Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 518 - FREESTANDING EMERGENCY CENTER CODE › Section 518.2010 - Radiological Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
			 freestanding emergency center shall maintain and provide radiological services
			 sufficient to perform and interpret the radiological examinations necessary for
			 the diagnosis and treatment of patients, to the extent that the complexity of
			 services is commensurate with the size and scope of the FEC. Additional
			 required services shall be provided by shared services or referral of
			 patients.
b) The physician
			 responsible for the direction of a radiological department or service shall be
			 board certified or eligible for certification by the American Board of
			 Radiology or equivalent. The physician shall have a written agreement with the
			 FEC to direct the radiological services on a full-time, part-time, or
			 consulting basis and be an approved member of the medical staff. The
			 responsibilities of the physician shall be identified in a policy and
			 procedures manual or other document.
c) Technicians employed in the radiological
			 services shall be accredited pursuant to 32 Ill. Adm. Code 401 as appropriate
			 and have sufficient training and experience to carry out the procedures safely
			 and efficiently commensurate with the size and scope of the service. A
			 procedure and means for evaluating qualifications shall be established and used
			 by the FEC.
d) Radiological
			 services shall be available at all times.
e) Complete, signed reports of the
			 radiological examinations shall be made part of the patient's record, and
			 duplicate copies shall be kept in the department for a period of time
			 established by the FEC.
f) Written
			 reports of each radiological interpretation, consultation and treatment shall
			 be signed by the physician responsible for conducting the procedure and shall
			 be a part of the patient's medical record. Maintenance and filing of records
			 shall be coordinated with direction and supervision by the medical record
			 administrator.
g) X-ray or roentgen
			 photographs shall be retained in accordance with the X-ray Retention Act, which
			 requires retention for five years and longer when notification of litigation is
			 received.
h) Radiological
			 facilities operated by an FEC constitute a "radiation installation" within the
			 meaning of the Radiation Protection Act of 1990 and are required to be
			 registered with the Illinois Emergency Management Agency.
i) Each radiological department or identified
			 distinct radiological service shall prepare and maintain a policies and
			 procedures manual, which shall be reviewed and updated annually and shall
			 include, but not be limited to, the following requirements:
1) The FEC shall establish and enforce safety
			 regulations that will protect both patient and radiological worker from
			 excessive or stray radiation pursuant to the Radiation Protection Act of 1990
			 and the federal regulations promulgated thereunder.
2) When a radiation hazard exists, the FEC
			 shall periodically obtain a survey and report by a diagnostic imaging
			 specialist or therapeutic radiological physicist that indicates whether
			 satisfactory conditions exist.
3)
			 Personnel Monitoring shall be performed pursuant to 32 Ill. Adm. Code
			 340.210 and
			 340.520.
A) Procedures for personnel monitoring shall
			 be maintained for each individual working in the area of radiation where there
			 is a reasonable possibility an individual will exceed 10% of annual
			 limit.
B) Personnel monitoring
			 records resulting from the use of film badges or dosimeters shall be
			 maintained. Readings shall be on at least a quarterly basis.
C) Upon termination of employment, each
			 worker shall be provided with a summary of the worker's exposure
			 record.
D) Permanent records of
			 exposure on all monitored personnel shall be maintained for review by the
			 Department.
4) Monthly
			 and yearly reports shall be maintained on the number of examinations done and
			 kinds of treatment given.
5) The
			 use of all radiological apparatus shall be limited to personnel designated as
			 qualified by the physician responsible for the direction and supervision of the
			 department or service. Qualified personnel shall comply with the Radiation
			 Protection Act of 1990 and the regulations promulgated thereunder, specifically
			 32 Ill. Adm. Code 401. The use of fluoroscopes shall be limited to persons
			 licensed under the Medical Practice Act of 1987, the Illinois Dental Practice
			 Act, or the Podiatric Medical Practice Act of 1987, and to personnel who meet
			 the requirements in 32 Ill. Adm. Code
			 360.50(n)(1) through
			 (4).
6) Radiological personnel accredited pursuant
			 to 32 Ill. Adm. Code 401 shall participate in continuing education pursuant to
			 32 Ill. Adm. Code 401.140. Physicians shall
			 participate in training pursuant to Subpart J of 32 Ill. Adm. Code 335 as
			 applicable. The physician is responsible for the direction and supervision of
			 radiological services. The continuing education shall be documented.
7) At all times, reasonable privacy shall be
			 provided for the radiological patient relative to dressing, evacuation, and the
			 study being performed.
8) Safety
			 policies shall be written for the radiological services to protect patients and
			 personnel. These policies shall relate to radiation pursuant to 32 Ill. Adm.
			 Code 310, 335, 340, and 360, electrical and mechanical hazards, prevention and
			 containment of fire and explosion, and prevention and treatment of any untoward
			 reaction to contrast media.
9)
			 Written policies and procedures shall be enforced for the radiological services
			 that relate to the management of critically ill patients and to the
			 administration of diagnostic agents by nonphysicians.
10) When nonphysicians are permitted to
			 administer diagnostic agents intravenously for radiological evaluations,
			 written safety guidelines shall specify which individuals have this authority
			 and require that a physician be immediately available. If radioactive materials
			 are being administered, accreditation and supervision rules apply. Refer to 32
			 Ill. Adm. Code 335.1050.
11) An emergency drug tray shall always be
			 present in the room or immediately available where parenteral diagnostic agents
			 for radiologic evaluations are being administered. A system shall be
			 established for maintaining an emergency drug tray with appropriate content and
			 no outdated medications or missing items. Oxygen, airways, syringes and
			 needles, intravenous administration sets, and appropriate parenteral solutions
			 shall be available at all times.
12) Written safety policies shall provide for
			 the steps to be followed in the event of a spill of radioactive material
			 pursuant to Subpart M of 32 Ill Adm. Code 340; for specific authority for any
			 nonphysician personnel who administer radioactive material intravenously
			 pursuant to 32 Ill. Adm. Code 335.1050; for the recording of cumulative
			 radiation exposure of all personnel pursuant to 32 Ill Adm. Code
			 340.1160 and 340.520; a
			 requirement for protective security from all radioactive areas for all
			 unauthorized personnel pursuant to Subpart G of 32 Ill. Adm. Code 340 and 32
			 Ill. Adm. Code 340.810; and the establishment
			 of a radiation protection survey at least once per week pursuant to 32 Ill.
			 Adm. Code 335.
13) Instrument
			 logbooks maintained by Radiological Services shall include calibration records
			 of equipment and monitors, maintenance and repair records, and the findings of
			 outside evaluators (if used), with the corrective action taken pursuant to 32
			 Ill. Adm. Code 340.1130.