Section 335.5030  Safety Precautions

a)         For each patient or human research subject who cannot be released under Section 335.2110 of this Part, the licensee shall:

1)         Perform radiation monitoring as required by 32 Ill. Adm. Code 340.510 for use in determining when the licensee shall supply appropriate personnel with individual monitoring devices as required by 32 Ill. Adm. Code 340.520. Records of the radiation monitoring indicating the date and time of the monitoring, an annotated diagram of the area and a list of points monitored, the measured dose rate, the manufacturer, model and serial number of the instrument used to perform the monitoring and the identity of the individual who performed the monitoring shall be maintained for 5 years. This radiation monitoring shall include, as a minimum, the dose rate in units, multiples or subunits of Sieverts or rem per hour at:

A)        The patient's bedside;

B)        1 meter from the patient;

C)        The patient's hospital room door; and

D)        Contiguous restricted and unrestricted areas. However, radiation monitoring of adjoining rooms is not required if a calculation of the dose rate to a patient in the adjoining room is made based on measurements obtained pursuant to subsection (a)(1)(A) or (B) of this Section.

2)         Prevent any patient who is not receiving radiopharmaceutical therapy, but who is occupying a room that adjoins the room of a patient who is receiving radiopharmaceutical therapy, to receive a dose greater than 1 mSv (100 mrem) during the patient's entire stay from radiation emitted by any therapy patient. The licensee shall verify compliance by performing radiation surveys based on the monitoring required by subsection (a)(1) of this Section.

3)         Prevent the placement of a therapy patient in the same room with a patient who is not receiving radiopharmaceutical therapy unless the licensee demonstrates, by monitoring or surveys, compliance with the requirements of 32 Ill. Adm. Code 340.310 at a distance of 1 meter from the therapy patient.

4)         Provide each therapy patient's room with a private sanitary facility.

5)         Post the patient's door with a "Caution: Radioactive Materials" sign. The posted sign shall indicate that pregnant women, or women who suspect that they are pregnant, shall contact the attendant staff for additional safety instructions or precautions. Also, a note shall appear on the door and on the patient's chart which states where and how long visitors may stay in the patient's room.

6)         Authorize visits by individuals under age 18 only on a patient-by-patient basis with the approval of the radiation therapy physician after consultation with the Radiation Safety Officer.

7)         Maintain and make available nursing instructions for the attendant nursing staff that list any restrictions and instructions that shall be followed regarding the care of therapy patients.

8)         Either monitor all items removed from the patient's room to determine that any contamination cannot be distinguished from the natural background radiation level with a radiation detection survey instrument set on its most sensitive scale and with no interposed shielding other than a plastic or cloth bag or handle all items removed from the patient's room as radioactive waste.

9)         Advise attendant nursing staff to notify the Radiation Safety Officer or the radiation therapy physician immediately if the therapy patient dies or has a medical emergency.

10)         Monitor the patient's room and sanitary facility for removable contamination. The room shall not be re-assigned until the requirements of 32 Ill. Adm. Code 340.320 and 340.510 have been met.

b)         The licensee shall implement the precautions required by subsections (a)(1) through (10) of this Section until all of the requirements of Section 335.2110 of this Part can be met.

(Source:  Amended at 30 Ill. Reg. 9029, effective April 28, 2006)