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The Use of Human Holders for Patients or Cassettes in X-Ray Procedures (2.3.17)

The Use of Human Holders for Patients or Cassettes in X-Ray Procedures (2.3.17) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.17


UW HEALTH CLINICAL POLICY 1
Policy Title: The Use of Human Holders for Patients or Cassettes in X-Ray Procedures
Policy Number: 2.3.17
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 6, 2016

I. PURPOSE

The purpose of this policy is to ensure compliance with good radiation safety practices and the Wisconsin
Administrative Code Section DHS 157.74(2)(g) whenever a patient or cassette must be supported by a
human holder during an x-ray procedure at UW Health (UWH) facilities.

Good radiation safety practice involves:

A. Ensuring that no one individual bears a disproportionate burden of radiation exposure.
B. Taking extra measures to minimize exposure to a developing embryo/fetus, which is most vulnerable to
adverse health effects from radiation.
C. Minimizing radiation exposure to all persons collectively.

II. POLICY ELEMENTS

A. No person shall be used routinely to hold cassettes, detectors or patients.
B. Mechanical holding devices shall be used when the technique permits. A list of individual projections where
holding devices often cannot be used shall be maintained by the department. (See section III.A.)
C. Requirements for selecting a holder and the procedures the holder shall follow for the listed
procedures. (See section III.B. and C.)
D. The human holder, preferably of post-reproductive age, shall be instructed in personal radiation safety and
protected from radiation during the procedure. Specifically, if anyone other than a UWH clinical staff member
is used as a holder, they will be provided with oral and written instructions on the proper holding techniques
to optimize image quality and minimize their own radiation exposure during the procedure.
E. In those cases where the patient must hold the cassette or detector, any portion of the body other than the
area of clinical interest struck by the useful beam shall be protected from radiation.
F. Trainees and students shall comply with their own accrediting school requirements.
G. Students employed outside of their academic program may participate in human holding.

III. PROCEDURE

A. List of specific procedures and projections where holding devices often cannot be used and human holders
may be used:
i. Cross-table hip exam
ii. Infant exams
iii. Exams involving sedated/medicated patients
iv. Upright exams on weak patients
v. Exams involving uncooperative or trauma patients
B. Requirements and procedures for selecting a holder:
i. Holders will be provided with information about assisting with x-ray procedures. They should be
selected in the following order from most preferred to least preferred, in order to minimize the
likelihood of any person serving as a holder on a regular basis. Family members may be allowed to
hold a patient if they volunteer to do so, but should not be asked to do so by UWH staff. :
a. Non-pregnant, non-Radiology staff
b. Non-pregnant Radiology Staff
C. Procedures to be followed when holding cassettes, detectors, or patients:
i. In general, good radiation safety practices should be observed by technologists and holders. The
technologist performing the exam is responsible for ensuring that these practices are followed. The
following practices should also be observed:
a. Appropriate collimation should be used for every exam.
b. Holders should avoid placing any part of their body in the useful beam.
c. The human holder shall be protected from the direct scattered radiation by a radiation
shield of not less than 0.25 mm lead equivalent material. Any part of the human holder
that may be struck by the useful beam shall be protected by not less than 0.5 mm lead



UW HEALTH CLINICAL POLICY 2
Policy Title: The Use of Human Holders for Patients or Cassettes in X-Ray Procedures
Policy Number: 2.3.17

equivalent material. In those cases where the patient must hold the cassette, any portion
of the body other than the area of clinical interest struck by the useful beam shall be
protected by not less than 0.25 mm lead equivalent material.

IV. COORDINATION

Author: X-Ray Safety Committee
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 21, 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.

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

Wisconsin Administrative Code Section DHS 157.74(2)(g)

VII. REVIEW DETAILS

Version: Revision
Next Revision Due: December 2019
Formerly known as: Hospital Administrative policy #8.08