Radiation Protection in Radiotherapy Part 16 Discharge of Patients IAEA Training Material on Radiation Protection in Radiotherapy.

Radiation Protection inRadiation Protection inRadiotherapyRadiotherapy

Part 16Part 16

Discharge of PatientsDischarge of Patients

IAEA Training Material on Radiation Protection in Radiotherapy

Part 16: Discharge of patients 2Radiation Protection in Radiotherapy

Discharge of patientsDischarge of patients

From a radiation safety perspective an issue...

If patients are discharged with radioactive sources remaining in the patient after a temporary implant - this is a severe accident

If a permanent radioactive implants are in place - others need to know about it

If the patient has been treated with unsealed radioactive isotopes (e.g. 131-I, 89-Sr) - NOT subject of this course but covered in the companion course on nuclear medicine


Advice from BSS appendix II.28. Advice from BSS appendix II.28. ““In order to restrict the exposure of any In order to restrict the exposure of any

members of the household of a patient who members of the household of a patient who has undergone a therapeutic procedure with has undergone a therapeutic procedure with sealed or unsealed radionuclides and sealed or unsealed radionuclides and members of the public, such a patient shall members of the public, such a patient shall not be discharged from hospital before the not be discharged from hospital before the activity of radioactive substances in the body activity of radioactive substances in the body falls below the level specifiedfalls below the level specified in Schedule III, in Schedule III, Table III-VI. Written instructions to the patient Table III-VI. Written instructions to the patient concerning contact with other persons and concerning contact with other persons and relevant precautions for radiation protection relevant precautions for radiation protection shall be provided as necessary”.shall be provided as necessary”.


ObjectivesObjectives

To appreciate the need for checks of patients To appreciate the need for checks of patients before discharge after radioactive implantsbefore discharge after radioactive implants

To understand the need to impose limit To understand the need to impose limit values for the discharge of patientvalues for the discharge of patient

To be familiar with the conditions for To be familiar with the conditions for discharge of patients with radioactive discharge of patients with radioactive implantsimplants

To be able to provide patients, clinicians and To be able to provide patients, clinicians and others with advice regarding the radiation others with advice regarding the radiation safety of the implant.safety of the implant.


ContentContent

1. Monitoring of patients after temporary 1. Monitoring of patients after temporary implantsimplants

2. Discharge rules for patients with 2. Discharge rules for patients with permanent implantspermanent implants

3. Information for persons in contact with 3. Information for persons in contact with patients who are discharged with patients who are discharged with permanent implantspermanent implants


1. Monitoring of patients after 1. Monitoring of patients after temporary implantstemporary implants If the implant is temporary, one MUST If the implant is temporary, one MUST

ensure that all sources are removed ensure that all sources are removed from the patient prior to dischargefrom the patient prior to discharge

This applies to all isotopes and all types This applies to all isotopes and all types of implants including HDR and LDR of implants including HDR and LDR remote afterloadingremote afterloading

All brachytherapy patients should be All brachytherapy patients should be monitored before dischargemonitored before discharge


Measurement objectiveMeasurement objective

Dose rate at 1m distance from the Dose rate at 1m distance from the patientpatient

1m


Potential for severe accidentsPotential for severe accidents

An example due to equipment design:An example due to equipment design: Sources were dislodged from the drive mechanism of Sources were dislodged from the drive mechanism of

an HDR remote afterloading machine and remained an HDR remote afterloading machine and remained in the patient; she died from radiationin the patient; she died from radiation

There were many contributing factors, such as:There were many contributing factors, such as: Equipment seemed not sufficiently testedEquipment seemed not sufficiently tested Conflicting signals of indicator for source positionConflicting signals of indicator for source position History of malfunction of a detectorHistory of malfunction of a detector

However, in any case the accident could have However, in any case the accident could have been prevented if appropriate patient monitoring been prevented if appropriate patient monitoring would have been in placewould have been in place


What needs to be established:What needs to be established:

Appropriate procedures in writingAppropriate procedures in writing An appropriately trained medical physicist An appropriately trained medical physicist

and/or RSO must be involved in the treatmentand/or RSO must be involved in the treatment A monitor at the door of brachytherapy A monitor at the door of brachytherapy

treatment rooms in the ward should be treatment rooms in the ward should be availableavailable

A portable radiation monitor available for A portable radiation monitor available for check of the patient prior to dischargecheck of the patient prior to discharge


Appropriate monitoringAppropriate monitoring

Requires trained Requires trained personalpersonal

Knowledge of the Knowledge of the sources usedsources used

Knowledge of the Knowledge of the implant typeimplant type

Radioactivesource


Brachytherapy with sealed sourcesBrachytherapy with sealed sources

Area monitor helps to Area monitor helps to monitor presence of monitor presence of radioactive sourcesradioactive sources

Typically there is no Typically there is no hazard from hazard from contamination of linen contamination of linen (however, for seed (however, for seed implants watch for lost implants watch for lost seeds) seeds)


2. Permanent radioactive implants2. Permanent radioactive implants

Short half life: 198-Au seedsShort half life: 198-Au seeds Most common: 125-I seed for Most common: 125-I seed for

prostate implantsprostate implants Increasingly popular: 103-Pd Increasingly popular: 103-Pd

(palladium) seeds for prostate (palladium) seeds for prostate implantsimplants

(Not considered here: radioactive (Not considered here: radioactive stents for prevention of restenosis in stents for prevention of restenosis in blood vessels (typically 32-P))blood vessels (typically 32-P))

Mentor


Characteristics of the isotopesCharacteristics of the isotopes

198-Au 125-I 103-Pd

T1/2 (d) 2.7 60 17

Mean/max gamma energy (keV)

420/680 28/35 20/480

Typical form seed seed seed

HVL (cm of water) 4 0.02 1.6


Risks:Risks: Dislocation of sourcesDislocation of sources Irradiation of other persons in contact Irradiation of other persons in contact

with the patientwith the patient Irradiation of persons in case of a Irradiation of persons in case of a

medical emergency involving the patientmedical emergency involving the patient Irradiation of persons after the patient’s Irradiation of persons after the patient’s

deathdeath


IAEA BSS (1996) App. II.28IAEA BSS (1996) App. II.28 BSS Schedule III, Table III-VI: Guidance level BSS Schedule III, Table III-VI: Guidance level

only given for 131-I: Maximum activity for only given for 131-I: Maximum activity for discharge 1100MBqdischarge 1100MBq

Other isotopes not mentionedOther isotopes not mentioned Legal limit values are stillLegal limit values are still

applicableapplicable


Legal limit valuesLegal limit values

May vary from state to stateMay vary from state to state May not be available for the isotope of May not be available for the isotope of

interest…interest… However, limit values should be However, limit values should be

established by each facility using established by each facility using professional judgement if no regulatory professional judgement if no regulatory guidance is availableguidance is available


Maximum activities of radionuclides at which patients may be dischargedfrom hospitals (adapted from NHMRC 1984). Please note that these limitvalues are guidelines only - they may need to be modified to suit localconditions and the life style of individual patients.

Isotope Typical application Maximum activity atdischarge (MBq)

32-P Systemic injection 120090-Y Local injection 1200125-I Seed permanent implant No limit131-I Systemic injection 600198-Au Seed permanent implant 200089-Sr Systemic injection 300

Example for limit values in AustraliaExample for limit values in Australia


Discharge rulesDischarge rules

In addition to the limit values for activity In addition to the limit values for activity within the patient other discharge rules within the patient other discharge rules may be established. Examples are:may be established. Examples are: Maximum dose rate at different distances Maximum dose rate at different distances

of the patientof the patient Likelihood of dislocation of sourcesLikelihood of dislocation of sources Consideration of the performance and Consideration of the performance and

mental status of the patientmental status of the patient


A set of typical discharge rules:A set of typical discharge rules: A patient shall not be discharged if it seems likely that a sealed

source (125-I, 198-Au) may become dislocated and lost. Patients treated with Co-60, Cs-137 or Ir-192 shall not be

discharged from hospital until the sources have been removed. A patient shall not be discharged if leakage from an unsealed

source is likely. It is assumed that patients who are discharged with incorporated

radioactive substances do not use public transport for more thanone hour to avoid long exposures of others.

Special precautions and advice must be given to female patientswho breast feed their babies. In particular radioactive iodine maybe excreted in breast milk and breast feeding mothers should onlybe treated with radioactive material in emergency situations.


3. Advice to patients:3. Advice to patients: IAEA BSS (1996) App. II.28:IAEA BSS (1996) App. II.28: ““Written instructions to the patient concerning Written instructions to the patient concerning

contact with other persons and relevant contact with other persons and relevant precautions for radiation protection shall be precautions for radiation protection shall be provided as necessary.”provided as necessary.”


Advice to patients:Advice to patients: Must be in writingMust be in writing Easy to understandEasy to understand May require translation in other May require translation in other

languageslanguages Should be discussed with the patientShould be discussed with the patient Should contain contact details for Should contain contact details for

clinical and radiation protection staffclinical and radiation protection staff


Advice on the implantAdvice on the implant

May be also provided to relatives and May be also provided to relatives and carerscarers

May be also provided to referring May be also provided to referring clinicianclinician

Information should be carried by the Information should be carried by the patient at all timespatient at all times


Advice to patientsAdvice to patients Describe the implant purposeDescribe the implant purpose Advice on precautions:Advice on precautions:

e.g.e.g. after 125-I seed implant in the prostate after 125-I seed implant in the prostate urinate through a strainer for a couple of urinate through a strainer for a couple of days to catch all dislocated sourcesdays to catch all dislocated sources

Any restrictions for contact: Any restrictions for contact: e.g.e.g. go not stay in the vicinity of pregnant go not stay in the vicinity of pregnant

women for an extended period of time women for an extended period of time (best specify the time)(best specify the time)


Advice to others who may be in Advice to others who may be in contact with the patientcontact with the patient RelativesRelatives FriendsFriends CarersCarers Referring cliniciansReferring clinicians


Also consider:Also consider:

What happens if the patient requires What happens if the patient requires emergency treatment?emergency treatment? Surgery?Surgery?

What happens if the patient dies? What happens if the patient dies? Autopsies?Autopsies? Cremation?Cremation?


Also consider:Also consider:

What happens if the patient requires What happens if the patient requires emergency treatment?emergency treatment? Surgery?Surgery?

What happens if the patient dies? What happens if the patient dies? Autopsies?Autopsies? Cremation?Cremation?

In practice this depends onmany factors - it is best to

involve the responsible medical physicist or RSO in

the procedure for advice


Emergency surgery, autopsies, Emergency surgery, autopsies, cremationcremation Must involve a radiation expertMust involve a radiation expert Therefore it is essential thatTherefore it is essential that

the patient can be identified as having a the patient can be identified as having a radioactive implantradioactive implant

it is possible for others to contact someone it is possible for others to contact someone who knows the radiation details of the who knows the radiation details of the implantimplant


Identification of patient who have Identification of patient who have a permanent implanta permanent implant Patient and relatives must know about itPatient and relatives must know about it Patient should carry relevant Patient should carry relevant

information (implant type, isotope, information (implant type, isotope, activity, date of implant, contact details) activity, date of implant, contact details) with him/her at all times:with him/her at all times: wristbandwristband card in walletcard in wallet


SummarySummary It is essential to monitor patients prior to It is essential to monitor patients prior to

discharge after they had received a discharge after they had received a temporary brachytherapy implanttemporary brachytherapy implant

There are recommended limit values for the There are recommended limit values for the implanted activity above which patients implanted activity above which patients should not be discharged from hospital. should not be discharged from hospital.

Written discharge rules should be established Written discharge rules should be established for patients with permanent implants which for patients with permanent implants which include limit values for activities in the patientinclude limit values for activities in the patient

Written advice must be provided to patients Written advice must be provided to patients with permanent implantswith permanent implants


Where to Get More InformationWhere to Get More Information

Parts 6 and 11Parts 6 and 11 References: NRCP 37References: NRCP 37

Any questions?Any questions?

Question:Question:

What information would you look for in an What information would you look for in an information sheet handed out to a patient information sheet handed out to a patient after a radioactive implant using 198-Au after a radioactive implant using 198-Au

seeds of a half life of 2.7 days?seeds of a half life of 2.7 days?


Information requiredInformation required Description of the implant including isotope, half life Description of the implant including isotope, half life

and estimated activityand estimated activity Treating clinician and/or other persons who could Treating clinician and/or other persons who could

provide more details on the implantprovide more details on the implant Contact in case of emergencyContact in case of emergency Advice on appropriate precautions: Advice on appropriate precautions: e.g.e.g. Do avoid Do avoid

contact with pregnant women and children for … dayscontact with pregnant women and children for … days Advice on appropriate actions if a source becomes Advice on appropriate actions if a source becomes

dislodgeddislodged A note to make sure other clinicians or health A note to make sure other clinicians or health

professionals are informed about the nature of the professionals are informed about the nature of the implant if they are in contact with the patient within the implant if they are in contact with the patient within the next … daysnext … days

Radiation Protection in Radiotherapy Part 16 Discharge of Patients IAEA Training Material on Radiation Protection in Radiotherapy.

Documents

radiation protection

discharge slide

discharge rules

discharge of patients6

discharge of patients9

discharge of patients12

portable radiation

patients death slide