UW HEALTH CLINICAL POLICY 1
Policy Title: Admission of Patients Treated with Radiopharmaceuticals
Policy Number: 2.1.19
Category: UW Health
Effective Date: July 21, 2016
To establish safety procedures for caring for inpatients, outpatients and Emergency Department (ED)
patients w ho have received therapeutic radiopharmaceuticals.
II. POLICY ELEMENTS
When a patient w ho has received a therapy containing unsealed radioactive material readmits or presents in
the ED for medical treatment, the on-call nuclear medicine staff physician and Radiation Safety Officer
(RSO) must be consulted to ensure radiation exposure is minimized.
A. Notif ication
i. The on-call nuclear medicine staff physician shall be contacted via hospital paging by the ED
physician or the admitting physician (w hoever has f irst contact w ith the patient) w henever a patient
presents at the ED or is admitted to an inpatient unit w ho has recently received a radioactive
therapy containing unsealed radioactive material (e.g., radioactive iodine (I-131) for thyroid cancer
or hyperthyroidism, or I-131-labeled antibody treatment for non-Hodgkin’s lymphoma).
ii. The nuclear medicine staff physician w ill review the patient information w ith the staff physician and
the RSO to determine if a special room (e.g., lead-lined room) needs to be obtained for the patient.
The nuclear medicine staff physician w ill w ork w ith the admitting physician and RSO to be sure the
correct room is obtained. The RSO w ill w ork directly w ith the admitting intern/resident so that house
staff w ill know w hat radiation safety precautions need to be placed in the patient's medical record.
B. Nuclear Medicine/ RSO
i. After a patient has been treated w ith a radionuclide therapeutic agent, a licensee may authorize the
release from its control of any individual w ho has been administered byproduct material if the Total
Effective Dose Equivalent (TEDE) to any other individual from exposure to the released individual
is not likely to exceed 500 mrem (5mSv). An exposure less than 100 mrem (1 mSv) can be
considered around pregnant w omen and children.
ii. If the patient does need to be placed in a special room (e.g., F6/6 lead lined room or corner room)
the nuclear medicine staff physician and/or RSO w ill be in charge of determining w hat the allow able
exposures are to the other health care w orkers and w ill post this on the patient room door. The
patient monitoring w ill be continued until patient is discharged. The RSO can be reached at (608)
445-2539 or by calling the University Hospital paging operator (608-262-2122) and asking to page
iii. The RSO w ill be responsible for follow ing the radiation exposure until the patient is discharged from
iv. Coordinate overall room preparation preadmission (e.g., door posting, disposable containers, room
stocked w ith disposable gloves and absorbent paper, adhesive f loor mats, mattress, etc.) and post
discharge clean up.
v. Ensure proper radiation safety training is provided to staff caring for patient.
vi. The RSO w ill notify the Core Laboratory if lab samples are to be considered contaminated w ith
C. Nursing and other Healthcare Workers if precautions are needed
i. Review the Radiation Protection Information and Physicians Order posted on patient's room and/or
included in the patient's chart.
ii. If a radiation dosimeter is assigned, make sure to w ear it at all times w hen providing patient care.
You may request a dosimeter from the RSO if you don’t have one.
iii. Know the exposure level measurements in the patient's room, how long you may remain in the
room at specif ic locations, and if there are any special instructions.
iv. Follow ing UWHC Administrative Policy #13.08 – Hand Hygiene don disposable gloves w hen you
enter the room. Place the gloves in the designated radioactive w aste container w hen leaving the
room. Mild hand w ashing is recommended if your hands w ere visibly soiled to w ash aw ay any
UW HEALTH CLINICAL POLICY 2
Policy Title: Admission of Patients Treated w ith Radiopharmaceuticals
Policy Number: 2.1.19
possible radioactive contamination of your hands. Excessive hand w ashing can open skin w ounds
allow ing the radioactivity to enter the body and is not recommended.
v. Notify your supervisor if you are, or suspect you are, pregnant. The supervisor shall notify the RSO.
vi. Make sure room is equipped w ith mattress covered w ith w aterproof mattress pad and disposable
containers for contaminated w aste and linen.
vii. If the patient vomits w ithin the f irst six hours after an oral administration, experiences urinary
incontinence, or exhibits excessive sw eating w ithin the f irst 48 hours, contact the patient's nuclear
medicine physician and/or the RSO.
D. Environmental Services
i. Do not enter, clean, or remove anything from the room until cleared by RSO.
E. Patient Death
i. In the case of a death, the RSO shall be notif ied to determine if special precautions are required.
See UWHC Nursing Patient Care Policy & Procedure 8.14AP - Postmortem Care (Adult and
Pediatric) for additional documentation requirements.
ii. Unexpected occurrences involving death are to be reported to the Department of Risk Management
per UWHC Policy #4.40, Reporting Unexpected Events & Determination of Sentinel Event Status.
See UWHC Administrative Policy #4.42 – Event Reporting for proper reporting requirements.
Author: Nuclear Medicine Manager
Senior Management Sponsor: VP, Professional and Supportive Services
Approval committees: UWHC Radionuclide Therapy Coordinating Committee; UW Health Clinical Policy
UW Health Clinical Policy Committee Approval: June 20, 2016
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter New comer, MD
UW Health Chief Medical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
UWHC Nursing Patient Care Policy & Procedure #8.14AP - Postmortem Care (Adult and Pediatric)
UWHC Administrative Policy #13.08, Hand Hygiene
UWHC policy #4.40, Reporting Unexpected Events and Determination of Sentinel Event Status
UWHC Administrative Policy #4.42, Event Reporting
VII. REVIEW DETAILS
Next Revision Due: July 2019
Formerly Know n as: Hospital Administrative policy #12.58