2018

RADIATION SAFETY
PROGRAM

HDR Cobalt-60 and LDR Cesium-137 BRACHYTHERAPY FACILITY

RADIATION ONCOLOGY SECTION

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PHILIPPINE GENERAL HOSPITAL, UP-MANILA | Taft Avenue, Malate, Manila

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 APPROVAL FOR IMPLEMENTATION

ELRICK T. INOCENCIO, M.Sc.

PREPARED BY: DATE:

EDILBERTO JOAQUIN V. FRAGANTE, JR, MD

REVIEWED BY: DATE:

JOHANNA PATRICIA A. CAÑAL, MD

APPROVED BY: DATE:

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TABLE OF CONTENTS

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 1 ALARA PROGRAM.............................................................................................................................................5
1.1 Description of the Organization......................................................................................................................5
1.2 Management Commitment.............................................................................................................................5
1.3 Radiation Safety Committee (RSC) Commitment...........................................................................................6
1.3.1 Review of Proposed Users and Uses..........................................................................................................6
1.3.2 Delegation of Authority...........................................................................................................................6
1.3.3 Review of ALARA Program.......................................................................................................................6
1.3.4 Radiation Safety Officer (RSO) Commitment...........................................................................................6
1.3.5 Authorized User’s Commitment...............................................................................................................7
1.3.6 Provision of Continuing Education to all Workers.....................................................................................7
1.3.7 Investigation Level...................................................................................................................................7
1.4 RSC DUTIES & RESPONSIBILITIES.................................................................................................................7
1.5 RSO AUTHORITIES, DUTIES & RESPONSIBILITIES........................................................................................8
1.5.1 Radiation Safety Officer / Assistant Radiation Safety Officer....................................................................8
1.5.2 Authorized User/s (Radiation Oncologist/s)............................................................................................9
1.5.3 Senior Medical Physicist / Supervised or Junior Medical Physicist/s........................................................9
1.5.4 RADIOTHERAPY TECHNOLOGIST/s.................................................................................................9
2 TRAINING PROGRAM..........................................................................................................................................9
2.1 Lists of training programs for each member of the team...............................................................................10
2.1.1 Radiotherapy Technologist.....................................................................................................................10
2.1.2 Medical Physicist....................................................................................................................................10
2.1.3 Radiation Oncologist..............................................................................................................................10
2.1.4 Brachytherapy Nurses............................................................................................................................11
2.1.5 Ancillary Personnel.................................................................................................................................11
3 PERSONNEL MONITORING PROGRAM..............................................................................................................11
3.1 Investigation & Action Levels.........................................................................................................................11
3.2 Pregnant Workers......................................................................................................................................11
4 CALIBRATION OF SURVEY INSTRUMENTS........................................................................................................12
5 LEAK TEST PROGRAM........................................................................................................................................12
5.1 Tests for Leakage and Contamination of Sealed Sources (for Co-6 & Cs-137).................................................12
5.1.1 Materials Needed...................................................................................................................................12
5.1.2 Procedure for Swipe Testing for Co-60...................................................................................................12
5.1.2 Procedure for Swipe Testing for Cs-137.................................................................................................12
6 RADIATION SURVEY PROGRAM.........................................................................................................................13

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 6.1 Area Monitoring............................................................................................................................................13
6.2 Equipment Monitoring..................................................................................................................................13
6.3 Patient Monitoring........................................................................................................................................13
7 OPERATING PROCEDURE...................................................................................................................................14
7.1 Remote Afterloading Unit Operating Procedure............................................................................................14
7.2 Procedure on the Maintenance & Repair of the HDR Equipment (CPR PART 14)...........................................15
7.3 Source Exchange for Co-60 (SagiNova User Manual Page 63 – 66; Rev.02/10.2014)......................................16
7.4 Manual Loading Operating Procedure...........................................................................................................20
7.4 Recordkeeping (CPR Part 14)........................................................................................................................20
8 RADIATION CONTROL PROCEDURES................................................................................................................21
8.1 Procedure for Control of Public Exposure.....................................................................................................22
8.2 Procedure for Visitor Control........................................................................................................................22
8.3 Procedure for Preparation and Transfer of LDR Cs-137 Sources.....................................................................22
8.4 Procedure for Radiation Safety During LDR Cs-137 Brachytherapy................................................................22
8.2 Procedure for Radiation Safety in Removal of LDR Cs-137............................................................................23
9 EMERGENCY PROCEDURES...............................................................................................................................23
9.1 In Case of Fire................................................................................................................................................23
9.2 In Case of Loss or Pilferage...........................................................................................................................24
9.3 In Case of Overexposure of Personnel...........................................................................................................24
9.4 In Case Radioactive Source does not Return to Safe.....................................................................................25
9.5 Reporting Incidents/Accidents to PNRI.........................................................................................................26
10 MANAGEMENT OF SPENT SEALED SOURCES.................................................................................................27
11 DECOMMISIONING PLAN.................................................................................................................................27

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ALARA PROGRAM

The effective and equivalent doses received by Radiation Users or other personnel, are dose limits. The
guiding principle of all radiation work is: the dose should be As Low As Reasonably Achievable, economic
and social factors being taken into account. This is called the "ALARA Principle" and is central to all
radiation safety. The facility ensures that every exposure of workers is kept as low as reasonably
achievable.
Any Radiation User whose annual or quarterly dose, as measured by external monitoring greatly exceeds
the normal value either for that individual or for persons carrying out similar work, is subject to
investigation by regulating bodies.

1.1 DESCRIPTION OF THE ORGANIZATION

Philippine General Hospital (PGH) is a tertiary state – owned hospital administered and operated by the
University of the Philippines Manila, the University of the Philippines
System’s Health Sciences Center. It is the largest government hospital administered by the university,
and is designated as the National University Hospital. It is located at Ermita, Manila. It is the biggest
hospital in the country with a 1,600 bed capacity. It is a mixed-use hospital, with 1000 beds for indigent
patients and 600 beds for private patients.
The Brachytherapy Facility is operated by the Section of Radiation Oncology, Department of Radiology,
University of the Philippines – Philippine General Hospital, with address at Taft Avenue, Malate, Manila.
UP-PGH is a government hospital/medical center under the University of the Philippines school system.
Vision
The PGH, globally competitive and committed to the health of the Filipino people, through networking
and teamwork of competent, compassionate and ethical health professionals, shall be the center of
excellence and leadership in health care training and research that impacts on health policies
Mission
To render health care through effective teamwork
To train health care professionals to become competent, humane and ethical health care providers,
educators and leaders
To undertake biomedical and health system research which serves as basis for relevant health policies
To develop a referral network and evolve as the center for complex health care problems
To be the role model for healthcare delivery

1. 2 MANAGEMENT COMMITMENT

We, the management of this facility, are committed to the program described herein for keeping
individual and collective doses as low as reasonably achievable (ALARA). In accord with this commitment,
we hereby describe an administrative organization for radiation safety and will develop the necessary
written policy, procedures, and instructions to foster the ALARA concept within our institution.
We will perform a formal annual review of the radiation safety program, including ALARA considerations.
This will include reviews of operating procedures and past dose records, inspections, etc., and
consultations with the radiation safety staff or outside consultants.
Modifications to operating and maintenance procedures and to equipment and facilities will be made if
they will reduce exposures unless the cost, in our judgement, is considered unjustified. If modifications
have been recommended but not implemented, we will be prepared to describe the reasons for not
implementing the changes.

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 In addition to maintaining doses to individuals as far as below the limits as reasonably achievable, the
sum of the doses received by all exposed individuals will also be maintained at the lowest practicable
level.

1.3 RADIATION SAFETY COMMITTEE (RSC) COMMITMENT

The Radiation Safety Committee has the general responsibility to oversee the safe use of all ionizing
radiation within the UP-PGH. It shall be composed of individuals who represent the various uses of
radiation within the institution. The RSC shall:

1.3.1 REVIEW OF PROPOSED USERS AND USES

The RSC will thoroughly review the qualifications of each applicant with respect to the types and
quantities of radioactive materials and methods of use for which application has been made to ensure
that the applicant will be able to take appropriate measures to maintain exposure ALARA.
The RSC will ensure that the users justify their procedures and that individual and collective doses will be
ALARA.

1.3.2 DELEGATION OF AUTHORITY

The RSC will delegate authority to the RSO for enforcement of the ALARA concept.
The RSC will support the RSO when it is necessary for the RSO to assert authority. If the RSC has
overruled the RSO, it will record the basis for its action in the minutes of the quarterly meeting.

1.3.3 REVIEW OF ALARA PROGRAM

The RSC will encourage all users to review current procedures and develop new procedures as
appropriate to implement the ALARA concept. The RSC will perform a quarterly review of occupational
radiation exposure with particular attention to instances in which the investigational levels are exceeded.
The RSC will evaluate our institution’s overall efforts for maintaining doses ALARA on an annual basis.
This review will include the efforts of the RSO, authorized users, and workers as well as those of
management.

1.3.4 RADIATION SAFETY OFFICER (RSO) COMMITMENT

1.3.4.1 ANNUAL AND QUARTERLY REVIEW

The RSO will perform an annual review of the radiation safety program for adherence to ALARA
concepts. Reviews of specific methods of use may be conducted on a more frequent basis.
Quarterly review of occupational exposures. The RSO will review at least quarterly the external radiation
doses of authorized users and workers to determine that their doses are ALARA.

1.3.4.2 EDUCATION RESPONSIBILITIES FOR ALARA PROGRAM

The RSO will schedule briefing and educational sessions to ensure that authorized users, workers, and
ancillary personnel who may be exposed to radiation will be instructed in the ALARA philosophy. They
should also be informed that management, RSC, and the RSO are committed to implementing the
ALARA concept.

1.3.4.3 COOPERATIVE EFFORTS FOR DEVELOPMENT OF ALARA PROCEDURES

Radiation workers will be given opportunities to participate in formulating the procedures that they will
be required to follow.

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 a. The RSO will be in close contact with all users and workers in order to develop ALARA
procedures for working with radioactive materials.
b. The RSO will establish procedures for receiving and evaluating the suggestions of individual
workers for improving radiation safety practices and will encourage the use of these programs

1.3.4.4 REVIEWING INSTANCES OF DEVIATION FROM GOOD ALARA PRACTICES:

The RSO will investigate all known instances of deviation from good ALARA practices and, if possible, will
determine the causes. When the cause is known, the RSO will implement changes in the program to
maintain doses ALARA.

1.3.5 AUTHORIZED USER’S CO MMITMENT

1.3.5.1 NEW METHODS OF USE INVOLVING POTENTIAL RADIATION DOSES

The authorized user will consult the RSO during the planning stage before using radioactive materials for
new uses.
The authorized user will review each planned use of radioactive materials to ensure that doses will be
kept ALARA. Trial runs may be helpful.

1.3.5.2 AUTHORIZED USER’S RESPONSIBILITY TO SUPERVISED INDIVIDUALS

The authorized user will explain the ALARA concept and the need to maintain exposures ALARA to all
supervised individuals.
The authorized user will ensure that supervised individuals who are subject to occupational radiation
exposure are trained and educated in health physics practices and maintaining exposures ALARA.

1.3.6 PROVISION OF CONTINUING EDUCATION TO ALL WORKERS

We commit that all Radiation Oncology personnel that include Radiation Oncologists, Medical Physicists,
Radiotherapy Technologists, Nurses and other medical allied personnel such as nursing aides involved in
the of patients undergoing brachytherapy procedures have received appropriate radiation safety training.
Thus, all members of the HDR brachytherapy team shall be trained for emergency procedures for each
type of application, with instructions on what to do during these emergencies.

1.3.7 INVESTIGATION LEVEL

Readings from the badges should not exceed an investigation level of 1.0 mSv effective dose in 2 months
and 3.4 mSv for the action level;
If these values are exceeded, a prompt investigation is conducted. If the person truly received more than
the investigation/action level, he/she shall be assigned to a position requiring lesser radiation exposure,
such as clerical work. This would prevent exceeding of the total annual dose limit of 20 mSv.
Note: OSLs are to be assessed and/or replaced every two (2) months by the PNRI-RPS.

1.4 RSC DUTIES & RESPONSIBILITIES

The main responsibilities of the Radiation Safety Committee are the following:
Supervises the entire program
Writes and documents policies to guarantee quality of patient care
Aids the staff in tailoring the policy to meet the needs of the department and for further
improvement
Monitors and audits the program to ensure that each component is being performed and
documented

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 Sets agreed action levels
Meets quarterly and documents minutes of the meeting, actions recommended and results
attained
As specified in CPR Part 14, Section 17 (b), the committee shall:
Review recommendations on ways to maintain individual and collective doses ALARA
Review quarterly, with the assistance of the RSO, a summary of the occupational radiation dose
exposure records of all personnel working with radioactive material, records of radiation level
surveys, and all incidents involving radioactive material with respect to cause and subsequent
actions taken
Review annually, with the assistance of the RSO, the inventory and disposition of sealed sources
Review annually, with the assistance of the RSO, the radiation safety program
Submit a report to PNRI on the occupational doses and an updated radiation safety program.

1.5 RSO AUTHORITIES, DUTIES & RESPONSIBILITIES

1.5. 1 RADIATION SAFETY OFFICER / ASSISTANT RADIATION SAFETY OFFICER

Serves as an advisor to users of radioactive materials and radiation producing equipment concerning
such matters as the types of materials and equipment that can be used under existing licenses and the
safe storage of materials and equipment, with responsibility for implementing established federal and
institutional policies and regulations.
Interprets institutional and non-institutional policies and regulations governing the use of radioactive
materials and radiation-producing equipment
Evaluates the effectiveness of existing radiation policies and programs including identifying deficiencies
and recommending modifications in them
Coordinates institutional radiation-safety activities with radiation safety policies, procedures, and
regulations established by various governing agencies involving such tasks as presenting and
interpreting new policies, regulations, and project proposals to institutional committees and presenting
the institution's position on a wide variety of radiation projects and regulations to outside agencies
Establishes, maintains, or supervises the maintenance of records reflecting the licensing and
registration of radioactive materials and radiation-producing equipment
Evaluates architectural drawings and specifications for adequate radiation shielding and contamination
control provisions, including identifying safety hazards and recommending required modifications
Reviews applications for procurement of radioactive materials and radiation-producing equipment to
ensure compliance with established policies and regulations governing procurement, use, and storage
and to eliminate duplication
Supervises receiving and acceptance of radioactive sources, decontamination of facilities, transport of
unusually hazardous radioactive material, and disposal of radioactive waste, with responsibility for
implementing effective safety measures
Investigates excessive personnel radiation exposures and accidents resulting in serious contamination
of facilities, including determination of causes and recommending preventive or remedial measures
All other duties and responsibilities of RSO / ARSO, as specified by CPR Part 14 Section 16
RSO should be given sufficient authority, organizational freedom, time, and resources to perform
his/her duties

1.5. 2 AUTHORIZED USER/S (RADIATION ONCOLOGIST/S)

Ensures overall patient protection and safety in the prescription of and during the delivery of medical
exposure Reviews patient history
Defines procedures, selects applicators

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 Performs procedure – applicator insertion
Defines active dwell positions and target volume Defines
optimization criteria
Reviews treatment plan
Authorizes treatment responds to emergencies as directed by the physicist
Disconnects patient and removes applicator with the help of the brachytherapy nurse in the post
treatment

1.5.3 SENIOR MEDICAL PHYSICIST / SUPERVISED OR JUNIOR MEDICAL PHYSICIST/S

Consults with the physician during pre-treatment preparation
Commissions new applicators
Reviews radiographs, prescription and verifies positional parameters Plans treatment
Checks treatment setup
Reviews daily QA
Monitors treatment progress
Supervises emergency procedures
Senior Medical Physicist ensures that above procedures are performed accordingly by the
Supervised/Junior Medical Physicist/s

1.5. 4 RADIOTHERAPY TECHNOLOGIST/S

Assists physician with the help of brachytherapy nurse
Performs daily QA
Reports immediately any deviations to the Medical Physicist prior to clinical use
Labels applicators
Connects unit to the catheters
Operates treatment unit
Monitors treatment progress
Setups patient
Compares treatment plan to prescription
Surveys patient and room after post treatment
Completes daily treatment record in patient’s chart
Secures treatment device

2 TRAINING PROGRAM

This program guarantees that all Radiation Oncology personnel that include Radiation Oncologists,
Medical Physicists, Radiotherapy Technologists, Nurses and other medical allied personnel such as
nursing aides involved in the of patients undergoing brachytherapy procedures have received
appropriate radiation safety training. Thus, all members of the HDR brachytherapy team shall be trained
for emergency procedures for each type of application, with instructions on what to do during these
emergencies.

2.1 LISTS OF TRAINING PROGRAMS FOR EACH MEMBER OF THE TEAM

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2. 1.1 RADIOTHERAPY TECHNOLOGIST
Training in the operation of the HDR unit.
Training in daily quality assurance and radiation safety procedures.
Training in emergency procedures for each type of patient treated, with directives on what to do when
the emergency procedures do not go according to plan
Training in monitoring the unit and patient during a patient treatment.
Training in detecting errors and potential problem situations.
Has had 40 hours classroom training in Radiation Safety or equivalent All other training
requirements specified in CPR Part 14
A need to undertake a refresher course on radiation safety as appropriate and approved by PNRI every
three (3) years

2. 1.2 MEDICAL PHYSICIST

Must be trained first in Radiation Oncology Physics
Specific training in brachytherapy to ensure accuracy and safety in the brachytherapy treatment planning
and delivery before fully becoming a Brachytherapy Medical Physicist.
Training on the specific model of the HDR unit including the dedicated Treatment
Planning System and safety procedures for the particular model of equipment.
Observation of planning for a patient’s treatment.
Exploration of all parts of the planning software, and how to recover fro inadvertent deviations from the
normal protocol.
Recognition of when optimization has failed to produce a desirable dose distribution, and interventional
techniques.
For the Supervised or Junior Physicist, a certificate of competency should be issued by the Senior Medical
Physicist.
Has earned units in Physics of Radiotherapy and Practical attachments in Radiotherapy in the MS degree
programs in Medical Physics. Has had at least 200 hours of classroom training that includes Radiation
Physics, Radiation Dosimetry, Radiation Protection, Radiation Biology and Nuclear Regulations and
Licensing which are part of the MS degree programs in Medical Physics.
All other training requirements specified in CPR Part 14
A need to undertake a refresher course on radiation safety as appropriate and approved by PNRI every
three (3) years

2.1.3 RADIATION ONCOLOGIST

Training in the nature of the applicators.
Discussion of desired dose distributions.
Instruction on the interpretation of the resultant information for a treatment plan (e.g., computer
printouts, isodose distributions).
Has undergone and completed residency training under the Philippine Radiation Oncology Society
(PROS) Program. Licensed by the PRC, and an active member of the PROS.
Has completed the Course on Medical Use of Radioisotope (CMR) All other training
requirements specified in CPR Part 14
A need to undertake a refresher course on radiation safety as appropriate and approved by PNRI every
three (3) years

2. 1.4 BRACHYTHERAPY NURSES

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 Appropriate training in nursing, together with specialist training in oncology Training in radiation
safety procedures
A need to undertake a refresher course on radiation safety as appropriate and approved by PNRI every
three (3) years

2.1.5 ANCILLARY PERSONNEL

Appropriate training in assisting nurses during brachytherapy procedures Training in radiation
safety procedures
A need to undertake a refresher course on radiation safety as appropriate and approved by PNRI every
three (3) years
For familiarization of the HDR unit, all members of the team must receive training on the specific model
of the equipment including the dedicated Treatment Planning System and safety/emergency procedures
where it is expected to take at least a week and may be provided on-site by specialist factory trainers.
Also, each of these individuals needs to be taught to identify the type of source that they work with and
how they will know if the source is in a safe or non-safe condition. They must also know what immediate
steps to take during an emergency.

3 PERSONNEL MONITORING PROGRAM

Monitoring is a necessary component of any radiation safety program as it involves the regular and
routine measurement of the factors applicable to radiation safety. Personnel monitoring is the
measurement of the total dose received by individual radiation workers over a specified period of time.
All personnel are given TLD/OSL badges that must be worn in the front of the uniforms at all times when
inside the facility but must be removed once exiting the facility. The badges should be returned to their
storage area when taken off. The TLD/OSL/OSL badges are submitted for evaluation every 2 months.

3.1 PINVESTIGATION &ACTION LEVELS

Readings from the badges should not exceed an investigation level of 1.0 mSv effective dose in 2 months
and 3.4 mSv for the action level;
If these values are exceeded, a prompt investigation is conducted. If the person truly received more than
the investigation/action level, he/she shall be assigned to a position requiring lesser radiation exposure,
such as clerical work. This would prevent exceeding of the total annual dose limit of 20 mSv.
Note: OSLs are to be assessed and/or replaced every two (2) months by the PNRI-RPS.

3.2 PREGNANT WORKERS

A pregnant worker shall be assigned to a position requiring lesser radiation exposure, such as clerical
work. This would prevent unnecessary exposure to the fetus.

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4 CALIBRATION OF SURVEY INSTRUMENTS

The calibration of the portable survey instrument is performed by the SSDL of the Radiation
Protection Services of the Philippine Nuclear Research Institute (PNRI/RPS) annually.

5 LEAK TEST PROGRAM

5.1 TESTS FOR LEAKAGE AND CONTAMINATION OF SEALED SOURCES

Tests for leakage and contamination is required by wiping the most accessible areas
likely to be contaminated if the source were “leaking”, this is performed only by persons
authorized to perform the tests. The following are guidelines in performing swipe test:

5.1.1 MATERIALS NEEDED

alcohol swab or filter paper
transfer tube
ziplock

5.1.2 PROCEDURE FOR SWIPE TESTING FOR Co-60 HDR BRACHYTHERAPY SOURCE
 Write the sample details in a paper
 Thoroughly wipe the connector end of one of the most used transfer tubes
 Place the sample in a ziplock.
 Send to PNRI for evaluation.

5.1.3 PROCEDURE FOR SWIPE TESTING FOR Cs-137 LDR BRACHYTHERAPY SOURCE
 Write the sample details in a paper
 Thoroughly wipe the entire surface of the brachytherapy tube source for Cs-137 and channel
openings for the LDR brachytherapy source using a filter paper or alcohol swab.
 Place the sample in a ziplock.
 Send to PNRI for evaluation

The results of the test shall be kept and maintained for five (5) years unless otherwise specified
by the administrative regulations.
The radioactive material shall be tested for leakage and contamination at intervals not to exceed
six months. In the absence of a certificate from a transfer or indicating that a test has been made
prior to the transfer, the sealed source shall not be put into use until tested.

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6 RADIATION SURVEY PROGRAM

6.1 AREA MONITORING

Controlled areas should have signs indicating that only authorized personnel are allowed inside. These
areas should not be left unattended and should be locked whenever nobody is inside. Controlled areas
include:
(a) Treatment room;
(b) Control room; and
(c) Storage room
All other areas including patient waiting areas should be supervised areas.
Radiation surveys should be done by the medical physicists every source exchange and/or semi-annually
or when there are any changes to the facility design or layout, especially after events, such as
earthquakes, that may cause cracks to appear in the walls.
Measurements should not exceed 7.5 μSv/h. Any defects identified should be accurately measured to
assess the action to be done.
A room survey should also be done during and after every patient treatment, which includes the door and
the control console.

6.2 EQUIPMENT MONITORING

Radiation surveys should be conducted at the source housing with a maximum radiation level of 10 cm
from the source of the source head shall not exceed 0.03 mSv/hr. (CPR Part 14 Section 25)

6.3 PATIENT MONITORING

Co-60 HDR Brachytherapy

Post treatment survey shall be conducted to ensure patient safety to confirm that the source has been
removed from the patient (CPR Part 14 Section 26).

Cs-137 LDR Brachytherapy

During insertion and removal of sources: (1) Storage room: (2) patient Room, 1 meter away, behind
shields, door: (3) Corridor.
During Treatment: (1) Patient room, near patient, door; (2) Corridor.
After the complete removal of radioactive sources from the LDR brachytherapy patient, all linens and
waste shall be checked by a survey meter. Clearance for patient discharge shall be issued after ensuring
that all sources are accounted for.
If readings are higher than usual report immediately to the RSO. All readings will be logged and made
available for PNRI Inspection.

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7 OPERATING PROCEDURE

Co-60 HDR Brachytherapy

7.1 REMOTE AFTERLOADING UNIT OPERATING PROCEDURE

1. HDR unit should be stored in a storage space provided with designated shielding room.
2. Pre-treatment safety checks should be performed before the treatment or at the start of the day.
3. Only the patient under treatment should be in the treatment room activation of HDR unit.
4. The ff. pre-treatment checks are to be performed before start of treatment:
a. Verify that the source activity and calibration date are correct on the printouts
b. Verify the correct patient file name in the case of multiple patient files on the computer
c. Verify that the printout matches the one shown on the afterloader printout
d. The planned dwell times should be verified before initiating the treatment
e. In multiple channel treatments, each catheter is connected to the correct machine channel.
Catheters should be marked and verified that the treatment plan and the afterloader match as
far as which catheter is which.
f. Verify correctness of patient information on printouts
g. Verify dwell positions with catheter measurements
h. Ensure that all catheters are fully seated into the machine connectors, with the connector
plunger fully extended
i. Before positioning the active source into the patient treatment catheter, the dummy source
wire will be run into each treatment catheter to verify that the catheter is not blocked or
kinked. The HDR afterloader will not run the active source into the catheter if the dummy wire
encounters resistance.
5. For each catheter channel run, check total source dwell time with manual timer and verify that the
manual timer measurement agrees with the total programmed dwell time.
6. The treatment plan data stored for each patient’s treatment will be labelled with the corresponding
patient’s name and identification number.
7. After each use of HDR unit, the operator should immediately ensure the source to have returned to the
full-shielded position and will perform a survey of the device and the patient.
8. If the radiation monitor or post treatment survey indicated that the source is not fully retracted to a
shielded position in the device, personnel (authorized physician and physicist) will immediately
implement the applicable emergency procedures. If however other emergencies occur during
treatment, authorized HDR personnel will immediately implement the applicable emergency
procedures.
9. No treatment procedure will be continued for which a de-coupled or jammed source cannot be
removed expeditiously from the patient and placed in the shielded container available in the room.
10. During all patient treatments using HDR device, both the authorized ph ysician and the medical
physicist must be physically present.

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7.2 PROCEDURE ON THE MAINTENANCE & REPAIR OF THE HDR EQUIPMENT (CPR PART 14)

1. Ensure that acceptance tests will be conducted following installation of a brachytherapy unit to verify
that the equipment conforms to technical specifications certified by the manufacturer.
2. Ensure that acceptance testing of the machine is performed after repairs or maintenance that has the
potential to alter the radiation output.
3. Perform maintenance checks on the brachytherapy equipment once in each calendar month.
4. Notify the medical physicist anytime there is repair regardless of its importance.
5. A summary of the repair and maintenance of brachytherapy equipment and treatment planning
equipment must be documented in the user’s logbook by the service engineer and transferred to the
medical physicist.
6. Full details of the repair and maintenance must be recorded in a service logbook, which must be readily
accessible at the equipment. Ensure that a system is in place for the equipment service records to be
transferred to the physicist
7. Ensure that only individuals who are specifically authorized and licensed by PNRI shall perform the
installation, repair and maintenance operations

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7.3 SOURCE EXCHANGE FOR CO-60 (SAGINOVA USER MANUAL PAGE 63 – 66; REV.02/10.2014)

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Planned maintenance and repair are done by the Service Engineer. The ff are done
during the source exchange (according to the Bebig Manual):

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Cs-137 LDR Brachytherapy

7.4 MANUAL LOADING UNIT OPERATING PROCEDURE

1. Radiation Oncologist explains the treatment procedure together with the radiation precautions to his/her
patient.
2. Staff nurse gives an orientation to the patient and relative with regards to the radiation precautions and
house rules that will be implemented/followed during nursing care before hospital admission.
3. Anesthesiologist administers spinal anesthesia.
4. Gyne-oncologist prepares the patient (gynecologic malignancy case.
5. After which, the Radiation Oncologist inserts the appropriate applicator and keeps it in place either
through suture or tape.
6. Radiologic Technologist takes lateral and /or AP projection/s radiograph of the applicator. The radiograph
confirms that the applicators are placed correctly inside the patient and shall be the basis of the Medical
Physicist for treatment planning.
7. As the patient is wheeled to his/her room, the Medical Physicist specifies the source configuration as
approved by the Radiation Oncologist.
8. Applicable dosimetry is recorded on patient’s chart.
9. The Medical Physicist or the Radiation Technologist prepares the sources as prescribed in the treatment
plan behind the L-block inside the storage room. (Note: All sources will be handled using forceps. Sources
are color coded for easy identification.
10. The Brachytherapy Section staff will wear personal dosimeters when working in the radiation area. A
survey meter is always available in the area as well).
11. The sources are then placed inside the carrier for transport to the patient room.
12. The Radiation Oncologist inserts the sources to the patient and makes final instructions to the patient
behind the bedside shield.
13. The technologist takes the exposure rate reading at 1 meter from patient above the shields and logged in
the patient’s chart. This is compared to the published exposure rate and will be the basis for errors in
administration of radioactive sources

7.5 RECORDKEEPING (CPR PART 14)

Keep record of the medical use of brachytherapy source indicating the activity of the source, date of use,
and patient’s name. Give a description of the treatment planning target volume and the doses delivered
to it, the doses to other relevant organs, the dose fractionation, and the overall treatment time.
Keep record of the results of the calibrations and periodic checks of the relevant physical and clinical
parameters selected during treatments.
Keep record of the quarterly physical inventory conducted to account for all sealed sources and devices
received and possessed. Each inventory record should be retained for five years. The inventory records
must contain:
Identity of each source radionuclide (element and mass number, chemical and physical form)
Model and serial number

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 Nominal activity of each source Location of each source
Signature of the RSO
Keep record of the ambient dose rates measured quarterly in all areas where the brachytherapy sources
are stored. The RSO will review and initial the survey records at monthly and also promptly in those cases
in which action levels were exceeded.
Retain record of the survey results for two years. Maintain also the following records:
 Copy of the license
 Dosimetry (current and prior work history) Instrument
QC tests and calibration
 Tests of leakage of radiation from radiation sources Incident and
accident investigation reports
 Audits and reviews of radiation safety program Installation,
maintenance and repair work
 Facility modification
 Training provided (initial and refresher) Waste
disposal
 Transportation
 Clinical dosimetry records and treatment prescriptions

8 RADIATION CONTROL PROCEDURES

The center follows the procedure stated in CPR Part 14, Appendix J:
1. Implement written security measures to prevent theft, loss, unauthorized withdrawal, damage to or
tampering with sources and equipment as stated in the Security Plan (please refer to the Security
Plan).
2. Conduct a semi-annual physical inventory to account for all sealed sources and devices received and
possessed. Each inventory record should be retained for three years. The inventory records must
contain:
 Identity of each source radionuclide (element and mass number, chemical and physical form)
a. Model and serial number
b. Nominal activity of each source
c. Location of each source
d. Date of inventory
e. Signature of the RSO
3. Lock equipment when not in use and secure sealed sources in a locked room or storage container.
4. Brachytherapy units should be provided with safety interlocks or other means designed to prevent
unauthorized clinical use. Safety interlocks should be designed such that operation of the unit can
be performed only by use of a key at the brachytherapy control panel and that access to the key be
restricted to specified personnel.
5. Verify that the interlocks are functional.
6. Restrict access to the controlled area. Post appropriate signs and instructions to control entry of
visitors, maintenance or housekeeping staff or unauthorized personnel.

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 7. Maintain records and control receipt, use, storage, transfer, transport and disposal of sealed
sources.
In addition, the following are Radiation Control Procedures for:

8.1 PROCEDURE FOR CONTROL OF PUBLIC EXPOSURE

Members of the public can access the Radiation Oncology Facility through the receiving area where they
are allowed to stay. Controlled areas should be specified and should have signage indicating that only
authorized personnel are to enter. Controlled areas include treatment room, control room and storage
room. These areas should not be left unattended and should be locked whenever nobody is inside.
The receiving areas should be surveyed often to ensure that exposure levels are below the limits for
public exposure.

8.2 PROCEDURE FOR VISITOR CONTROL

Co-60 HDR Brachytherapy

Access of visitors in the controlled areas should be supervised by authorized personnel with the
permission of the RSO/ARSO.
Cs-137 LDR Brachytherapy
Access of visitors in the controlled areas should be supervised by authorized personnel with the
permission of the RSO/ARSO. Only visitors who have undergone Orientation for Radiation Protection on
LDR Brachytherapy Treatment shall be allowed to visit the patient and may be limited to one half hour
per day. Visitors may be allowed a few moments at the bedside, but should stay at least six feet from the
patient and preferably behind the shielding barrier. Pregnant women and children under 18 years are not
allowed to visit these patients.

8.3 PROCEDURE IN PREPARATION AND TRANSFER OF LDR Cs-137 SOURCES

The authorized technologist wears gloves, pen/digital dosimeter and makes a survey meter available
before entering the storage room.
Keeps a copy of the treatment planning and doctor’s orders and loads the radioactive tube sources (taking
note of the activity and serial numbers of sources) in the equivalent carrier of inserted applicators behind
the L-block.
Transfers the carriers using a forceps to the lead cart and covers it. He then logs the sources.
The carrier is then brought to the patient room. Using forceps, the authorized technologist passes the
carrier one by one to the radiation oncologist for insertion to patient.
After the procedure, the cart is checked for presence of radioactivity then returned to the storage room. If
there is a significant reading, he reports it to the RSO immediately

8.4 PROCEDURE FOR RADIATION SAFETY DURING LDR Cs-137 BRACHYTHERAPY

Maximum time spent by the Brachytherapy Section staff in the patient room is indicated in the following
table:

Activity of Cs-137 in Patient (MRE) Maximum time for Nursing Personnel near
Bedside (Hrs)

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 10-19 3
20-29 2
30-59 1
60-89 0.5
90-120 0.25
Note: The number of hours is increased by a factor of 2 if a barrier shield is in place
The patient is always confined to his/her bed during treatment. If in any case that the patient will be
removed, the Technologist removes the sources from the patient and placed in the carrier. Time of
removal is noted on patient’s chart.
During regular visits and endorsement of patient to the next nurse-on-duty, the nurse handles a survey
instrument and confirms presence of radioactivity in the patient. He/she does ocular inspection of the
integrity of the applicator. In the event that the source is dislodged from the patient, he/she picks-up the
sources with the forceps and safely keeps them in the source carrier, logs in the patient chart the time
and date of discovery and informs the Radiologic Technologist, Medical Physicist and / or Radiation
Oncologist for proper disposition.
The hospital strictly follows a “NO VISITOR” policy for brachytherapy patients.

8.6 PROCEDURE FOR RADIATION SAFETY IN REMOVAL OF LDR Cs-137 SOURCE IN PATIENT

1. The authorized technologist wears gloves, pen/digital dosimeters and makes a survey
meter available before entering the storage room
2. He pulls out the carrier and brings it to the patient room.
3. Using forceps, he safely returns the carriers to the cart and covers it.
4. The cart is then transported to the storage room.
5. Using forceps, the sources are then placed in the lead vault and locked.
6. The returned sources are then logged and the cart monitored for any presence of
radioactive materials.

9 EMERGENCY PROCEDURES

In case of any emergency situations, the personnel shall be well-informed and trained on the proper
procedures and their respective roles in conducting these procedures. These situations and the procedures to
be done are discussed below.

9.1 IN CASE OF FIRE

In case of fire, the following are to be followed:
1. Notify other persons in the area to leave immediately.
2. Report the location of radioactive sources to the fire fighting teams and to estimate any
additional risk, which these sources may present.
3. The Radiation Safety Officer will survey the premises at the end of the emergency and, before
authorizing access to the premises, will ensure that there is no significant risk of radiation
exposure.
9.2 IN CASE OF LOSS OR PILFERAGE

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 In a situation where any of the check sources are lost, the following step-by-step procedure should be
followed:

1. Inform the RSO.

2. Check the inventory to determine the type and activity of the source and activity, when and
where they were last known to be, and who last took possession of them.
3. Close the area where the sources were last known to be.
4. Conduct a survey of the area using the survey meter to find the lost source.

9.3 IN CASE OF OVEREXPOSURE OF PERSONNEL

In the case where there is an overexposure of personnel, the following can be done:

1. Inform the RSO.

2. Transfer the personnel temporarily to an area where there is less radiation such as the
reception area for some time until the TLD/OSL reading report will be available, which will tell
the extent of his/her transfer in the less radiation area.

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9.4 IN CASE RADIOACTIVE SOURCE DOES NOT RETURN TO SAFE

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The emergency procedures for stuck sources are posted at the treatment unit.
Use the source driving mechanism to return the source to the shielded position. If
this is not immediately successful and there is a patient present, the patient must be
removed from the radiation field and the area must be secured from further entry.

Inform the RSO.

Manual return of the source should be conducted as quickly as possible before

continuing operation.
Submit a written report to the RSC including a detailed description of the event,
actions taken, and results of the tests.

Below is the emergency prodecure posted in the control room with the contact
details of persons to inform during the emergency

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9.5 REPORTING INCIDENTS/ACCIDENTS TO PNRI

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Unusual events or incidents namely lost sources, loss or pilferage, and a receipt of a specific or
malicious threat of the radioactive sources, will be reported to PNRI within 24 hours.

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10 MANAGEMENT OF SPENT SEALED SOURCES

All radioactive material must be stored in shielded containers, which are marked with the
following:
a description of the contents of the container, including radionuclide, chemical form,
physical form if appropriate, maximum activity on a stated date, and; a radiation warning
sign.
The manufacturer takes back the radioactive source, which is a part of the manufacturer’s
brachytherapy contract (please refer to the attached certificate) with no additional cost. The
sources will then be transported and disposed of in compliance with the applicable local and
international regulations
Qualified and trained engineer/s will put back the old source inside the dual channel container
and will then be placed in a transport drum
Attach the radioactive labels and measure and record the surface dose on your radiation-
monitoring logbook.
Measure the dose rate at 1 m from the surface of the drum. Indicate Transport Index (TI) on the
transport drum label
Notify local broker / supplier for source shipment back to manufacturer and secure transport
certificate from PNRI.
After source exchange, the depleted source is temporarily stored in the storage cabinet located
in the Brachytherapy Treatment Room. The Storage Cabinet keys are kept by the Medical
Physicist and should only be opened once the supplier takes back the source.

11 DECOMMISIONING PLAN

The RSO, ARSO, medical physicists and radiation technologist are responsible in ensuring that the
decommissioning plan is undertaken correctly. Controlled areas in the facility to be decommissioned
should be specified. Signage should be placed in specified controlled areas. Unauthorized personnel
should be denied access to the controlled areas.
TLD/OSL badges are given to all members of the decommissioning team, which should be worn in
the front of the uniforms at all times, when inside the facility but should be removed once exiting
the facility. The TLD/OSL badges should be returned to their storage area when taken off.
The facility must be surveyed by the medical physicists to check exposure levels and contamination
if any. A survey logbook and report should be completed with the following information:

 The date, area surveyed and the equipment used.

 The name of the person who performed the survey.

 The radioactive and hazardous materials present.

 The radiation and contamination levels.

In the presence of radioactive and hazardous materials, medical physicists should wear protective gloves
and clothing. For contaminated areas, decontamination should be made.
All radioactive material must be stored in shielded containers, which are marked with the following:
a description of the contents of the container, including radionuclide, chemical form, physical form if
appropriate, maximum activity on a stated date, and; a radiation warning sign.

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If the Cobalt-60 source needs to be disposed, the manufacturer takes back the radioactive source, which
is a part of the manufacturer’s brachytherapy contract with no additional cost. The sources will then be
transported and disposed of in compliance with the applicable local and international regulations
Qualified and trained engineer/s will put back the old source inside the dual channel container and will
then be placed in a transport drum
Attach the radioactive labels and measure and record the surface dose on your radiation-monitoring
logbook.
Measure the dose rate at 1 m from the surface of the drum. Indicate Transport Index (TI) on the transport
drum label
Notify local broker / supplier for source shipment back to manufacturer and secure transport certificate
from PNRI.
The facility shall submit to PNRI a copy of all reports of the decommissioning plan 12 months prior to
decommissioning activities.

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