or touching anything in the room. Remove gloves and place in designated waste container before leaving the room.
   3. Gowns should be worn if significant time will be spent in the room or whenever necessary to protect your clothes from contact with the patient or items in the room.
   4. Shoe covers should be worn when in the patient's room. They must be removed when leaving the room to avoid tracking contamination from the room.
   5. Use special caution when encountering vomit within the first 24 hours, or spills of urine or urinary incontinence within the fist 48 hours. Call VEHS if this occurs.
   6. Disposal items such as plates and eating utensils should be used whenever possible. These items must be placed in the designated waste container.
   7. Bedclothes, towels, and bed linen used by the patient should be placed in the laundry bag provided and left in the patient's room until monitored by VEHS. If contaminated, they will be collected and later released when they are no longer radioactive.
   8. All items within the room should be checked for contamination by VEHS staff before being removed.
   9. Excess food may be flushed down the toilet.
   10. Nursing staff should not provide assistance in bathing the patient for the first 48 hours unless specifically approved by the physician. However, the patient should be encouraged to bathe daily.
   11. All specimens of tissue, blood, ascetic fluid, or excreta from radioiodine patients must be labeled as "Radioactive" before delivery to a clinical laboratory.
        
6. Before the patient's room can be reassigned to another patient, VEHS must survey the room for contamination and remove all radioactive waste. The room will be decontaminated if necessary.

G. Radiation Precautions regarding Patients receiving Radioactive Phosphorus

1. General Principals
   1. Radioactive phosphorus (32P) may be injected into the pleural or peritoneal space for treatment of malignant effusions. Since the radioactive material remains in these cavities no special precautions are necessary for the patient's urine, vomit, etc. Care must be taken, however, if there is leakage from the puncture wound.
   2. 32P may also be given orally or intravenously for treatment of polycythemia vera, leukemia, or bone metastases.
   3. Special radiation precautions are not required for patients administered 32P.
   4. There is no external radiation emitted from these patients. Patients are allowed visitors in accordance with the usual hospital rules.
   5. Patient must have private room. However, patient may be allowed to leave room for medical care, visiting, etc.
       
2. Intracavity Injections - Nursing Care
   1. Surgical dressings over the incision may be changed only as directed by a physician. If at any time the dressing becomes damp, stained, or bloody, the physician in charge shall be notified. Contaminated dressings should be placed in a plastic bag and held for disposal by VEHS. If there is no drainage from the wound after the first few days, dressings may be handled in the usual manner.
   2. Gloves should be worn when cleaning any area around the incision or when handling contaminated dressings.
   3. Bedding may be changed unless there has been drainage from the puncture wound, in which case VEHS should be notified.
       
3. Oral Administration or Intravenous Injection - Nursing Care
   1. During the first 24 hours, care should be exercised when handling urine. Gloves should be worn and any spilled urine should be wiped up with paper towels, placed in a plastic bag, and held for disposal by VEHS.
   2. If the 32P has been administered orally, care must also be exercised when handling any vomit that occurs within 24 hours. Handle in the same manner as urine.

H. Patients receiving small doses of radioactive material for diagnostic studies or minor therapies

1. General Principals
   1. The most commonly used radioactive material in Nuclear Medicine studies is technetium-99m (99mTc), a gamma emitter with a half-life of 6 hours. In many of the studies, especially bone and renal studies, the radioactive compounds are removed from the body in the urine and occasionally in the stool. Most of the radioactivity is gone after 24 hours.
   2. The objective in diagnostic procedures involving radionuclides is to determine something about an organ's shape or function. The administered dose must be small so as not to produce any radiation effect, which might result in a change in the status quo of the patient.
   3. With minor therapies, such as radioiodine for treatment of hyperthyroidism, the amount of radioactivity administered is sufficiently small to permit outpatient treatment of these patients.
   4. Relatively little radiation exposure or contamination hazard is associated with patients receiving radionuclides for minor therapies or diagnostic studies. Radiation warning signs are not posted for these patients.
       
2. Patient/Visitor Restrictions
   There are no restrictions on the patient's activities or contacts with other patients or visitors, unless otherwise advised by the physician or VEHS.
    
3. Nursing Care
   No special precautions are required when working with these patients, except during the first 24 hours when normal hygienic precautions (such as wearing gloves) should be followed when handling bodily fluids. Nursing personnel are not required to wear radiation monitoring badges. No special precautions are needed for dishes, instruments, or linen. Reducing time spent at bedside during the first 24 hours will minimize external radiation.

I. VEHS Responsibilities during patient procedures involving radioactive material

1. Brachytherapies
   1. Temporary Implants:
      VEHS will post radiation warning signs and measure radiation levels when notified on implants occurring during normal working hours.
   2. Permanent Implants:
      1. VEHS will post warning signs and make the required radiation measurements, and instruct nursing personnel as necessary.
      2. VEHS will determine the date when radiation precautions may be removed.
      3. Upon removal of radiation precautions, VEHS will perform a final survey and remove warning signs.
   3. VEHS will provide monitoring assistance in surgery when requested or deemed necessary.
   4. Records of the surveys made for each patient will be collected by VEHS and maintained for inspection by the Tennessee Division of Radiological Health.
   5. VEHS will test all sealed sources for contamination at intervals not to exceed every six months.
   6. VEHS will conduct a physical inventory of all sealed sources at quarterly intervals.
   7. VEHS will be available for any emergency situation.
       
2. Radiopharmaceutical Therapies
   1. Radiation warning signs must be posted whenever the administered activity exceeds the release criteria. These signs will be posted and removed by VEHS.
   2. After administration of the radiopharmaceuticals, VEHS will perform the radiation surveys required by State regulations.
   3. VEHS will determine when a patient may be released from the hospital or radiation precautions may be removed. The Nuclear Medicine physician can also determine when to release the patient, based on professional judgment.
   4. Bags of radioactive waste generated by radiotherapy patients will be collected and disposed by VEHS. Odorous waste will normally be collected on a daily basis.
   5. Before a therapy patient's room can be assigned to another patient, the room must be surveyed for contamination. VEHS will decontaminate the room. When surveys indicate that no contamination exists above allowable limits, the room warning sign will be removed. Removal of this sign signifies that another patient may occupy the room.
   6. Records of all surveys will be maintained for inspection by the State regulatory agency.
   7. The VEHS phone number listed on the radiation warning sign, is available for routine consultation and will be available for any emergency situation.

J. Transportation Service

Occasionally patients who have received therapeutic levels of radioactivity must be transported within the Medical Center. The risks associated with transportation of such patients are small, and results in a very insignificant exposure if the following procedures are followed:

1. The individual transporting the patient shall be instructed of the better end from which to push the stretcher. The better end is the end that will position the transporter at the greatest distance from the radiation source.
2. Transport the patient by the most direct route.
3. The patient shall not be left in public waiting areas or corridors. If necessary the transporter shall remain in the area to keep other people at least 6 feet from the patient.
4. When transporting the patient, do not share elevators with other staff or patients.
5. Pregnant employees should not be used to transport radioactive patients.