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Radiation Protection for Operating Room Staff (2.3.3)

Radiation Protection for Operating Room Staff (2.3.3) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures


Policy Title: Radiation Protection for Operating Room Staff
Policy Number: 2.3.3
Category: UW Health
Type: Inpatient
Effective Date: January 21, 2016


To provide radiation protection procedures to Operating Room (OR) staff, hospital employees, and patients
during surgical procedures or intraoperative radiation implant treatment (i.e. I-125).


A. All patients shall be protected to minimize exposure to radiation per exam and receive only the amount
necessary to get a diagnostic radiograph or provide intra-operative radiation treatment.
B. State regulations require gonadal shielding w henever it is practical and w ould not compromise the


A. Patient Radiation Safety for X-ray Imaging
i. The radiation f ield is to be collimated only large enough to include the anatomic part to be imaged.
ii. Where practical, the gonads on all patients are to be protected from primary and scattered radiation
by the use of a gonads shield, except w hen the examination w ould be compromised.
iii. Exposure factors utilized must produce minimum amount of patient exposure that w ill produce a
diagnostic radiograph.
B. Patient Radiation Safety for Intra-operative Radiation Treatment
i. Before treatment, radiation therapy personnel w ill determine dose and portal. Surgeons w ill recheck
placement of portal. Sentinel Events related to prolonged fluoroscopy include: prolonged
fluoroscopy cumulative dose greater than 1500 rads to a single f ield, or any delivery to the w rong
body region greater than 25% of the planned radiotherapy dose.
C. Employee Radiation Safety for X-ray Imaging
i. The x-ray beam from the x-ray tube shall not be directed tow ard the entrances to the room.
ii. All surgery room entrance doors must be closed during x-ray exposures.
iii. Anyone holding or monitoring a patient during an exposure (including the mini OEC imaging
system) must w ear a protective lead apron or vest and skirt. Thyroid lead shields w ill be available
to staff.
iv. Radiology personnel should stand at least six feet from the patient during portable examination
exposures w henever possible.
v. Whenever possible, the portable x-ray machine is to be betw een the Radiology Technologist and
the patient.
vi. Directly prior to taking an x-ray exposure the Radiology Technologist w ill announce an alert that x-
rays are about to be taken.
vii. Employee exposure monitoring w ill be determined by the Hospital Radiation Health Physicist.
D. Inspection Radiation Protection Items
i. Whenever a new diagnostic radiology protection item is acquired, the OR Materials Managers shall
notify the Diagnostic Radiology (DR) manager for checking these items. The technologists
approved for testing w ill inspect the items by radiographic/f luoroscopic means. They w ill keep a
record of each item along w ith its dates of testing. Each item w ill be tagged w ith a barcode.
ii. Radiation protection items in use w ill be tested by radiographic/f luoroscopic inspection every tw o
years. If any radiation protection item in use is discovered to not have been tested for more than
tw o years, the DR manager shall be notif ied by the OR Materials Managers. Each employee and
managers are also responsible for performing ongoing visual inspections of personal radiation
protection items and then bringing any item that appears damaged to the attention of the OR
Materials Managers w ho w ill, in turn, have the DR staff test it.
iii. OR Materials Managers are responsible for notifying the Radiology Equipment Coordinator or DR
manager of any personal radiation protection items that are removed from service. This is essent ial
for the proper accounting of these items by the Radiology Equipment Coordinator/DR staff.
E. The quality assurance tests of the x-ray equipment for proper image quality and radiation safety are outlined
in the Quality Control Agreement w ith Medical Physics Section: Comprehensive quality assurance tests are

Policy Title: Radiation Protection for Operating Room Staff
Policy Number: 2.3.3

performed on the radiographic equipment at average annual intervals, w ith spot checks performed as
requested, and after major repairs such as x-ray tube replacement. These tests include measurements of
image quality, radiation safety, and overall performance of the equipment.


Author: Director, Surgical Services
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Associate Professor, Medical Physics and Radiology; Diagnostic Radiology Manager; Surgical
Materials Coordinator
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

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.


Jeff Grossman, MD
UW Health CEO

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


UWHC policy #12.13, Inspection of Radiation Protection Items (Lead Aprons)
UWHC policy #8.98, Recording and Review of X-ray Exposure for Procedures Using Fluoroscopy

Version: Revision
Next Revision Due: January 21, 2019
Formerly Know n as: Surgical Services Departmental policy #6.06