Purpose: To ensure that staff are following proper radiation monitoring techniques.
Scope: All departments utilizing Radiation Producing Equipment and Radioactive sources
Policy: The recommendations of the National Council on Radiation Protection and Measurements (NCRP) established the basis through which agencies regulating the use of ionizing radiation throughout the country have set regulatory standards. Three agencies directly or indirectly regulate the Hospital’s use of radioactive materials and use of radiation-producing equipment: the Nuclear Regulatory Commission (NRC), the Joint Commission on Accreditation of Hospitals Organization (JCAHO), and the State of Connecticut Department of Environmental Protection (DEEP). These regulatory bodies have adopted the NCRP guidelines for personnel monitoring into their requirements. The Vendor providing the service for occupational monitoring will be a National Voluntary Laboratory Accreditation Program (NVLAP) approved dosimetry service.
Personnel to be monitored:
Midstate Radiology Associate locations are required to monitor occupational radiation exposure per Connecticut Title 22a 19-24 Section 19-24-6 to:
- Adults likely to receive in any calendar quarter, from radiation exposure external to the body, a dose above 25 percent of the occupational exposure limits specified in Section 19-24-5.
| Connecticut Title 22a Section 19-24-5 | Per Calendar Quarter (mRem*) |
|---|---|
| Whole body; head and trunk; active blood-forming organs; lens of eyes, or gonads | 1250 |
| Skin of whole body | 7500 |
| Hands and forearms; feet and ankles | 18750 |
* The unit mRem (roentgen equivalent man) is used in reporting the radiation exposure received from medical x-rays and natural radiation background sources
- Adults entering a high or very high radiation area:
The Radiation Safety Officer (RSO) will review the individual’s work environment and may monitor the employee for a trial period before determining if continued monitoring is required.
Our ALARA Program Notification Thresholds
The radiation safety program is based on the premise that radiation exposure is not risk-free and therefore, exposure should be kept to levels below the limits permitted by the State of Connecticut Department of Energy and Environmental Protection and the Nuclear Regulatory Commission. The intent of the ALARA program is to maintain exposure to radiation at levels that are “As Low as Reasonably Achievable”. ALARA is critical to current radiation protection philosophy.
Occupationally monitored personnel are notified when a quarterly occupational exposure meets a Level-I or Level-2 Exposure Investigation limit. The Radiation Safety Officer reviews occupational exposure data each Quarter and is available for questions or concerns regarding occupational exposure at the hospital. Level-1 recipients receive a letter from the RSO. Level-2 recipients discuss exposure specifics with the RSO.
| Body Region | Annual Exposure Limit | Quarterly Exposure Limit | Level-1 Investigation limit | Level-2 Investigation limit |
|---|---|---|---|---|
| Whole Body; Head & Trunk (DDE) | 5000 mRem | 1250 mRem | 325 mRem | 650 mRem |
| Lens of the Eye, or Gonad (LDE) | 5000 mRem | 1250 mRem | 325 mRem | 1125 mRem |
| Skin of the Whole Body (SDE) | 30000 mRem | 7500 mRem | 1250 mRem | 3750 mRem |
| Hand; Forearm; Feet; and Ankles (SDEME) | 50000 mRem | 12500 mRem | 1250 mRem | 3750 mRem |
Occupational Radiation Monitoring General information:
Each dosimeter is assigned to a department and must remain at that location at all times.
- The facility ‘Dosimetry Orientation Packet’ must be completed and returned to your supervisor for the RSO or RSO designee to order an occupational monitor. Once received the dosimeter will be sent to your Supervisor/department.
- Dosimeters are to be stored in YOUR department on the department storage board (or assigned storage location) when not in use.
- Dosimeters are sent for processing each month or each quarter and have a processing expiration date.
- All occupational radiation exposure data is reviewed by the Radiation Safety Officer (RSO) or designee.
- Exposure reports are available by request at any time through the Radiation Safety
Department at RadiationSafetyDepartment@hhchealth.org.
Dosimeter Specifics
- The dosimeter is to be worn at the collar level
- If a Lead Garment is worn – the dosimeter is worn outside protective lead apparel
Fetal Monitoring Program
- Midstate Radiology Associates has a voluntary fetal monitoring program available for pregnant occupational workers
- The fetal monitoring program is optional and confidential
- Contact your RSO or site manager if you are pregnant and choose to be monitored for occupational radiation exposure.
Definitions:
- Whole Body Exposure Deep Dose Equivalent (DDE)- Dose equivalent at a tissue depth of 1 cm.
- Eye Dose Equivalent (EDE)– Dose equivalent at a tissue depth of 0.3 cm
- Shallow Dose Equivalent – Whole-Body (SDE)- Dose equivalent at a tissue depth of 0.007 cm.
- Extremity Exposure (SDEME)- Hand, elbow and below, foot, or leg below the knee.
Keywords:
Dosimetry, Occupational Monitoring, ALARA, Radiation, Radioactive, NVLAP, NCRP, NRC, RSO, DEEP
Appendices: N/A
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