Cardiovascular Catheterization Laboratory Department

Radiation Safety Manual

Hospital
Cardiovascular Catheterization Laboratory

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 APPROVAL SHEET

This Manual entitled

Radiation Protection in Cardiovascular Catheterization Laboratory

is prepared and presented by:

Ludwig John Buencamino, Radiologic Technologist

as one of the requirements for the application of Radiation Safety Officer in the
Department of Health (DOH), is hereby endorsed for approval.

Dr. Juan Buan Dr. Dancel Manor

Medical Director Chairman Cardiovascular Section
Date: Date:

Dr. Ben K. Cablar Ms. Anna Marie Viron

Chairman Cardiovascular Catheterization Cathlab Manager

Date: Date:

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 Table of Contents
Approval Sheet ----------------------------------------------------------------------- Page 2
Table of Contents -------------------------------------------------------------------- Page 3
Table of Contents (Continuation) ------------------------------------------------- Page 4
Preface ------------------------------------------------------------------------------- Page 5
Preface (continuation) ------------------------------------------------------------ Page 6
Acknowledgement ----------------------------------------------------------------- Page 7
Hospital History and Profile ----------------------------------------------------- Page 8
Mission and Vision -------------------------------------------------------------- Page 9
Hospital Organizational Chart --------------------------------------------------- Page 10
Cardiovascular Catheterization Laboratory Department Profile ----------- Page 11
Organizational Chart ---------------------------------------------------------- Page 12
Standard Operating Procedures ------------------------------------------------ Page 13
Pre-Procedure ------------------------------------------------------ Page 13
During the Procedure ------------------------------------------------------ Page 14
Post Procedure -------------------------------------------------------------- Page 17
Guidelines and Policy on Radiation Safety ---------------------------------- Page 19
Basic Radiation-Control Principles in Cardiac Catheterization
Laboratory ------------------------------------------------------------------ Page 20
Policy for Pregnant Employees ------------------------------------------------ Page 21
Radiation Quantities and Sources -------------------------------------------- Page 22
Cardiac Catheterization Devices and Equipment -------------------------- Page 23
Architectural shielding ---------------------------------------------- Page 23
Disposable radioprotective drapes ------------------------------------ Page 24
Personal Protective Equipment ---------------------------------------- Page 24
Fluoroscopy and Cine Acquisitions Settings ------------------------------------------------ Page 25
Minimizing the Radiation Dose by Proper Table Positioning ---------------------------- Page 26
Procedural Summary of Radiation protection for patient and health care workers ------ Page 27

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Radiation Personnel Monitoring -------------------------------------------------------------- Page 28
Investigation Levels -------------------------------------------------------------------------- Page 29
Example of Radiation Dose Reading ------------------------------------------------------ Page 30
Dose Limit ------------------------------------------------------------------------------------- Page 32
Pregnant workers exposure limit ------------------------------------------------------------ Page 33
Quality Assurance Program ------------------------------------------------------------------ Page 34
Radiological Emergency Procedure ---------------------------------------------------------- Page 35
Continuing Education Program of Staff ------------------------------------------------------ Page 36
References --------------------------------------------------------------------------------------- Page 37
Location Map ------------------------------------------------------------------------------------ Page 38

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 PREFACE

Both ionizing and non-ionizing radiation are used in medical practice; however, ionizing
radiation is of primary concern to cardiologists because of its risk of producing biological injury.
Ionizing radiation is any electromagnetic or particulate energy capable of producing ions by
interaction with matter and includes X-rays from X-ray producing equipment and gamma rays
from radioactive material. Whereas X-ray units only produce radiation when they are energized,
radioactive material used in nuclear medicine emits radiation continuously. Non-ionizing radiation
includes ultrasound, magnetic resonance imaging (MRI), and radiofrequency electromagnetic
radiation, which in turn includes laser beams, xerox machine and microwaves.

Occupational radiation exposure is a major concern for cardiac catheterization laboratory

workers. Radiation has no minimum safety threshold and its adverse effects occur in a linear, dose-
dependent risk. Ionizing radiation’s harmful effects on human tissues have been recognized to
either be deterministic or stochastic. Staff and interventional physicians are at risk from radiation
injury given their chronic radiation exposure in cardiac catheterization laboratories. Compared to
clinical physicians who work outside the cardiac catheterization laboratory, they can develop
somatic DNA damage and chromosomal abnormalities.

Regulating safety is a national responsibility. States have an obligation of diligence and

duty of care, and are expected to fulfill their national and international undertakings and
obligations. International safety standards provide support for countries in meeting their
obligations under general principles of international law, such as those relating to environmental
protection. International safety standards also promote and assure confidence in safety and
facilitate international commerce and trade.

In 1996, the International Atomic Energy Agency (IAEA), published the Basic Safety
Standards entitled “Basic Safety Standards for Protection against Ionizing Radiation and for the
Safety of Radiation Sources”. This standard contains recommendations on the safe use of radiation
sources. This is intended to prevent the occurrence of harmful effects of ionizing radiation, ensure
the control of radiation exposure of workers, medical patients, the public and the environment and

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prevent the occurrence of short-term effects from high radiation doses and to minimize the risk of
long-term effects.

The Department of Health (DOH) adopted the IBSS followed with the issuance of the
Administrative Order (AO) No. 149 entitled “Basic Standards on Radiation Protection and Safety
Governing the Authorization for the Introduction and Conduct of Practices Involving X-ray
Sources in the Philippines.”

The guidelines and procedures outlined in this manual are designed to protect patients,
visitors, employees and the facility from unnecessary and potentially harmful radiation exposure
measures. The Cardiovascular Catheterization Laboratory is committed to uphold safe practices
and will observed the acceptable standards in Radiation Protection.

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 ACKNOWLEDGEMENT

We would like to thanks the Almighty for giving us his grace, wisdom and good judgement.
We would like to acknowledge the support of our Medical Director, and the Department Chair,
Dr. Benjie Abueva for the invaluable support in pursuing this Radiation Safety Program for our
Department. We are delighted for encouraging us to continue engaging in our profession and
service to the department. We would also like to acknowledge the help of our colleagues in the
department for the reproduction of the needed copies and pertinent documents to finish this
Manual.

Greatest gratitude to the efforts of the Department Head, Ms. Arlene Reynes and to the
other Radiologic Technologists staff, Nurses and Co-workers of Hospital Cardiovascular
Catheterization Laboratory Department in giving us the support to fulfill this mission.

In the coming days, we are looking forward to work together in disseminating that
information and observe strict adherence in our Department Policy especially in Radiation
Protection. We believe that working together would keep us to unite together in all problems and
wearies that we will be facing as we continue in providing services to our patients.

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 Introduction

Hospital History and Profile

Founded in 1982 by a group of 20 doctors, the Hospital is a premiere private tertiary hospital
that serves both local and international clients. It provides holistic care that exceeds industry
standards and that anticipates and responds to the needs of the patients, their families and the
communities.

Owned by group of medical doctors is the health care affiliate of ABC Foundation, Inc., the
corporate social responsibility arm of the ABC Group. It is located at 57 Ramos Avenue, Manila.

It has grown into a hospital complex providing holistic and globally competitive healthcare.
Strategically located in the business district of Manila and a stone’s throw away from its historic
sites, the Hospital embodies the resilience and dynamism of the nation’s capital.

Over the years, the hospital continually developed its entire medical and support departments
to become one of the top Hospital in Metro Manila. Recognized by international accreditors for
providing quality and safe patient care, it is the first hospital to acquire an ISO 9001:2000
Certification in 2005.

The hospital’s adherence to the principles of accreditation in upholding the standard of

excellence and quality improvement in its policies, practices, and programs.

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 Mission
“We provide sustainable quality and socially responsible healthcare across generations”

Vision
“One of the leading centers for holistic care preferred by patients and healthcare professionals
by 2030”

Goal
“To provide holistic quality and safe patient care for all Filipino and international clients”

Commitment

To provide compassionate and safe environment where our patients always comes first.
To be a dependable partner to our physicians and employees.
To create value and sustainable growth for our stakeholders.

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 Hospital Organizational Chart

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Cardiovascular Catheterization Laboratory Department Profile

A growing number of tertiary hospitals have endeavored to have several major services
available, like the Cardiovascular Center composed of Cardiovascular Catheterization Laboratory,
cardio vascular surgery, and cardiovascular anesthesia. In keeping up with the advancement in
technology the Hospital built sophisticated facilities that will cater to diagnostic and interventional
procedures which aim to provide a full range of diagnostic and interventional modalities for
evaluation and treatment of adult and pediatric patients with known or suspected heart, brain and
peripheral diseases.

Vision: The Cardiac Catheterization Laboratory shall be the center of excellence in the provision
of holistic, high quality state of the art, and patient center care in the field of diagnostic and
interventional cardiology, radiology and neuro-radiology, through the effective teamwork of
dedicated and competent health care professionals, cognizant of the institution’s commitment to
service, training and research as well.

Mission: To provide high quality diagnostic and interventional cardiology and radiology services
at an affordable cost, within reach to the largely middle to low income patient populace, and its
foreign patients.

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 Organizational Chart

President

Hospital Director

Medical Director

Cardiovascular Center Chairman

Cardiovascular Catheterization Laboratory Department Chairman

Cathlab Manager

Cathlab nurse Radiologic technologist Admin Assistant Nursing Aide

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 Standard Operating Procedures

The Cardiac Catheterization Laboratory (Cathlab) is a highly specialized facility capable of

providing both diagnostic and interventional procedures requiring the use of fluoroscopy. Its
commitment to deliver and perform the necessary procedures for patients was established between
the management, doctors and staff which aims to develop and further improve the system.

PRE-PROCEDURAL

1. All cases shall be scheduled on the regular working hours. Beyond working hours,
weekends and holidays are subject for additional rates and on “First come-first serve basis.”

2. The Cathlab Circulating Nurse-On-Duty (CNOD)/ Medical Secretary/ Rad Tech receives
request of procedure in accordance with Cathlab Scheduling Guidelines and registers
patient in Cathlab Schedule of procedure logbook.

3. The Cathlab CNOD is responsible for receiving Department of Medicine (DEM) patients,
in-patients or patients transferred from other institutions and OPD.

4. For DEM Patients, the Cathlab Circulating Nurse-On-Duty (CNOD) properly identifies the
patient and other pertinent data; confirms if the patient or any immediate relative of the
patient (if the patient is unable to give consent) has consented for the procedure and for the
induction of anesthesia, as may be required.

5. The Cathlab CNOD receives endorsement of the DEM Admission Sheet and ensures that
the Doctor’s Order is duly carried out.
6. For inpatients, the Cathlab CNOD receives endorsement from the staff nurse; checks the
complete accomplished Form of Consent, Pre-Procedure Checklist, Doctor’s Order for
Catheterization, Laboratory Result like creatinine, 2D Echo (if available).

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 7. For patients transferred from other institutions, the Cathlab CNOD properly identifies the
patient and other pertinent data. They secure the patient’s complete medical abstract and
ensure that there is a physician’s order for the procedure. The Cathlab CNOD will ask
relative to sign consent using the institution form of consent for procedure.

8. For OPD, patient needs to secure a written request for the coronary angiogram procedure
from the requesting interventionist. Patient also needs to bring their laboratory result.
Cathlab CNOD shall ask the patient to fill- out an OPD Form and Accomplished Consent
for Operation and Pre-Catheterization Checklist. The Cathlab CNOD/medical secretary
enters data in the Bizbox for charging and ACOM PC for the report. The Cathlab CNOD
will secure a IV line prior to procedure.

9. The Cathlab CNOD, together with the AP or the Interventionist, assesses the patient after
proper identification of the patient and upon receiving the patient. The Cathlab CNOD
categorizes the patient as Emergency or Non-emergency. Non-emergency cases are
scheduled cases. For emergency cases, the Cathlab CNOD assures that there are complete
records endorsed.

DURING THE PROCEDURE

1. The CNOD/ SNOD and the Rad Tech accompany patient to the Cathlab Procedure
Room and attends to their need after receiving and assessing the patient.

2. The CNOD transfers the patient to Cathlab table, positioned him comfortably; secured
safety (according to the Patient Safety Guidelines) and hooked to monitoring devices;
a cautery plates are attached (if applicable).
3. The CNOD registers and hooks the patient to the physiologic machine and to the
anesthesia machine as needed.

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 4. The Cathlab CNOD and Rad Tech prepare the site of the catheterization (in accordance
to the Operating Room Complex (ORC) Skin Preparation Guidelines) and drapes the
patient all the while ensuring the sterility.

5. The CNOD checks the patient’s monitoring equipment and duly documents the
preparation process along with the patient’s initial Vital Signs. The CNOD documents
preparation process, records the initial Vital Signs and maintains the hemodynamic
status continually.

6. The Cathlab Scrub Nurse-on-duty (SNOD) prepares the procedure table and the sterile
equipment, accessories and instruments that shall be used for the catheterization
procedure.

7. Sterile instruments, pack supplies and equipment needed during the procedure is
opened in accordance with Guidelines in Opening Sterile Packs, Instruments and
Supplies.

8. Cathlab Interventionist, fellow and Cathlab SNOD scrub gown and glove in accordance
with Scrubbing, Gowning and Gloving Guidelines.

9. The CNOD makes additional request as needed for the procedure.

10. Start of the catheterization procedure, either Diagnostic or Interventional, is done after
preparing the patient for the procedure.

11. The Cathlab SNOD assists the Interventionist in performing any of the catheterization
procedures.
12. Induction of anesthesia is given in accordance with PSA Guidelines for Safe Anesthesia
Practice (refer to General Anesthesiology Policies and Procedure).

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 13. The Cathlab CNOD assists in monitoring and provides care for the patient in the
Procedure Room or should the patient be transferred in the Cathlab Holding Area as
the catheterization case ends.

14. Cathlab CNOD observes and monitors patient and documents pertinent data while a
patient is in the Procedure Room or Holding Area in the Cardiac Catheterization
Laboratory. CNOD notes and records Vital Signs in the Vital Signs Sheet or print out
from physiologic machine during procedure.

15. In case of cardio-pulmonary arrest, the AP/Interventionist/Cathlab CNOD performs all

necessary measure to revive the patient in accordance with Anticipating and Assisting
in Code Guidelines.

16. The Cathlab CNOD, Rad Tech, Interventionist and Anesthesiologist are responsible
for ensuring patient stability.

17. The Cathlab CNOD and the Interventionist discharge the patient from the Cathlab
after giving the post catheterization care after the procedure and when the patient is
stable.

18. The Cathlab CNOD ensures that the Cathlab pre-operative procedures are documented
and that the forms are duly filled-out, including the CATHETERIZATION
LABORATORY REPORT, CARDIAC CATHETERIZATION LABORATORY
NOTES, HEMODYNAMIC MONITORING SHEET, ANESTHESIA RECORD
SHEET (as applicable), and POST CATHETERIZATION ORDERS.
19. The Cathlab CNOD, Rad Tech-On-Duty and the Cathlab Medical Secretary
countercheck all the supplies, equipment and medicines used and unused in accordance
with Counter-checking and Charging Guidelines.

20. For Outpatients – the Cathlab CNOD assigned to the procedure encodes the charges
and prints it through the Computer-Generated Charge Slip and instructs patient or

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 companion to settle account in accordance with Cashier Service Policies and
Procedure.

21. For Inpatients – the Cathlab CNOD encodes all charges and prints it through the
Computer-Generated Charge Slip in accordance with Patients Accounts Policies and
Procedure.

POST PROCEDURE

1. Transfer to Room – Patients for transfer to designated unit or room. The CNOD calls the
nurse of the unit where the patient is admitted to bring the necessary monitoring equipment
and to receive, endorse and transfer patient from the Cathlab back to his/her room.

2. Transfer to Special Area – Patients needing religious monitoring are transferred to special
areas such as Intensive Care Unit (ICU) and Coronary Care Unit (CCU). Pediatric patients
who are undergone catheterization are transferred to the Neonatal Intensive Care Unit
(NICU) or Pediatric Intensive Care Unit (PICU) as ordered by the doctor. The CNOD
endorses the Post Catheterization Orders and the Pre-operative events to the receiving
nurse. If the patient is originally from the floor but will be transferred to a special area, the
nurse from the previous floor endorses the Kardex, medication cards and other pertinent
data concerning the patient. Resident-On-Duty (ROD) is called to accompany the transport
of the patient from the Cathlab. The CNOD calls the nurse of special area to bring the
necessary monitoring equipment and to receive and transfer patient from the Cathlab.

3. The Cathlab CNOD verifies the Doctor’s Order for room transfer.

4. A Cathlab nurse will accompany the transport of the patient to the special area when patient
has invasive arterial monitoring, when patient is hooked to an IABP Counter Pulsation
Machine or when the patient is in a critical condition such as when he is a post-arrest
patient.

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 5. DEM Patient No Room Available – if in case patients from Emergency Room Post
Catheterization and No Room Availability, the Cathlab CNOD calls the DEM to pick-up
their patient and endorse to DEM nurse post catheterization procedure. In case DEM
patients were brought to Cathlab for procedure but he/she has room already, the Cathlab
CNOD is the one will transfer the patient to admitting room.

6. Transfer to the other Institutions – Cathlab CNOD and Interventionist explain discharge
instructions to patient discharged from the Cathlab Procedure Room. Patients are given
original copies of their Catheterization Laboratory Report duly signed and filled-out by
their Interventionists. They are discharge after their settlement of the Cathlab and other
hospital charges. The Cathlab CNOD secures the OR receipt of the patient’s payment and
takes a photocopy of it for filling.

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 GUIDELINES AND POLICIES ON RADIATION SAFETY

Objective:

The Cardiac Catheterization Laboratory radiation safety program aims to manage patient and staff safety
by reducing exposure to ionizing radiation to a level that is as low as reasonably achievable (ALARA).

1. The first step in radiation safety is to avoid unnecessary use of ionizing radiation.

2. Dose Limitation by lowering the fluoroscopic time

3. Maximizing the Distance from the source

4. Minimizing the Time of exposure

5. Maximizing the protective shielding

Radiation Safety Officer Duties and Responsibilities:

1. The Radiation Safety Officer (RSO) is the individual specifically appointed by the
Hospital and named on the licenses. The RSO establishes and enforces applicable
regulation in compliance with Radiation Safety and Laws governing the safety of the
workers inside the Radiation facilities.

2. The RSO shall establish radiation exposure investigation levels and, if those levels are
exceeded, he must initiate a prompt investigation of the cause of the exposure and a
consideration of actions that might be taken to reduce the probability of recurrence.

3. The RSO must establish safe guidelines protocol on handling the ionizing radiation.

4. The RSO must train, inform and educate the health workers inside the Cathlab facility.

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 Basic Radiation-Control Principles in Cardiac Catheterization Laboratory

1. Must apply the cardinal principles of radiation control: time, distance and shielding.

2. Do not execute any programs without familiarization.

3. Do not stand near the source of radiation during exposure; the dose in Cathlab is far greater
than the ordinary diagnostic x-ray.

4. Always wear protective shielding during procedure.

5. Always wear a personnel radiation monitoring device and position it outside the protective
lead apron on the collar.

6. Always restraint the patient before start of the procedure, to establish safety and unwanted
movements.

7. Lower the fluoroscopy rate whenever possible.

8. Observe proper collimation, limit the field of exposure on the area of interest only.

9. Optimize proper distance between image intensifier and the patient.

10. Always collimate to the smallest field size appropriate for the examination.

11. Wear complete shielding during fluoroscopy testing and limit the time of exposure.

12. Red-colored light bulb with a warning sign stating: “Do not enter when the red light is on”
and warning sign for pregnant women must be present in the holding area and in each
examining room.

13. Unnecessary personnel should not be inside the Catheterization Laboratory.

14. Turn off the fluoroscopy after the procedure to avoid unnecessary exposure.

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 Policy for Pregnant Employees

These policies are followed when a member of the Cathlab Team declared that she is pregnant:

1. When an employee declares a pregnancy, she will be investigated as to when the

conception started.
2. The RSO will conduct a personal counselling.
3. The RSO will endorse to the immediate superior regarding his findings.
4. The RSO will recommend safety protocol during the pregnant employee’s time of work.
5. The pregnant employee will be advised to wear an apron lead gown during her stay inside
or whenever nearer to procedure room.
6. The staff and the pregnant employee will work together to try to limit the radiation
exposure.
7. Pregnant workers will be provided with additional personnel monitoring device and will
be placed on her abdominal area.
8. During the first trimestral of pregnancy, employee will be assigned to other areas away
from the procedure room.

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 Radiation Quantities and Sources

Patient exposure is measured as Air Kerma (Kinetic Energy Released in Matter) and Dose Area
Product (DAP), which represent the dose of radiation delivered to the air and human tissues. Air
Kerma is the amount of kinetic energy delivered to air, measured 15 cm on the X-ray tube side of
isocenter (the point at which the primary X-ray beam intersects with the rotational axis of the C-
arm gantry). The international system of units (SI) unit of Air Kerma is Gray (100 rad). Air Kerma
has been associated with the deterministic effects of radiation.

DAP, also referred to as Air Kerma Area Product, is the cumulative product of Air Kerma and the
X-ray radiation field area. It is measured in Gray.cm2, and is thought to correlate with the
stochastic or probabilistic effects of radiation. Operator exposure is expressed as equivalent dose
for organ–specific exposure and effective dose for whole-body exposure. The effective dose
represents the sum of equivalent doses from different tissues, adjusted to the radiation sensitivity
of each tissue. Operator exposure is measured in Sievert (1 Sv=100 mrem).

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 Cardiac Catheterization Devices and Equipment

1. Architectural shielding

Architectural shielding is built into the cardiac catheterization laboratory structure. This also
includes rolling and stationary leaded transparent plastic shields that protects staff. Equipment-
mounted shielding consists of ceiling- suspended shields, table-suspended drapes, and disposable
protective patient drapes. Ceiling-suspended shields are typically made of transparent leaded
plastic or glass that are readily adjustable during the procedure. Precise positioning of this is the
key in significantly reducing operator exposure.

The ceiling-suspended shield should be located far from the scatter source and near the operator.
For example, in femoral artery access sites, it should be positioned just cephalad to the groin and
as close as possible to the patient surface. Throughout the procedure, frequent repositioning of the
upper body shield should be kept in mind as the table is moved to maintain effective protection.

Ceiling suspended with Table suspended Dra

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2. Disposable radioprotective drapes

Contain metallic elements and are effective in reducing exposure of the operator. Exposure
reductions can be particularly useful in interventional procedures associated with higher exposure
of the operator and staff, such as chronic total occlusion intervention, procedures in morbidly obese
patients, and procedures performed using radial and femoral access.

3. Personal Protective Equipment

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Personnel shielding is designed to effectively attenuate scatter X-ray levels, not primary beam
exposures. As the X-rays are scattered, they undergo loss of energy and penetration ability.

A. Protective lead aprons including vest and skirts

B. Thyroid shields
C. Leaded goggles
D. leaded caps
E. Leaded Gloves

The International Council for Radiation Protection a recommends of no less than 0.5 mm lead thickness
which can attenuate approximately 90% or more of the scatter. The wrap-around vest and skirts
configuration offer a 0.25 mm lead-equivalent protection that can increase to a 0.50 mm (or 0.70 mm) lead-
equivalent anteriorly where the apron folds overlap. The Thyroid shield should have at least 0.5-mm lead
equivalent thickness for neck and thyroid protection. Typical lead equivalent thickness of radiation
protective eyewear is 0.75 mm with lead barrier on each side

Proper maintenance and storage of lead aprons is necessary, as sitting on the aprons or folding
them may result in loss of their protective effect.

Fluoroscopy and Cine Acquisitions Settings

Adjusting Fluoroscopy Rate and X-Ray System Settings Fluoroscopy can significantly reduce radiation

exposure. It is most commonly performed at 15 frames-per-second for cine acquisitions and 10 pulse per

second for fluoroscopy. Decreased rate during cannulation, positioning of catheter and wiring. Consider

also using low-frame fluoroscopy in complex procedures, such as chronic total occlusion interventions and

electrophysiology procedures. Step on pedal when looking at the screen.

Limit the scattered radiation by proper collimation and maximizing filtration. Storing the last fluoroscopic

images to lessen cine acquisitions.

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 Minimizing the Radiation Dose by Proper Table Positioning

Panel A. The patient should be placed away from the radiation source and close to the image intensifier.

Panel B . A lower table setting without changing the source-intensifier distance results in higher
dose due to proximity of the patient to the radiation source.
Panel C. Elevation of the image intensifier results in higher dose owing to geometric
magnification by the intensifier.

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 Procedural Summary of Radiation Protection for Patient and

Health-care Workers

I. Pre-procedure

A. Application of the Radiation safety program for catheterization laboratory

1. Dosimeter use, shielding, training/education
B. Imaging equipment and operator knowledge
1. On-screen dose assessment (AK, DAP)
2. Dose saving: Store fluoroscopy, adjustable pulse and frame rate, and last image hold
C. Pre-procedure dose planning
1. Assess patient and procedure, including patient’s size and lesion(s) complexity
D. Inform patient with appropriate consent

II. During Procedure

A. Limit fluoroscopy: Step on pedal only when looking at screen
B. Limit cine-angiography: Store fluoroscopy when high image quality not required
C. Limit magnification, frame rate, steep angles
D. Use collimation and filters to fullest extent possible
E. Vary tube angle when possible to change skin area exposed
F. Position table and image receptor: X-ray tube too close to patient increases dose; high image
receptor increases scatter
G. Keep patient and operator body parts out of field of view
H. Maximize shielding and distance from X-ray source for all personnel
I. Manage and monitor dose in real time from the beginning of each case

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III. Post-procedure
A. Record or document radiation dose
B. Notify patient and referring physician when high dose delivered
C. Assess and refer adverse skin effects to appropriate consultant

Radiation Personnel Monitoring

1. Personal dosimeter must be used by all staff employed in an area utilizing ionizing
radiation.
2. Two dosimeters systems are most commonly recommended, one worn at the thyroid collar
and a second one worn under the protective apron.
3. Reading period of every two months are submitted to the provider for processing.
4. The workers must be responsible for proper use of OSLD badge.
5. All OSLD badges must be placed in a secured cabinet in a controlled area.
6. Background OSLD badges are placed in a radiation safe area.
7. Never leave the OSLD badges at the exposure room or near the source of radiation.
8. NO sharing of OSLD badges to co-workers.
9. Never leave the OSLD badges attached to lead gown.
10. Report lost or damages OSLD badges.
11. Never wear the OSLD badges outside the hospital premises.
12. All workers must be AWARE and acknowledge their OSLD reading.
13. The Radiation Safety Officer must be aware of the report of the monitoring device of the
workers at all time and ensure that maximum permissible doses are not exceeded.
14. No tampering of the OSLD badge without authorization.

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Personnel dosimetry monitors include:

1. film badges which uses x-ray films

2. thermoluminescent dosimeters (TLDs), which use lithium fluoride crystals.
3. Optically Stimulated Luminescence

Investigation Levels

The Radiation Safety Officer shall establish investigation levels, i.e. levels of radiation dose
received during a monitoring period, for each category of "normally exposed" radiation users.
Whenever the dose recorded by a dosimeter exceeds the investigation level, the RSO shall cause
an investigation to be made to determine the cause of the dose and steps that might be taken to
prevent recurrence. A written report is required to be submitted to the authorities including doses
received, date and causes of the event. Corrective actions should then be taken to determine the
cause and steps should be made to prevent recurrence.

Investigatory Level 0.5 mSv/month, 1 mSv/2 months

Action Level 1.7 mSv/month, 3.4 mSv/2 months
Dose limit to abdomen of woman of reproductive capacity 13 mSv in 3 months
Dose Constraint for fetus during pregnancy 1mSv

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 EXAMPLE OF RADIATION DOSE READING:

Hp(d) – “the dose equivalent in soft tissue, at an appropriate depth, d, below a specified point on the
body”(ICRU,1993)

• Hp(0.07) or skin or shallow dose – depth at 0.07mm (weakly penetrating radiation)

• Hp(3) or lens of the eye dose – depth at 3mm (weakly penetrating radiation)

• Hp(10) or whole body dose – dose at 10mm (strongly penetrating radiation)

Unit: mSv

IMPORTANT NOTE: At the time ICRP 103 (2007) was published, the Commission was already considering
that the dose limits to the lens of the eye were not appropriate. This review culminated in ICRP
statement 4825-3093-1464 of 21 April 2011.

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Dose Limits (Occupational Exposure)

The occupational exposures of any worker shall be controlled so that the following limits are not
exceeded:

Application Occupational Dose Limit

Effective Dose 20 mSv per year, average over defined period
of 5 years

50 mSv in any single year

Annual equivalent dose in:
The lens of the eye 20 mSv
The skin 500 mSv
The hands and feet 500 mSv

Dose Limits (Public)

Application Occupational Dose Limit

Effective Dose 1 mSv in a year (*)
Annual equivalent dose in:
The lens of the eye 15 mSv
The skin 50 mSv

International system for radiation protection

(*) In special circumstances, an effective dose of up to 5 mSv in a single year provided that the average dose over five
consecutive years does not exceed 1 mSv per year

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Pregnant Workers Exposure Limits

The dose limit to an embryo/fetus during the entire pregnancy, due to occupational exposure of a
declared pregnant woman, is 500 millirem (5 mSv). No more than 50 millirem (0.5 mSv) be
received during any one month during a declared pregnancy.

If the pregnant woman has not notified RSO and her estimated date of conception, the dose to the
fetus shall not exceed 50 millirem (0.5 mSv) per month during the remainder of the pregnancy

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 QUALITY ASSURANCE PROGRAM

1. Periodic maintenance and services shall be agreed by the exclusive service provider of the
Angiography unit, the scope of work includes the following:
a. Equipment diagnostics and check-up
b. Physical assessment of the hardware
c. Electronic sub systems
d. Functional test of its parts including collimator, wedging, C-arm movement and other
peripherals
e. Image quality check
f. Safety control check
g. X-ray field and Image receptor alignment test
h. Radiation dose measurement and calibration
i. Submission of PMS report

2. Daily cleaning of the equipment, especially x-ray tube and detector area must be clear
from any form of liquid (e.g. blood)
3. Installation of uninterrupted power supply in case of an electrical trouble and power
disturbance
4. Occupational Dose monitoring of All Cardiovascular Catheterization staff and
Interventional Doctors
5. Regular checking of Radiation Safety Equipment and personal protective devices
6. Yearly conformance testing from a government accredited and reputable company to
conduct an Independent and unbiased assessment of the x-ray dose quantities and
calibration.
7. Maintaining proper air-conditioning inside the procedure and Gen-set room

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 8. Regular staff training to keep up with latest updates in modalities and new techniques

Radiological Emergency Procedure

Those investigating incidents arising from interventional radiology procedures should aim at:

 Establishing the whole scenario of the events.

 Establishing and marking the non-safe area/perimeter and limiting the entry of personnel.
 Identifying the failure of equipment or processes.
 Deciding on action plan to minimize the chance of a similar failure.
 Estimating the likely doses received by the patient and the operator.
 Preparing internal reports of all incidents and referring to for educative purposes during
reviews and training sessions.
 Counseling that patient and informing the implication of the unintended exposure.
 Informing appropriate hospital authorities and the radiological assessor team if radiation
exposure is suspected.

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 Continuing Education Program of Staff

As the year’s past, and as new technology emerges, there has been a continuous modification
of standards in terms of Radiation Safety, considering the advances in modern field of science. It
is in our dire desire to keep up and stay updated with the latest trends and innovations.

Proper and ongoing education of the catheterization laboratory team members is crucial; thus,
the Radiation safety training has been shown to increase operator awareness and limit exposure.

Comprehensive training should be offered to all members of the catheterization team, both at
the time of initial employment and as part of a continuing medical education program. The
importance of training has been demonstrated in a large-scale retrospective analysis that
implemented clinical practice and technical changes to raise radiation awareness and reduce
patient dose.

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 References:
Recommended to add the DOH AO’s (35 and 149 in complete tittle)

Hendry JH. Radiation biology and radiation protection. Ann ICRP 2012; 41:64–71.
ICRP. Avoidance of radiation injuries from medical interventional procedures. Ann ICRP 2000;
30:7–67.
Bushong, S. C. (2016 11th E) Radiologic Science for Technologists.
Grupen, C. (2010). Introduction to Radiation Protection.
Annals of the ICRP, ICRP Publication 103 Volume 37. No. 2-4 2007.
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Radiation Dose to
Patients from Radiopharmaceuticals: A Third Amendment to ICRP Publication 53, Publication
106, Elsevier (2008)
International Commission on Radiation Units and Measurements, Fundamental Quantities and
Units for Ionizing Radiation, Report No. 60, ICRU, Bethesda (1998)
International Commission on Radiation Units and Measurements, Fundamental Quantities and
Units for Ionizing Radiation, Report No. 60, ICRU, Bethesda (1998)
Optimizing Radiation Safety in the Cardiac Catheterization Laboratory: A Practical Approach
Georgios Christopoulos, md. et al (2015)

https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---
safework/documents/publication/wcms_152685.pdf
https://www-pub.iaea.org/MTCD/Publications/PDF/PUB1775_web.pdf
https://www-pub.iaea.org/MTCD/publications/PDF/p1531interim_web.pdf

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https://www-pub.iaea.org/MTCD/publications/PDF/Pub1578_web-57265295.pdf
https://ww2.fda.gov.ph/attachments/article/507321/Draft%20AO%20Diagnostic%20and%20Inte
rventional%20Radiology%20%20AS%20OF%20MAY%2017,%202018.pdf
https://www.doh.gov.ph/sites/default/files/transparency%20seal/Consolidated_Citizens_Charter.
pdf

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 FIRE EXIT
GEN SET ROOM 1

GEN SET ROOM 2 CONTROL ROOM 1

CONTROL ROOM 2
CATHLAB 1 – PROCEDURE ROOM

CATHLAB 2 – PROCEDURE ROOM

HOLDING AREA

STOCK ROOM
DOCTOR’S OFFICE
LOUNGE

CCU DEPARTMENT

LOCATION MAP ABC BLDG 2nd Floor.

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