Radiological Services

Section 518.2010  Radiological Services a)         The freestanding emergency center shall maintain and provide radiological services sufficient to perform and interpret the radiological examinations necessary for the diagnosis and treatment of patients, to the extent that the complexity of services is commensurate with the size and scope of the FEC. Additional required services shall be provided by shared services or referral of patients. b)         The physician responsible for the direction of a radiological department or service shall be board certified or eligible for certification by the American Board of Radiology or equivalent.  The physician shall have a written agreement with the FEC to direct the radiological services on a full-time, part-time, or consulting basis and be an approved member of the medical staff. The responsibilities of the physician shall be identified in a policy and procedures manual or other document. c)         Technicians employed in the radiological services shall be accredited pursuant to 32 Ill. Adm. Code 401 as appropriate and have sufficient training and experience to carry out the procedures safely and efficiently commensurate with the size and scope of the service.  A procedure and means for evaluating qualifications shall be established and used by the FEC. d)         Radiological services shall be available at all times. e)         Complete, signed reports of the radiological examinations shall be made part of the patient's record, and duplicate copies shall be kept in the department for a period of time established by the FEC. f)         Written reports of each radiological interpretation, consultation and treatment shall be signed by the physician responsible for conducting the procedure and shall be a part of the patient's medical record.  Maintenance and filing of records shall be coordinated with direction and supervision by the medical record administrator. g)         X-ray or roentgen photographs shall be retained in accordance with the X-ray Retention Act, which requires retention for five years and longer when notification of litigation is received. h)         Radiological facilities operated by an FEC constitute a "radiation installation" within the meaning of the Radiation Protection Act of 1990 and are required to be registered with the Illinois Emergency Management Agency. i)          Each radiological department or identified distinct radiological service shall prepare and maintain a policies and procedures manual, which shall be reviewed and updated annually and shall include, but not be limited to, the following requirements: 1)         The FEC shall establish and enforce safety regulations that will protect both patient and radiological worker from excessive or stray radiation pursuant to the Radiation Protection Act of 1990 and the federal regulations promulgated thereunder. 2)         When a radiation hazard exists, the FEC shall periodically obtain a survey and report by a diagnostic imaging specialist or therapeutic radiological physicist that indicates whether satisfactory conditions exist. 3)         Personnel Monitoring shall be performed pursuant to 32 Ill. Adm. Code 340.210 and 340.520. A)        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. B)        Personnel monitoring records resulting from the use of film badges or dosimeters shall be maintained. Readings shall be on at least a quarterly basis. C)        Upon termination of employment, each worker shall be provided with a summary of the worker's exposure record. D)        Permanent records of exposure on all monitored personnel shall be maintained for review by the Department. 4)         Monthly and yearly reports shall be maintained on the number of examinations done and kinds of treatment given. 5)         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). 6)         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 physician is responsible for the direction and supervision of radiological services.  The continuing education shall be documented. 7)         At all times, reasonable privacy shall be provided for the radiological patient relative to dressing, evacuation, and the study being performed. 8)         Safety policies shall be written for the radiological services to protect patients and personnel.  These policies shall relate to radiation pursuant to 32 Ill. Adm. Code 310, 335, 340, and 360, electrical and mechanical hazards, prevention and containment of fire and explosion, and prevention and treatment of any untoward reaction to contrast media. 9)         Written policies and procedures shall be enforced for the radiological services that relate to the management of critically ill patients and to the administration of diagnostic agents by nonphysicians. 10)       When nonphysicians are permitted to administer diagnostic agents intravenously for radiological evaluations, written safety guidelines shall specify which individuals have this authority and require that a physician be immediately available. If radioactive materials are being administered, accreditation and supervision rules apply.  Refer to 32 Ill. Adm. Code 335.1050. 11)       An emergency drug tray shall always be present in the room or immediately available where parenteral diagnostic agents for radiologic evaluations are being administered.  A system shall be established for maintaining an emergency drug tray with appropriate content and no outdated medications or missing items.  Oxygen, airways, syringes and needles, intravenous administration sets, and appropriate parenteral solutions shall be available at all times. 12)       Written safety policies shall 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 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. 13)       Instrument logbooks maintained by Radiological Services shall 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.