activities. The list of medical activities subject to registration has been defined on the basis of the radiation protection risks (see Table 1) by ASN resolution 2021-DC-0704 of 4 February 2021. This system is applicable to computed tomography and to FGIPs, activities with radiation protection implications. Conventional radiology and dental radiology will continue to come under the notification system. The licensing system is maintained for external-beam radiotherapy, brachytherapy and diagnostic and therapeutic nuclear medicine. 1.3.4 The particularities of radiation protection of patients Justification and optimisation – The protection of patients undergoing medical imaging examinations or therapeutic procedures using ionising radiation is regulated by specific provisions of the Public Health Code (Art. R. 1333‑45 to R. 1333‑80). The principles of justification of the procedures and optimisation of the delivered doses constitute the cornerstone of this regulation. The principle of dose limitation does not apply to patients due to the need to adapt the delivered dose to the diagnostic or therapeutic end-purpose for each patient. ASN ensures that this regulatory framework is updated through specific provisions with regard to optimisation, quality assurance, training and qualification as described below. The required qualifications – The use of ionising radiation on the human body is restricted to physicians and dental surgeons having the necessary skills to perform these procedures (Article R. 1333‑68 of the Public Health Code). ASN updated and specified the necessary qualifications in October 2020. This aim of the updating is to adapt the regulatory provisions to the developments in the techniques and conditions of practise. ASN resolution 2020‑DC-0694 of 8 October 2020, approved by Order of 5 July 2021, entered into effect in July 2021. It repeals the resolution of 23 August 2011 (2021-DC-0238) and updates the qualifications required for physicians and dental surgeons who perform procedures using ionising radiation for medical purposes or human subject research, and for the physicians appointed to coordinate a medical nuclear activity or who apply for a license or registration as a natural person. The quality assurance obligations – To control the doses delivered to patients and thereby contribute to improved treatment safety, the obligations of persons/entities responsible for nuclear activities with regard to quality assurance for all medical activities involving ionising radiation are now governed by two ASN resolutions: ∙ resolution 2019-DC-0660 of 15 January 2019 in medical imaging, that is to say in nuclear medicine for diagnostic purposes, in dental and conventional radiography, in computed tomography and for FGIPs; ∙ resolution 2021-DC-0708 of 6 April 2021 for therapeutic procedures, that is to say external-beam radiotherapy, including contact therapy and intraoperative radiotherapy, brachytherapy, nuclear medicine for therapeutic purposes (ITR) and radiosurgery. These resolutions oblige the head of the nuclear activity, with requirements proportionate to the radiation protection risks, to formalise the processes, procedures and work instructions associated with the operational implementation of the two general principles of radiation protection, namely justification for the procedures and dose optimisation, and those concerning the lessons learned from the events, the training of professionals and, for therapeutic procedures, the prospective risk analysis. ASN resolution 2021-DC-0708 of 6 April 2021 updates and tightens the quality assurance requirements, particularly when there is an organisational or technical change, and when services are outsourced. Training in patient radiation protection – The obligations for continuous training in patient radiation protection are set in Articles L. 1333‑19, R. 1333‑68 and R. 1333‑69 of the Public Health Code. The system as a whole was revised in ASN resolution 2017-DC-0585 of 8 January 2015 amended, further to discussions with all the National Professional Councils (CNP) concerned in order to clarify and reinforce the teaching objectives concerning justification, to integrate new players and to foster links with the other continuous training instruments. Since this resolution entered into application, some twenty professional guides have been produced by the learned societies, validated by ASN and put on line on asn.fr. To monitor the practical implementation of this new framework, a qualitative and quantitative assessment was initiated at the end of 2021, involving all the players. An inventory of the training offerings has been drawn up to identify the main players (health facilities, learned societies, continuous training organisations). For the guide for radiotherapy professionals and the guide for radiographers working in imaging, a specific assessment has been conducted by the Centre of Studies on the Evaluation of Protection in the Nuclear Field (CEPN) at the request of ASN, on the number and content of these two training courses. This assessment focused on compliance with the regulations, the organisation of the training courses, their teaching methods and the level of satisfaction of the professionals who have followed the courses. The first results show that the training guides are broadly followed by the training organisations (whether public or private). This work will be presented in 2023 to the committee that monitors the national plan for controlling imaging doses. TABLE Classification of nuclear-based medical activities according to the radiation protection risks ACTIVITIES PATIENTS PROFESSIONALS PUBLIC AND ENVIRONMENT External-beam radiotherapy 3 1 1 Brachytherapy 2 2 2 Internal targeted radiotherapy 3 2 3 Fluoroscopy-guided interventional practices 2 to 3 depending on the procedures 2 to 3 depending on the procedures 1 Diagnostic nuclear medicine 1 to 2 depending on the procedures 2 to 3 depending on the procedures 2 Computed tomography 2 1 1 Fluoroscopy-guided procedures on remotely controlled table in radiology department 1 1 1 Conventional radiology 1 1 1 Dental radiology 1 1 1 1 : no risk or low risk – 2: moderate risk – 3: high risk 1 ASN Report on the state of nuclear safety and radiation protection in France in 2022 211 • 07 • Medical uses of ionising radiation 07 01 08 13 AP 04 10 06 12 14 03 09 05 11 02
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