Christie Medical Physics and Engineering Newsletter 70 May 2022

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Christie Medical Physics & Engineering Newsletter and Educational Resource 70 – May 2022

The aim of the newsletter is to both raise awareness of radiation protection activities and provide educational material across:

Imaging with X-ray

Magnetic Resonance Imaging

Radiation Protection advice on X-ray, Nuclear Medicine and Radiotherapy

There is valuable Continued Professional Development content and we encourage reading by employers and those working with radiation. We hope that you enjoy the content and would love to receive any feedback to the christie.cmpe.info@nhs.net

Training opportunities

Contents

Radiation Protection Supervisor Training

CMPE currently offer an RPS basic training course which runs 3-4 times per year. This allows users to gain information about the role of the RPS under IRR17 and a basic knowledge of theory and tasks through talks, discussions, and group exercises. This course is also accredited by the Society of Radiographers with 5 hours of content equivalent to 5 CPD points. CMPE will be running two more training courses for Radiation Protection Supervisors in 2022. The course is open to staff from organisations who receive services from CMPE and who have been recently appointed RPS or who will soon be involved in RPS work. This includes: diagnostic radiology staff (X-ray), members of oral surgery departments, community clinics, general dental practices, radiotherapy staff, nuclear medicine staff, PET staff and other users of radioactive materials. We can accept non-customers with a fee if there is space. Contact us if you or your colleagues would like to attend one of the next courses this year. The dates of the courses are as follows: • 14 th June 2022 • 6 th October 2022 Delegates can register through the following webpage: https://www.eventbrite.co.uk/e/rps-basic-training-day tickets-50847125120

CMPE Training opportunities

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BIR radiation protection advice sheets

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• Radon in the workplace (including at home) • CMPE general Staff Update • MR Team Update • MR and the NW Imaging Networks • Medical Physics Roles – what can we do for you? • The role of the MPE and RPA • IRR17 vs IRMER17, a reminder • Radiation shielding assessment • Electrical Safety & Testing • CQC 2020-21 Report Summary • Inclusive Pregnancy Guidelines • Staff protection when seated in fluoro screening exams • ‘ Clinically Significant ’ incidents • Personal Dosimetry • Treatment of our staff • Contact details • Hotline

Copyright © 2022 by The Christie NHS Foundation Trust. All rights reserved. This document or any portion thereof may not be reproduced or used in any manner whatsoever without the permission of The Christie NHS Foundation Trust.

depending on their geographical location and whether or not they have a basement.

BIR Advice Sheets

The UK Health Security Agency (formerly Public Health England) has published a radon map of the UK which shows the “maximum radon potential” in each area. The map can be found on the UKHSA website (see Further Information for links). To use the map simply type in the appropriate postcode for the property and then, once the map has zoomed into the correct area, click on the button labelled “show radon data”. The “maximum radon potential” shown on the map is not the measured radon level in that area, but an indication of how likely properties in the area are to be above the threshold where radon reduction measures are required. This determines what level of radon monitoring is required. Areas which have a maximum radon potential of 1% or above are classed as “Radon Affected Areas”. These areas are colour coded on the map, with darker coloured shading indicating higher maximum radon potentials. Areas which have a maximum radon potential of less than 1% (i.e. non-Affected Areas) are shown in white (i.e. no colo ur shading added when the “show radon data” button is pressed). • All workplaces are required to perform radon assessments for any basement areas which are occupied for more than 1 hour per week (50 hours per year), regardless of radon status or geographical location. • Workplaces in Radon Affected Areas are also required to perform radon assessments on the ground floor. N.B. : Basements are defined as rooms/stories with at least 1 wall interfacing with the ground or whose floor is at least 1.2m below ground level. Unfortunately radon levels in a building cannot be predicted based on measurements in nearby buildings; even in adjacent buildings radon levels can differ by up to a factor of 10 due to differences in geology, building design and construction. Therefore all buildings meeting

British Institute of Radiology (BIR) Radiation Safety week 28th February – 4th March 2022. The BIR Radiation Safety week falls in the last week in February annually, and is a week dedicated to promoting best practice and excellence in radiation safety. In light of the occasion, the radiation safety special interest group for BIR released daily advice sheets throughout radiation safety week, highlighting practical tips and guidance on a given topic. The topic headings for the five sheets are Patient Dose Management, In-Room Radiation Shielding, Implementing a Radiation Incident Coding System, Equipment Quality Assurance (QA) Programme and Image Optimisation Teams. The new radiation safety advice sheets build on five similarly released for BIR’s Radiation safety week in 2019. These advice sheets cover the topics of Radiation risks, PPE, Keeping Dose ALARP, Ionising Equipment and Non Medical Referrers.

The sheets can all be found through the following link:

Radiation safety advice sheets - British Institute of Radiology (bir.org.uk)

Radon in the Workplace

Which workplace areas require assessment?

It is a legal requirement for Employers to assess health and safety risks to their employees (and other persons with access to their workplace) and act to reduce those risks as far as reasonably practicable. Exposure to radon should be considered among these risks. Almost all hospitals will need to perform radon monitoring in some areas. Smaller facilities (e.g. dental surgeries, GP practices) may also need to perform radon monitoring

the criteria (occupied basement or in an Affected Area) will need to be assessed.

Co-operation between employers

When employees of one Employer work on the premises of another Employer, there should be cooperation and appropriate exchange of information between Employers in order to coordinate measures required to comply with statutory duties, to inform each other of the risks to employees, the control measures in place and to allocate responsibilities for aspects of the management. This includes a need to share information when work will take place in a building where radon levels exceed 300Bq/m 3 , even if the employees will not be exposed to any other source of ionising radiation as part of their work. The Health and Safety Executive have updated their advice to reflect the increasing numbers of people working from home. It is the HSE’s expectation that employers will consider radon levels as part of risk assessments for staff who work from home. Employers should therefore include a check on the radon status of each employee’s home as part of their home working risk assessment. All employees should be advised to perform domestic radon monitoring if they will be working in a basement. Employees who live in radon affected areas should be further advised to perform radon monitoring if they are working on the ground floor. Employees living in rented accommodation should be advised to contact their landlord regarding radon monitoring, as they are legally obligated to provide this for all basement properties, and for ground floor properties in radon affected areas. If the results of domestic radon monitoring are between 200 and 300 Bq/m 3 then working from home is permitted, but the employee should be strongly advised to pursue radon mitigation options to protect their family’s health. If the results are above 300 Bq/m 3 then the employee must not be permitted to work from home unless radon mitigation measures are put in place to bring the levels below this threshold. Staff working from home

Site specific reports

The radon map is divided into 1km 2 sectors which are shaded according to the maximum radon potential at any point within that sector. It is therefore possible that specific addresses within a sector may have a lower radon potential than indicated by the map. For this reason Employers whose premises are in radon Affected Areas (according to the map) may wish to purchase a site specific report. Small properties (less than 25m in length) can order these reports from UKHSA while for larger buildings or groups of buildings a British Geological Survey report is required. Monitors can be ordered from UKHSA or other validated radon testing services. For large properties it may be advisable to contact the testing service for advice regarding the number of monitors required and suitable locations before placing an order. Note that monitors will need to remain in place for 3 months and any building work in the area during the monitoring period will invalidate the result, so monitoring should be planned accordingly. Following is a flowchart to determine whether rad on assessment is required on the employer’s premises: Assessing radon levels

Raising awareness with employees

Awareness of radon and the need for monitoring is poor among the general population. Therefore, the HSE

strongly advise employers to recommend domestic radon monitoring to their staff if they live in a radon affected area (or have an occupied basement in their home, though this is uncommon in the UK). This advice should be given regardless of whether or not they are working from home. This is because staff may be receiving significant exposures at home, outside of their working hours. Employers should therefore aim to raise awareness of radon with their staff, particularly if their premises are in or near radon affected areas.

Safety Expert conference in April 2021, passed the MRSE exam in October 2021 and passed the portfolio assessment in early 2022.

Further information can be found on the following websites:

Management Degree – Conor Clancy

UKHSA radon map: http://www.ukradon.org/information/ukmaps

We are delighted to announce that Conor Clancy (Principal Clinical Scientist) was registered with the Chartered Management Institute (CMI) following successful completion of a two-year management degree apprenticeship, provided through the Business School at Manchester Metropolitan University. Funded by The Christie apprenticeship levy, the apprenticeship included academic and work-based learning covering management in health and social care. With his studies behind him, Conor is looking forward to applying his learning to deliver enhanced service provision to our customers and their patients.

Site specific reports - UKHSA (premises up to 25m long): http://www.ukradon.org/services/address_search

Site specific reports - British Geological Survey (premises more than 25m long): https://shop.bgs.ac.uk/Shop/Department/GeoReports

CMPE general Staffing Updates

MRSE Certification – Steven Jackson

On 1st September 2021 applications opened for IPEM’s Magnetic Resonance Safety Expert (MRSE) Certificate of Competence. The certification model requires candidates to demonstrate sufficient MR safety knowledge via an international MRSE exam, and sufficient MR safety experience via a structured portfolio covering 19 core areas of MRSE practice. Though MRSE certification is currently voluntary, we expect that the certification will become a requirement of the role and the title certified MRSE will be recognised as similar to Medical Physics Expert (MPE) and Radiation Protection Advisor (RPA). The certification provides assurance to MR departments that MR safety support and guidance is provided by suitably knowledgeable and experienced individuals. Steven Jackson from CMPE MR physics group has recently become one of the first few people in the UK to become an IPEM certified MRSE, after he attended the IPEM MR

IRR Lead – Jaddy Czajka

Jaddy has been appointed as a Lead Principal Clinical Scientist in the Imaging Physics & Radiation Protection (IPRP) group, heading up compliance with the Ionising Radiations Regulations 2017 for the team and the North West region. This will afford a deeper understanding of the application of the regulations, inform and improve radiation protection culture, facilitate wider shared

learning and ultimately meet the growing expectations of the HSE.

Magnetic Resonance Imaging Team Profile

Mike Hutton, MR Group Lead, Consultant Clinical Scientist

HSST Registration – Christie Theodorakou

Michael.hutton6@nhs.net

Christie has been successful in completing the 5 year Higher Specialist Scientific Training (HSST) scheme to gain Consultant Clinical Scientist status. She has also been successful at interview to gain a consultant post in CMPE ’ s IPRP group with leadership roles in research and education. This will be of particular importance to the NW as we aim to more than double the workforce in 5 years.

Mike is the MR Group lead and a consultant clinical scientist specialising in MR. He took over the group lead role in 2019 having joined The Christie MR Physics Group in 2013. Prior to this he was an MR clinical scientist in Sheffield having completed his medical physics training there. Mike has worked with most (but not all) MR departments in the region during his time at The Christie. His focus now is steering the MR Group through challenging times, but he does still find time to do some clinical support and some science. Mike is a serving member on the IPEM MR Special Interests Group and is increasingly involved in UK-wide initiatives and working parties in the field of MR.

Long Service Awards

Congratulations to Conor Clancy and Christie Theodorakou who this year receive their 10 years’ service award with The Christie. CMPE thanks them for their dedication and continued hard work for the benefit of patients across the North West of England.

Dr Jude Kilgallon, Principal Clinical Scientist

MR research work at national and international conferences.

Judith.kilgallon@nhs.net

Michael Dubec, Principal Clinical Scientist Michael.dubec@nhs.net

Jude is the longest serving member of the MR Group. She joined The Christie as a trainee clinical scientist having completed her degree in Physics from the University of Leeds and PhD in Experimental Nuclear Structure Physics from The University of Manchester. Jude is mostly involved with the provision of our regional MR service. She also supervises our trainee clinical scientists and is heav ily involved with the group’s teaching activities. As you may have guessed, Jude likes to spend her downtime with her beloved horse.

Michael joined the MR group in 2014 after completing a BSc (Hons) in Physics, an MSc in Medical Radiation Physics and an MSc in Clinical Science (Medical Physics) as part of the NHS scientific training programme. In addition to his clinical duties, Michael is heavily involved with developing MR for radiotherapy planning, guidance and assessing treatment response and was co-author of the IPEM national guidance on MR for radiotherapy treatment planning. He is also currently undertaking a part-time PhD entitled ‘Optimising oxygen -enhanced MRI biomarkers of hypox ia for use in advanced radiotherapy’. In his spare time Michael likes cycling and slapping the bass.

Steve Jackson, Principal Clinical Scientist

Steven.jackson6@nhs.net

Dr David Buckley, Honorary MR Physicist David.buckley5@nhs.net

Steve completed a degree in maths and physics, an MSc in theoretical physics and the NHS Scientist Training Programme (STP), specialising in MRI. His current work involves clinical scientist support for several MR departments in Greater Manchester and North West England, as well as a leading role in MR imaging support for radiotherapy treatment planning at The Christie. Steve has a strong track record teaching MR physics and MR safety, and recently had significant input into the design of a new CPD module at the University of Liverpool, aimed at ensuring radiographers new to MR become valuable members of the team quickly. He has presented

David joined the group in July 2020. He is seconded to the group part- time from his “day job” at the University of Leeds where he is Professor of Medical Physics specialising in MRI. David’s role at Th e Christie is to support MRI in the Radiology department (both clinical practice and research) and to support studies on the MR simulator in the Proton Beam Therapy centre and the MR linac.

David has a wealth of experience in MRI research, having obtained his PhD in MRI back in the previous century. Between 1999 and 2008, he worked for The University of Manchester where he was involved in a number of studies at The Christie and also acted as a PhD supervisor.

support to our clinical sites and utilising his strong academic background for the other half by supporting radiotherapy-related MR research at The Christie hospital.

Guy Drabble, Clinical Scientist g.drabble@nhs.net

Chris Moore, Clinical Scientist

Christopher.moore24@nhs.net

Guy originally joined The Christie back in 2014 on the STP, having completed a degree in physics with particle physics and cosmology. He completed his training in 2017, specialising in Radiotherapy and gaining his MSc in Clinical Science (Medical Physics). Guy briefly left The Christie in 2019 to work in the education sector. Working at The University of Manchester, he helped to run the academic section of the Higher Specialist Scientist Training (HSST) programme. Guy returned in June 2021 to join the MR Group and retrain as an MR physicist.

Chris completed an undergraduate physics degree at The University of Manchester and after a brief intermission as a software engineer successfully applied for the STP in medical physics. Having completed the programme in September he has now taken on a clinical role in the Group. Chris splits his time between work at The Christie and sites in the region, as well as contributing to the department ’ s teaching and research work.

Dr Damien McHugh, MR Physicist

Damien.mchugh@nhs.net

Asher Ezekiel, Trainee Clinical Scientist asher.ezekiel@nhs.net

Damien joined the MR Group in January 2021. He is currently working towards acquiring his HCPC registration, having completed a PhD at The University of Manchester. His research was mainly focused on diffusion-weighted imaging and his PhD thesis was entitled ’The effect of tumour microstructure on diffusion-weighted MRI measurements'. Damien has a 50/50 split role within the Group, dedicating half of his time to providing clinical MR

Asher joined our Group through the STP and recently began the specialist part of his training. Before this, Asher completed his undergraduate degree in Physics at the University of Birmingham. He then moved to London to join a publishing company, working on a science journal covering research across biology, chemistry and physics. During this time, he also completed an MSc in

Astrophysics at Queen Mary, University of London. Asher moved up to Manchester to start his STP training in September 2020, specialising in MRI.

• Sustained local services for scanning close to where people live • Access to specialist opinion across a wider geography and quality improvements

• Reduced risk of missed diagnosis

CMPE MR physics group and the North West Imaging Networks

In the North West of England we now have three imaging networks as shown in the image – Lancashire and South Cumbria (5), Greater Manchester (6) and Cheshire and Merseyside (7). These are rapidly developing entities, which will lead to closer collaboration between NHS trusts within each network and the building of new CDCs. These CDCs will deliver imaging services away from acute sites and to be badged as a CDC each must have a full range of diagnostic services, including MRI and CT. As laid out in the Richards report, there ’s an expectation that the number of imaging systems will grow significantly over the coming years, but also imaging services must become more efficient and this is one of the key areas where medical physics involvement is vital.

Introduction

There is currently a great deal happening within the North West Imaging Networks, much of it involving The Christie IPRP group. In this article I’ll start by giving a little background on imaging networks and then I’ll summarise the lead role that the CMPE MR physics group have had with the North West Imaging Networks over the past year. We’ve been working closely with NHSEI to ensu re that MR services will be appropriately supported across the North West Imaging Networks as the number of MR scanners and departments in creases. We’ve also had a key role in an initiative to provide additional capacity with the current install base of MR scanners in the region. The NHS Long Term Plan was published in January 2019, which laid out a vision for transforming the delivery of NHS services to improve the quality of care patients receive across England. This report was followed in November 2019 by the report on transforming imaging services in England (Transforming Imaging Services in England: A National Strategy for Imaging Networks) and then in October 2020 by the report that many of you will be most familiar with – the Richards report on diagnostic recovery and renewal (Diagnostics: Recovery and Renewal – Report of the Independent Review of Diagnostic Services for England). These documents have led to the development of imaging networks across England, which will affect all of us who are involved in delivering imaging services. Following on from the Richards report is (yet!) another report, this time from NHS England and NHS Improvement (NHSEI) entitled The Diagnostic Imaging Network Workforce Guidance Document. This is an important document and lays out the anticipated benefits to patients from the development of imaging networks and community diagnostic centres (CDCs), which will include: Brief Background to Imaging Networks

In the short term, in part due to the Covid-19 pandemic, there’s a need to rapidly increase imaging capacity to clear the huge backlog of patients waiting for diagnostic tests and imaging. However, we’re all aware of the workforce challenges in expanding imaging services – even if we could install hundreds of new MR and CT scanners across England this year, we’d be unable to run these due to the national shortage of radiographers. New

departments and scanners also need support from medical physics and there would be similar workforce challenges in providing experienced MR physicists to support these new scanners to ensure safe and efficient imaging services. This is a brief background of where we’re up to with the North West Imaging Networks and I’ll now summarise the key developments and initiatives that the CMPE MR physics group have been leading. Working alongside the Lead Healthcare Scientist for the North West and the NHSEI Regional Diagnostic team, CMPE have led in establishing a formal advisory group that will link directly to the North West Imaging Steering Group (NWISG). The NWISG sits within NHSEI and is leading on the transformation of imaging services in the North West. Due in no small part to the work of CMPE, the NWISG have recognised the key role that medical physics have in their strategy. The NWIMPAG meetings are chaired by Will Mairs and Mike Hutton from CMPE. For MR imaging we are formally supporting the NHSEI North West Regional Diagnostic team in network-wide initiatives already and have been recognised as a key partner in transforming the delivery of MR services across the North West Imaging Networks. Below, the figure shows the core structure of the North West Regional Diagnostic team at NHSEI showing the key input provided by the NWIMPAG. North West Imaging Medical Physics Advisory Group (NWIMPAG)

MR physics workforce and service specification

CMPE have led in writing a report on the status of the MR physics workforce in the North West. This report summarises the current MR physics workforce providing support across all three North West Imaging Networks and lays out the challenges faced across the region as more MR scanners are installed and CDCs are commissioned. We have insufficient MR physics staffing levels across the North West Imaging Networks for the current number of MR systems and departments so any significant growth will add pressure on an already stretched workforce. Recently the North Imaging Academy has been established, which will have a key role in training new staff as well as upskilling the current imaging workforce. The CMPE MR physics group and other members of CMPE are part of the governance board for the North West Imaging Academy, but we will also be looking for opportunities to train the MR physics workforce through these new training centres. The MR physics workforce report also address the gulf in the level of MR physics support offered to MR departments across the North West Imaging Networks from different medical physics providers, which we need to address in order to ensure that all patients receive the same high level of care close to home. CMPE are already providing what is considered gold standard MR physics support, but we have a role in increasing support to those trusts who currently have limited or no MR physics support. To support standardisation of MR physics support across the North West Imaging Networks we have worked with all providers in the North West to develop an MR physics service specification, which is closely aligned to the level of support currently provided by the CMPE MR physics group. The workforce report and the MR physics service specification document will be presented to the North West Regional Diagnostic Board in the near future. The workforce report will allow us to work with the NHSEI Regional Diagnostic team to address the MR physics workforce challenges, while the service specification may soon become the standard against which MR physics services are procured against in the North West.

Acceleration technology If you work in MR you may already have heard of the advanced acceleration technology (AAT) project across the North West. The bid for and allocation of funding was led by Nicola Scott who is the Diagnostic Transformation Manager for Imaging in the North West Regional Diagnostic team. The CMPE MR physics group have had a significant role in supporting this project since December 2021 to help ensure that all trusts with eligible MR systems receive the most suitable AAT software for their systems. The AAT has the potential to provide a significant increase in imaging capacity to the region (with no detriment to image quality) and help address the backlog of patients waiting for MR scans. Approximately £4 million has been allocated for the North West, with the majority of implementation taking place in the next financial year. We expect to achieve a >10% increase in capacity at roughly a tenth of the equivalent cost of outsourcing for the same gain, thus offering exceptional value for money. The AAT consists of three main technologies – simultaneous multi-slice (SMS), Compressed Sensing (CS) and artificial intelligence deep learning reconstruction algorithms (see Fig. 3). The anticipated benefits of these techniques will only be realised after an initial investment of time to apply them across imaging protocols with support from MR physicists. For our customers who have benefited from this technology, the CMPE MR physics

group will be working with you over the coming months to ensure that the techniques are implemented and new protocols are optimised. It’s important to be aware that a condition of the funding is that each trust will report back to NHSEI in approximately 12 months' time and be able to demonstrate an increase in capacity. Example 1 of the AAT technologies: below is Air Recon DL deep learning reconstruction algorithm on a GE system – the image on the left is a conventional acquisition taking 2:50min, while the image on the right is the Air Recon DL image taking only 1:28min (image courtesy of GE Healthcare).

Example 2: (split column image below) simultaneous multi-slice on a Siemens MR system showing the potential to reduce scan times with no detriment to image quality (image courtesy of Siemens Healthcare).

careers highlighted the achievements of the healthcare science workforce in combining patient-centred innovation with clinical practice. It describes a highly motivated, scientifically trained, research literate clinical community that frequently embeds and creates innovation as part of their core practice. The healthcare science workforce is well-placed to support and lead the integration of future intelligence and technology adoption and provide insight in terms of how research fits into a clinical context, looking ahead to which technologies will be relevant in the future and considering the impact of these technologies on service providers and the health system as a whole. The following is an overview of the various roles of clinical scientists. Specialist legal adviser/expert roles undertaken are marked in bold. Total quality assurance and governance support including accreditation of service quality • Improved patient care by striving for the right test at the right time with no unnecessary/repeat imaging • Regulatory advice and compliance audit . Continually drawing attention to the latest guidance and advice on implementation • Specification, procurement and commissioning of equipment and services • Key to improving access to diagnostic and therapeutic procedures, closer to the patients home • Uptake and validation of new equipment & technology • Preparing for new technology that will be Clinical scientists Specific competence •

Medical Physics Roles

Who are medical physics and what can we do for you?

This article is written with a focus on imaging and radiation protection physics within the diagnostic and interventional radiology specialism (x-ray). This covers physics support to modalities using x-rays., for example, planar x-ray, CT, fluoroscopy, mammography and dental imaging etc. Many of the roles and competencies can be extrapolated into other medical physics disciplines. Imaging and radiation protection physicists sit within the healthcare science NHS Employer profiles. They are a bridge between science and the clinical environment, fulfilling roles that facilitate and optimise medical imaging to improve patient outcomes while ensuring the radiation safety of patients, staff and members of the public. The profiles are split into healthcare science practitioner roles (often called clinical technologists) and healthcare scientist roles (associated with the protected title of registered ‘clinical scientist’ – regulated by the Health and Care Professions Council). Healthcare role regulation is designed to assure patients and the public, as well as employers, that professionals on a register are appropriately qualified and competent to practice. Where physics roles are required in a clinical environment, they should be performed by a clinical scientist or be overseen by one. Within this structure there is a career pathway for support roles from assistant to advanced practitioner and scientist progress to consultant status (with service manager options for both roles). These same employees undertake expert, legally defined roles, in both an accountable capacity and through advising employers on compliance with key regulations including The Ionising Radiations Regulations 2017 (IRR17) and The Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER17). Roles and added value Clinical scientists have general and specific competence that enables safe, timely, high quality, state of the art imaging activities. A recent review (cited within NHSE&I Science in Healthcare Strategy) on clinical academic

used within the clinical environment, validating efficacy, developing tests to ensure it is suitable for use and continues to be over its lifetime

• Equipment quality assurance programme development and performance testing • Identification of equipment issues and support to return to clinical service • Directly impacting on up time of equipment

Ensuring evidence for presentation to suppliers to demonstrate poor performance when equipment not fit for purpose or appropriate for acceptance against the specification

• Development of the profession and evidence based practice • Multidisciplinary team working and networking • Leadership in clinical services, imaging networks and government bodies • Knowledge transfer between academia and industry and adoption of ideas to improve outcomes • Engagement with the public around science MPE activities contribute to maintaining and improving the quality, safety and cost-effectiveness of healthcare services and are based on current best evidence or self driven scientific research when the available evidence is not sufficient. IRMER17 has increased the expectation of the MPE role in diagnostic imaging in both competence and WTE. Simultaneously, the competence expectation of the role has been defined and enhanced with formal recognition through an assessment body. The four main elements of the MPE competence are regulatory compliance, equipment life cycle, patient dosimetry and optimisation of imaging. Diagnostic imaging is the largest manmade source of exposure to the population and it must be managed to ensure the safety of staff, patients and the public. In addition to the MPE role (patient focused) there is the role of the Radiation Protection Adviser (RPA) required under IRR17. This focuses on the radiation protection of staff and members of the public to ensure radiation doses are As Low As Reasonably Practicable (ALARP) to limit the risk of radiation induced tissue damage and cancer. Medical Physics Expert (MPE) Radiation Protection Adviser (RPA)

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• Integration with manufacturers and managed equipment services to improve equipment management pathways and efficiencies • Development of procedures including in specialised/complex services • Development of imaging protocols & standardisation • Optimisation (dose & image quality), including multidisciplinary optimisation team membership • Patient and staff radiation dosimetry (individual/population) • Increased personalised care • Set up of size specific adult and peadiatric imaging protocols • Effective use of dose management • Research study set up, quality, dose and risk estimation and Medical Physics Expert sign off • Teaching ( regulatory needs , clinical science, academic, bespoke) • Medical physicists, radiographers, radiologists, dentists and clinicians using radiation General leadership and support to organisations • Staff/service management/development • H&S management, incident support • Risk and Quality management • Research and development project design, support and implementation • Data analysis and interpretation • Improvement projects • Regulatory inspection support • Support to infrastructure and software e.g. Radiology Information Systems (RIS), Picture Archiving and Communication System (PACS), dose management software • Interface between clinical and management staff groups systems that track cumulative dose and support justification of repeat or high dose examination

Legal roles of the Medical Physics Expert and Radiation Protection Adviser

Legal role of the Medical Physics Expert (MPE) Under the provisions of the Ionising Radiation (Medical Exposure) Regulations 2017, Regulation 14, a Medical Physics Expert must —

a) be closely involved in every radiotherapeutic practice other than standardised therapeutic nuclear medicine practices; b) be involved in practices including standardised therapeutic nuclear medicine practices, diagnostic nuclear medicine practices and high dose interventional radiology and high dose computed tomography; c) be involved as appropriate for consultation on optimisation, in all other radiological practices and d) give advice on — i) dosimetry and quality assurance matters relating to radiation protection concerning exposures; ii) physical measurements for the evaluation of dose delivered; iii) medical radiological equipment. e) be entitled as ‘Operator’ under the Employer’s written procedures. a) optimisation of the radiation protection of patients and other individuals subject to exposures, including the application and use of diagnostic reference levels; b) the definition and performance of quality assurance of the equipment; c) acceptance testing of equipment; d) the preparation of technical specifications for equipment and installation design; e) the surveillance of the medical radiological installations; f) the analysis of events involving, or potentially involving, accidental or unintended exposures; g) the selection of equipment required to perform radiation protection measurements; h) the training of practitioners and other staff in relevant aspects of radiation protection; i) the provision of advice to an employer relating to compliance with these Regulations. An MPE must also contribute to the following matters — Legal role of the Radiation Protection Adviser (RPA) Under Regulation 14(1) of the Ionising Radiations Regulations 2017, the RPA should be consulted where advice is necessary to ensure observance of the Regulations. This must include the following:

• The implementation of requirements as to controlled and supervised areas. • The prior examination of plans for installations and the acceptance into service of new and modified sources of ionising radiation in relation to any engineering controls, design features, safety features and warning devices provided to restrict exposure to radiation. • The regular checking of equipment provided for monitoring levels of radiation and the regular checking that such equipment is serviceable and correctly used. • The periodic examination and testing of engineering controls, design features and warning devices and regular checking of systems of work provided to restrict exposure to ionising radiation. • Advice on the use of dose limits when averaged over periods greater than a single calendar year (Schedule 3) In addition, the Approved Code of Practice (ACOP) states that the RPA must be consulted about: • The radiation risk assessment (Regulation 8) and local rules (Regulation 18). • The designation of controlled and supervised areas (Regulation 17) • The conduct of investigations required by the Regulations e.g. for a suspected overexposure of a member of staff or staff exceeding an investigation level. • Contingency plans (Regulation 13) • Dose assessment and recording (Regulation 22), including dosimetry for accidents (Regulation 24) In addition, the ACOP states that the RPA should be consulted about: • Optimisation and establishment of appropriate dose constraints • Classification of workers and the suitability of dosimetry services for assessment and recording of doses received by the classified persons • Outside workers • Workplace and individual monitoring programmes and related personal dosimetry • Appropriate radiation monitoring instrumentation • Selection of adequate and suitable PPE

• Arrangements for prevention of accidents and incidents • Investigation and analysis of accidents and incidents and appropriate remedial actions • Training and retraining programmes for exposed workers (information, instruction and training) • Investigation and analysis of accidents and incidents and appropriate remedial actions • Employment conditions for pregnant and breastfeeding workers • Preparation of written procedures • Suitability of RPS appointments • Selecting investigation levels • The working lifetime of sealed sources, as required (Regulation 28)

IRR17 and IRMER17

Physics in project timelines – Issues with shielding Recently several issues have been discovered by CMPE with regards to the protective sheilding in various facilities. This represents a risk to staff, patients and the public. Potentially leading to over exposures i.e. exceeding the IRR17 dose limts. Employers need to ensure physicists are involved in the specification, design, critical exam and commissioning of equipment and facilities to ensure protection is adequate. Ongoing survaliance of protection should fall within quality assurance programmes and estates (or others) should not be allowed to replace or alter the structure of an x-ray room without physics involement. Lead glass was found cracked during the critical exam of an x-ray room.

There are two key pieces of legislation that underpin radiation protection in hospitals, the Ionising Radiations Regulations (IRR17) and the Ionising Radiation (Medical Exposures) Regulations (IRMER17). It is important to understand the differences between them, and the different aspects which apply to work with radiation in healthcare. The following diagrams illustrate the key differences and important aspects.

Upon further inspection by physics it was discovered that protection discountinuities were present in the framework holding the lead glass in place i.e. the non-glass part of the operator screen, as shown on a DR plate image below (black shows radiation getting through):

around CT scanners. Potential incidents arising from inadequate shielding in new facilities can be avodied through cooperation between employers (the organisation, the contractors and physics) to ensure communication and smooth handover of controlled areas. It is important that issues are identified immediately, before equipment is used during installation, critical exam/commissioning and long before it is used clinically. Multiple visits to new facilities may be required for thorough shielding measurements before the installers put equipment in and use radiation. On top of this, it is recommended that two days are scheduled into timelines for thorough completion of commissioning checks. Sufficient time should be factored into timelines to allow for physics to analyse data and issue a report before equipment is put into clinical use (a week in total from testing the unit to issuing a report would be a reasonable timeline but while the workforce is so reduced, this is aspirational). Furthermore, the possibility of potential issues occurring should be factored into timelines when considering new equipment. Physics often find problems. It should not be assumed that as soon as we leave the equipment will be ready to use on patients. The employer is required to decide if equipment can be put into clinical use. Physics data and the installer data contribute to this consideration but physics are not responsible for that decision. However, we can work as part of a multidisciplinary team drawing on all relevant expertise. Involve physics in your project development and timelines and keep us in the loop so you can start imaging patients, safely, sooner. Electrical Safety CMPE x-ray imaging physicists do not perform electrical safety testing. We require this to be performed and evidence provided before we undertake critical examinations and/or commissioning tests on imaging equipment. It is down to the equipment owner to ensure electrical safety is satisfactory when first installed and throughout its lifetime. Although there are no specific regulations related to medical electrical installations, there is a duty of care supported with standards and guidance (see below) that

The gap ran from the lead glass to the lower panel section, which could be a result of both sections not firmly assembled together or a missing lead strip, or both. CMPE also found shielding issues when assessing a mobile CT van. The structure of the van was tested using scattered radiation from a phantom on the CT bed and a dose rate meter providing Instantaneous Dose Rates (IDRs). Discountinuities were found where lights were fitted on the van, at joins between panels, around the base where the floor slides out to let patient beds into the van at the lift and around door frames. The IDRs were such that additional lead had to be put in place to reduce levels below acceptable dose constraints e.g. <0.3mSv per year when occupancy is taken into consideration. The lesson to others is that mobile imaging environments are a particular risk and require signiicant physics time to ensure the safety of staff, patients and members of the public. Don ’ t assume that the roof shielding is not a concern as, particularily for CT imaging, the scattered dose rates can reach staff in a second floor office if located beside these mobile imaging structures. A further example of inadequate shielding at installation of a facility came with our discovery of a CT control room window with normal glass with no radiation protection qualities. CT control rooms normally have at least 2 mm of lead equivalence due to the very high dose rates

will be drawn on in a court of law in the event of related injury or death. It is of paramount importance that this serious risk is managed every single time new equipment is installed and there should be cooperation between employers to share the outcome of the testing before anyone starts to use or further perform quality assurance testing on the equipment.

The main issues identified in the report are in the following areas:

• Staffing (especially due to COVID absence) • Training (records, competency processes and review) • Effective communication and governance frameworks It is important to monitor incident trends (e.g. equipment, staff, time of day etc.) to identify themes which may require notification to the CQC. There was a significant reduction in exams over 2020 2021 due to COVID, which also resulted in fewer incident notifications being made when compared to previous years. 88% of the notifications came from NHS Trusts which isn’t unsur prising. The most common error resulting in notification to the CQC was incorrect patient. This mostly happened at the referral stage or where the operator failed to correctly identify them. The largest proportion of SAUE notifications came from diagnostic radiology; however, this may be due to the large relative number of exams when compared to nuclear medicine or radiotherapy. The highest sub modality notifications came from CT exams. The North West had the highest number of notifications geographically (1.2 per 100,000 people); however, this could be influenced by various factors such as reporting culture, guidance interpretation and/or operational delivery. There were two main areas highlighted which should be distinguished between before submitting notifications to CQC to ensure clarity and correctly reporting: Difference between clinically significant accidental and unintended exposures (CSAUE) and significant accidental and unintended exposures (SAUE). • Difference between clinical and regulatory audit •

Departments are reminded of the following requirements:

BS 7671:2018 + Amendment 2:2022 – this is the 18th Edition of Requirements for Electrical Installations (IET Wiring Regulations).

Also, the associated Guidance Note 7 on Special Locations.

BS EN 60601-1:2006+A2:2021 Medical electrical equipment. General requirements for basic safety and essential performance.

A useful pocket guide is available here:

https://medical-locations.co.uk/wp content/uploads/2019/04/Pocket-Guide-for-Medical Electrical-Installations-11-April-1.pdf This document also references Department of Health and Social Care guidance HTM 06-01: Health Technical Memorandum 06-01: Electrical services supply and distribution (2017 edition) (england.nhs.uk) [https://www.england.nhs.uk/wp content/uploads/2021/05/Health_tech_memo_0601.pdf]

Summary of CQC IR(ME)R Annual Report 2020-21 – Diagnostic Radiology

The CQC published their annual report based on findings from inspections and notifications between April 2020 and March 2021. The mains areas from this report, which relate to diagnostic radiology are summarised below. We would like to remind organisation ’ s board members to read the full document to ensure they understand current issues which are highlighted and take appropriate action. Please also see the full document for further analysis.

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