12.56 Radiation Safety in the Lithotripsy Suite ‐ Urology Clinic
Category: UWHC Departmental Policy
Policy Number: 12.56
Effective Date: December 4, 2013
Section: Clinic Specific (Ambulatory)
To establish a process to minimize the amount of radiation exposure received by staff in the lithotripsy suite.
Lithotripsy specialist will assume responsibility for coordination of staff involved in extracorporeal shock wave
lithotripsy (ESWL) to ensure radiation safety.
A. Lithotripsy personnel, including anesthesiologists, shall use appropriate protective equipment (lead gloves,
aprons, and thyroid shields).
B. Lithotripsy personnel shall maintain a practical distance between themselves and the source of radiation
when a patient is being exposed. Non-essential personnel shall leave the lithotripsy suite when x-ray is
C. Lithotripsy specialist and physician shall remain in the control room and view the procedure through the
lead-lined glass window.
D. Lead protective devices shall be handled carefully (unfolded and hung on designated hangers when not in
use) to minimize damage.
E. Lead protective devices shall be examined by Radiology every two years or when damage is suspected, to
assure their effectiveness. Refer to Administrative Policy 12.13 – Inspection of Radiation Protection Items
F. Employee exposure monitoring will be determined by the Hospital Radiation Health Physicist.
UWHC Administrative Policy 12.13 - Inspection of Radiation Protection Items (Lead Aprons)
V. REVIEWED AND APPROVED BY
Clinic Manager, Urology Clinic
Ambulatory Policy and Procedure Committee
Deborah D. Tinker, MSN RN, CENP, Director, Ambulatory Nursing