General Policies and Procedures Manual

Section 250 Section 250.630  General Policies and Procedures Manual Each radiological department or department in charge of an identified distinct radiological service shall prepare and maintain a policies and procedures manual.  It shall be reviewed and updated annually.  It shall include but not be limited to provisions for the following identified requirements: a)         The hospital shall establish and enforce safety policies that will protect both patient and radiological worker from excessive or stray radiation in accordance with the Radiation Protection Act of 1990 and the regulations promulgated thereunder. b)         Personnel Monitoring shall be performed pursuant to 32 Ill. Adm. Code 340.210 and 340.520. 1)         Procedures for personnel monitoring shall be maintained for each individual working in the area of radiation where there is a reasonable possibility an individual will exceed 10% of annual limit. 2)         Personnel monitoring records resulting from the use of film badges or dosimeters must be maintained. Readings must be on at least a quarterly basis. 3)         Upon termination of employment, each worker shall be provided with a summary of the worker's exposure record. 4)         Permanent records of exposure on all monitored personnel shall be maintained for review by surveyors for licensing. c)         Monthly and yearly reports shall be maintained on the number of examinations done and kinds of treatment given. d)         The use of all radiological apparatus shall be limited to personnel designated as qualified by the physician responsible for the direction and supervision of the department or service.  Qualified personnel shall comply with the Radiation Protection Act of 1990 and the regulations promulgated thereunder, specifically 32 Ill. Adm. Code 401.  The use of fluoroscopes shall be limited to persons licensed under the Medical Practice Act of 1987, the Illinois Dental Practice Act, or the Podiatric Medical Practice Act of 1987, and to personnel who meet the requirements in 32 Ill. Adm. Code 360.50(n)(1) through (4). e)         Radiological personnel accredited pursuant to 32 Ill. Adm. Code 401 shall participate in continuing education pursuant to 32 Ill. Adm. Code 401.140.  Physicians shall participate in training pursuant to Subpart J of 32 Ill. Adm. Code 335 as applicable.  The continuing education shall be documented. f)         At all times, there shall be reasonable privacy for the radiological patient relative to dressing, evacuation, and the study being performed. g)         The hospital must develop and maintain written safety policies for the radiological services to protect patients and personnel.  These policies must relate to radiation pursuant to the Radiation Protection Act and the regulations promulgated thereunder, electrical and mechanical hazards, prevention and containment of fire and explosion, and prevention and treatment of any untoward reaction to contrast media. h)         The hospital must enforce written policies and procedures for the radiological services that relate to the management of critically ill patients and to the administration of diagnostic agents by nonphysicians. i)          When qualified personnel are permitted to administer diagnostic agents intravenously for radiological evaluations, the hospital shall develop and enforce written safety guidelines specifying which individuals have this authority and whether a physician shall be physically present or immediately available, in accordance with 32 Ill. Adm. Code 360.50(n)(1) through (4).  If radioactive materials are being administered, accreditation and supervision rules apply.  Refer to 32 Ill. Adm. Code 335.1050. j)          There must always be an emergency drug tray in the room or immediately available where parenteral diagnostic agents for radiologic evaluations are being administered.  The hospital must maintain a system for maintaining an emergency drug tray with no outdated medications or missing items, and to ensure that the tray's content is appropriate.  Oxygen, airways, syringes and needles, intravenous administration sets, and appropriate parenteral solutions shall be available at all times. k)         Policies and procedures for the administration of radiological drugs shall be coordinated with and approved by the Pharmacy and Therapeutics Committee.  (Refer to Subpart R Section 250.2140). l)          Written safety policies must provide for the steps to be followed in the event of a spill of radioactive material pursuant to Subpart M of 32 Ill. Adm. Code 340; for specific authority for any nonphysician qualified personnel who administer radioactive material intravenously pursuant to 32 Ill. Adm. Code 335.1050; for the recording of cumulative radiation exposure of all personnel pursuant to 32 Ill. Adm. Code 340.1160 and 340.520; a requirement for protective security from all radioactive areas for all unauthorized personnel pursuant to Subpart G of 32 Ill. Adm. Code 340 and 32 Ill. Adm. Code 340.810; and the establishment of a radiation protection survey at least once per week pursuant to 32 Ill. Adm. Code 335.2080 if applicable. m)        Instrument logbooks maintained by radiological services must include calibration records of equipment and monitors, maintenance and repair records, and the findings of outside evaluators (if used), with the corrective action taken pursuant to 32 Ill. Adm. Code 340.1130. n)         Requests by attending members of the medical staff for radiological examinations must contain a concise statement of the reason for the examination.