ATTENTION X-ray Equipment Users!

Requirements to comply with New York City/Bureau of Radiation Health (NYC/BRH) Regulations

There are a number of items that operators/owners of medical x-ray equipment must do in order to comply with NYC/BRH regulations and the CPMC Joint Radiation Safety Committee (JRSC) provisions. Some of these items are enumerated below for your edification.
I. New Equipment Acquisitions 
II. Radiology Physics Services 
III. Operator/owner Responsibility: QC tests 
IV. Questions and Assistances 

I. New Equipment Acquisitions
  1. Contact Radiology Physics (Tel: 212-305-5005) to calculate the radiation shielding requirements for the x-ray equipment;
  2. Install the necessary radiation protection barriers (lead lining to walls and control booths);
  3. Notify the JRSC and Radiology Physics of the impending new equipment acquisitions;
  4. Have Radiology Physics perform a Physics Acceptance Testing of the X-ray equipment in order to ensure regulatory compliance, radiation safety and image quality;
  5. Have Bio-medcial Engineering perform electrical grounding checks of the equipment
  6. Have Radiology Physics check the radiation shielding for voids, perform and document a Radiation Protection Survey of the facility;
  7. Make certain that the equipment is covered by the current NYC/BRH permit for the Medical Center or file for an appropriate NYC/BRH X-ray equipment permit. Contact the Radiation Safety Office (RSO) for more information;
  8. Make certain that the staff has Radiation Badge Monitors and receive a lecture from the RSO;
  9. Make certain that staff is qualified to operate the X-ray equipment (physician or registered X-ray technologist) and has been trained in the proper usage of the equipment;
  10. Make certain that FDA compliance forms have been filed by equipment rendor and copies given to operator/owner of the X-ray equipment;
  11. Assign a staff member to be liaison and attend JRSC subcommittee meetings (about two per year). Contact Radiology Physics at 212-305-5005 (or ext. 5-5005).

II. Radiology Physics Services

 Radiology Physics must be scheduled to perform the following services in order to be in compliant with NYC/BRH and JRSC.
  1. Complete X-ray equipment QC testing every six months, i.e., twice a year;
  2. Quarterly (every three months) X-ray tube collimator tests;
  3. Annual radiation patient dose and scatter radiation assessments;
  4. Physics records permanently maintained in Radiology Physics Office;
  5. Assistance during NYC/BRH, NYS/ERP and JCAHO inspections;
  6. Meetings and required at least annual lectures on Radiation Safety classes.

III. Operators/owner Responsibility: QC Tests

 
To:	All Radiology Administrators and Supervisors
From:	Dr. Edward L. Nickoloff, Chief Hospital Physicis
Date:	3-5-96

INTRODUCTION

It became apparent from several recent discussions with x-ray supervisors that there is some uncertainty about the QC tests and the frequency which they must be performed under NYC/BRH regulations. Hence, as a review, I have listed below those QC tests which are the responsibility of the x-ray supervisors.

I. DAILY REQUIRED RT QC TESTS

   1. Film Processor Sensitometry
	A) Speed Index
	B) Contrast Index
	C) Base Plus Fog Level
	D) Developer Temperature
   2. Warm-up of X-ray Tubes
   3. Visual Checks of X-ray Rooms
   4. Maintain a Patient Log Book Containing:
	A) Name of Patient;
	B) Date of Exam;
	C) Type of Examination;
	D) # of Views.
   5. Records of Any Patient Holding During X-ray Examination
	A) Name
	B) Date
	C) # of views
	D) Reason for holding patient
	E) Lead apron et cetera that were given to person holding
	F) Risks were explained
	G) Measured scatter radiation to individual holding patient
	   obtained from radiation monitor

II. WEEKLY REQUIRED RT QC TESTS

   1. CT Scanner Image Quality Checks with A Water Bath
	A) Mean CT Number
	B) Standard Deviation

III. MONTHLY REQUIRED RT QC TESTS

   1. Repeat Rates
   2. Multi-format camera evaluations on CT and MRI units
   3. Distribution and collection of monthly radiation film badges for
      area personnel.
   4. Film processor PM to be performed by processor service and
      documented.
   5. A calibration check of film densitometer used for sensitometry must
      be performed and documented.
   6. Continuing education lectures for the RT's on Radiation Safety and
      Quality Control procedures must be conducted and documented with
      names and dates.

IV. QUARTERLY REQUIRED RT QC TESTS

   1. Records of film-screen cassette inspection and cleaning (Note
      Mammography must clean and inspect cassettes on a weekly basis).
   2. Repeat Rate Statistics

V. SEMI-ANNUAL REQUIRED RT QC TESTS

   1. Lead aprons, gloves, thyroid shields and drapes must be inspected
      for tears and the results documented.
   2. Darkroom fog evaluations.
   3. Viewbox evaluations.

VI. ANNUALLY REQUIRED RT QC TESTS

   1. Reject analysis (Actually, this evaluation should be done more
      frequently. Mammography must do this test quarterly.)
   2. Technique chart update.
   3. Film-screen contact and evaluation of cassettes more than four years
      old.
   4. PM to be performed on all x-ray equipment and documented.
   5. Policy and procedures related to radiation safety must be reviewed,
      modified if necessary and dated/signed.
   6. Radiation Safety QA/QC Subcommittee must meet and minutes must
      document the meeting.
   7. License renewals and copies to Radiology Administration.

For more information, please contact Physics at 212-305-5005.

IV. Questions and Assistances

Various questions and assistance with items required to meet regulatory compliance and radiation safety issue can be provided by the following offices: