/ Policy Title: Radiation Exposure to Pregnant
Employees
Category:
Number
Date Originated:
August 2013 / Effective Date:
Last Review Date:

PURPOSE:

Provide safeguards against overexposure to fetus of occupationally exposed employees.

Definition of Occupationally Exposed Personnel:

Any employee who receives or is likely to receive a dose in one year in excess of 10% of the applicable value specified in WAC 246-221-010 of Washington State regulations. Specifically, this applies to any employee that may receive 5mSv (500mrem) per year.

All occupationally exposed personnel at Providence Sacred Heart Medical Center (PSHMC), Providence Holy Family Hospital (PHFH), Inland Imaging LLC (IILLC) and Holy Family Imaging Center (HFIC) are required to wear a film badge and/or a TLD dosimeter.

Special Circumstances:

A special circumstance arises when an occupationally exposed woman is pregnant. Radiation exposure to the abdomen of the employee also results in exposure to the unborn child, which is known to be more radiation sensitive and warrants a more conservative exposure level. Specifically, the USNRC Office of Nuclear Regulatory Research Guide 8.13 recommends an exposure limit of 500mR per pregnancy to the unborn child or 0.50mSv (50mrem) per month maximum. For the length of an employee’s pregnancy, PSHMC, PHFH, IILLC and HFIC, will equate the fetal exposure to the maternal exposure.

POLICY:

The responsibility of PSHMC, PHFH, IILLC and HFIC is threefold:

1)  All female personnel will be informed at the time of orientation of the risks of radiation exposure during pregnancy, and that for those interested employees, in-depth information is available from their supervisors. The USNRC Regulatory Guide 8.13 will be made available to all women who request it, being the most authoritative reference currently available on the potential hazards of radiation exposure while pregnant. A notice of available pregnancy radiation risk information will be made available to all badged female employees at the time of distribution of yearly accumulated film badge dose reports and a signed receipt will be required.

2) It shall be the policy of PSHMC, PHFH, IILLC and HFIC to reduce radiation exposure to the lowest level practical by providing radiation protection devices such as lead aprons, lead barriers, leaded glass shields, and promoting proper radiation usage technique. To further reduce potential exposure to pregnant women, reassignment to areas of lower potential exposure may be done where staffing requirements permit unless refused by the employee.

3) Pregnant employees should be prohibited from performing certain procedures with a higher than average potential for radiation exposure. Specifically, pregnant nurses and technologists shall be prohibited from participating in brachytherapy source implantation and therapeutic administrations of radioactive materials such as 131 Iodine and 32 Phosphorous.

NOTE: A second radiation badge (fetal monitoring) will be provided for monthly fetal dose monitoring and the employee will be instructed on its use.

Responsibility of the Employee:

1) It is the pregnant employee's responsibility to notify her supervisor in writing as soon as she thinks she may be pregnant. The requirement for notification of supervisors will be explicitly stated in the information mentioned in the hospital's yearly notice and at orientation of new employees. At the time of supervisor notification, specific instructions and recommendations concerning pre-natal radiation exposure will again be made available to the employee. The notification in writing of pregnancy, including estimated date of conception, is required by state regulations (WAC 246-221-055) to satisfy the definition of "declared pregnant women."

2)  Precautions to be taken by employee

- the employee shall provide, in writing from her doctor, a statement describing any

limitations in performance of her normal work assignments

- avoid unnecessary radiation exposure by

- wearing effective wrap-around lead aprons during fluoroscopy, portable and surgical

procedures

- whenever possible, stand behind permanent or portable lead barriers

- maintain maximum distance from primary radiation beam

- wear normal and fetal radiation monitoring badges as instructed

3)  Using the information provided by the hospital and any other sources, each woman must decide to:

a)  remain working under the above conditions,

b)  take a leave of absence for her pregnancy, or

c)  resign her position.

REVISION HISTORY
Date of Revision / Revision Explanation / Author

send to .