ASN Report 2018

fixed C-arms in dedicated rooms also remains low, even if they are on the whole better trained. Although collective radiation protection equipment is available for the interventional imaging departments, it is still too rarely present in the operating theatres. A substantial improvement is expected in the coordination of prevention measures with the outside contractors working in the interventional imaging departments and operating theatres, where ASN observes that few prevention plans are signed with all the service providers (17% of the inspected centres have a document signed by all the outside contractors formalising the coordination of prevention measures). • More specifically in the operating theatres… In only 60% of the inspected sites do the operating theatre professionals have at their disposal dosimetric monitoring devices that are appropriate for the worker exposure and in sufficient quantity. The lack of appropriate dosimetric monitoring for certain fluoroscopy-guided procedures, particularly at the extremities, and the absence of medical monitoring of the practitioners, make it difficult to assess the status of worker radiation protection in the operating theatres. ASN nevertheless observes improvements in the departments having been inspected previously. There were still organisational difficulties for the RPE-Os who did not always have the means or the necessary authority to perform their duties in full. ASN notes that the RPE-Os analyse the dosimetric results in order to detect incorrect practices and remedy them, above all in the interventional imaging departments. In the private sector, in the operating theatres, the dosimetric monitoring, the medical monitoring and, where applicable, that of the employees, represent a recurrent difficulty. • Radiation protection technical controls… Radiation protection external technical controls were carried out in more than 70% of the interventional imaging departments and about 55% of the operating theatres. In both cases, the nonconformities observed previously had either been or were being corrected in slightly more than 70% of the inspected facilities when the inspection took place. 5.3.2  –  Radiation protection of patients The findings established on completion of the inspections in 2018 with regard to patient radiation protection confirm the observations made over the last few years (see Graph 14). ASN thus still observes low involvement of medical physicists in the departments practicing fluoroscopy-guided interventional procedures, and shortcomings in the description of the medical physics organisation in the POPMs (the duties and times of presence of the medical physicist according to the activities are not specified). This constitutes a hindrance to application of the principle of optimisation; greater involvement of the medical physicist would, in particular, permit more effective utilisation of the equipment, with the implementation of protocols adapted to the procedures performed, recording of doses delivered and the evaluation with regard to the dosimetric reference levels to be defined locally. When medical centres use outside companies proposing medical physics services, it is observed that few centres embrace the optimisation approach. These observations were noted in particular in the operating theatres, where the optimisation approach is rarely put in place. 7. Improving patient monitoring in interventional radiology and fluoroscopy-guided procedures – reducing the risk of deterministic effects. • In interventional imaging departments and in operating theatres The observed shortcomings concern firstly a lack of training of medical professionals in patient radiation protection, and secondly, deficiencies in application of the principle of procedure optimisation, as much in the adjustment of the devices, the protocols used and the practices. ASN observes that although doses are recorded, they are rarely analysed (29% for operating theatres, 53% for imaging departments). Patient monitoring if the exposure threshold is exceeded (skin exposure threshold) defined by the HAS (7) is not very satisfactory, particularly in the operating theatres. Reference levels for the most common examinations were being developed locally more and more often. This approach also enables, among other things, alert levels to be set to trigger appropriate medical monitoring of the patient according to the dose levels received. The patient dose archiving and analysis systems currently being deployed facilitate the development of local reference levels and alert levels per machine and per type of procedure. These systems are an asset for determining the doses previously received by the patient and for monitoring the patient. The quality controls of the medical devices are generally carried out at the right frequency and on the day of the inspection any previously detected nonconformities had been or were being corrected, equally well in the operating theatres as in the interventional imaging departments. • More specifically in the operating theatres… The medical personnel in the operating theatre had insufficient knowledge of the reference dose levels for the type of procedure performed. The theatre C-arms, due to their mobility, are more rarely connected to the centre’s archiving systems than the fixed C-arms of the interventional imaging departments. 5.3.3  –  Reported events relating to fluoroscopy-guided interventional practices The putting in place of a system for recording adverse events in operating theatres and interventional imaging departments is moving forward (80% of the departments inspected in 2018 have put this system in place). 29 significant events were reported in this area in 2018. Among these events: ∙ ∙ fifteen concerned overexposure of patients, some of which led to deterministic effects such as transient hair loss (alopecia) (4 cases) or slight erythema (1 case) . ∙ ∙ thirteen concerned exposure of workers; ∙ ∙ two concerned pregnant women exposed during a fluoroscopy-guided interventional examination; these women were unaware of their pregnancy at the time of exposure. The majority of the ESRs concerning patient overexposures were due to long, complex and repetitive procedures. One case of patient overexposure was reported for an interventional procedure carried out on a CT scanner described below (reported as a CT scanner ESR notifications). The reported ESRs concerning worker overexposure were due to accidental exposure: in one case during the cleaning of operating theatre rooms (device powered on), in the other case during a surgical procedure (personnel not protected). Three workers received a high level of exposure to the hands during fluoroscopy-guided interventional practices. The ASN report on the state of nuclear safety and radiation protection in France in 2018  223 07 – MEDICAL USES OF IONISING RADIATION 07