Transcript Radiation Detection Demonstration Project PowerPoint by M.E.

Radiological Incident
Preparedness for
Community Hospitals: A
Demonstration Project
Mary Ellen Jafari, MS, DABR
Radiation Safety Officer
Gundersen Lutheran Health System
La Crosse, Wisconsin
Overview
The design and implementation of a radiological
incident response plan at a community hospital is
described.
This project demonstrated that the Wisconsin
State Expert Panel report, The Management of
Patients in a Radiological Incident, provides a
flexible template that can be implemented at
community hospitals using existing staff for an
approximate cost of $25,000.
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Topics
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Motivation & Introduction
Hazard Vulnerability Analysis (HVA)
Evaluation of Existing Capability
Equipment Purchase
Response Plan
Training
Testing
Staffing/Workload Implications
Conclusions
3
Consider these
questions
• How would your hospital respond to an
emergency involving radiation?
• Would you know if a patient in your ER was
contaminated with radioactivity?
• Could you provide lifesaving patient care and
also keep your staff and facility safe?
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How should your
staff to react to a
radiological incident?
Like this?
Or like this?
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MOTIVATION
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Motivation
• The potential for an incident involving injured
patients and radioactive materials is growing
due to:
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industrial and medical use of radioisotopes
worldwide increase in terrorist activities
renewed interest in nuclear energy
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Contaminated
Patients
Individuals involved in
such incidents may be
contaminated with
radioactive materials
and, if injured, will
require emergency
medical treatment.
D. Morse, Armed Forces Radiobiology
Research Institute (AFRRI)
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Would you Know
Radiation is Involved?
• First responders transporting patients may not
know that the incident involved radiation.
• Contaminated patients may self present for
medical care.
• Without independent radiation detection
capability, a hospital emergency center won’t
necessarily know if a radiation hazard exists.
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What is Needed?
A Radiological Incident Response plan that
includes the following:

technical capabilities to detect, measure, and
identify sources of radiation

procedures for staff to follow
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INTRODUCTION
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Wisconsin State
Expert Panel Report
Nov 2007: Wisconsin Division of Public Health
Hospital Disaster Preparedness Program State
Expert Panel on Radiation Emergencies issued
their report:

The Management of Patients in a
Radiological Incident. Generic template
intended to be tailored to the specific
management structure and infrastructure at
each facility where it is implemented
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Topics Covered in State
Expert Panel Report
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Notification & Verification of Radiation Accident
Preparing for Patient Arrival
Patient Arrival and Triage
Patient Assessment & Treatment of Contaminated
Patients
• Decontamination (External & Internal)
• Transfer of Patient from Emergency Department
• Doffing of Personal Protective Equipment
Appendices cover Training/Education, Nuclear Radiation, Radiation
Injury, Detection of Radiation, Personnel Monitoring, Radiological &
Lab Assessments, Treatment for Internal Contaminants, and more.
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Demonstration
Project
• The Division of Public Health solicited
applications from hospitals to conduct a
demonstration project implementing the
recommendations of that report.
• Gundersen Lutheran Health System was
selected.
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Gundersen Lutheran
Health System
Headquartered in
La Crosse, WI
Serves patients
throughout 19
counties in western
Wisconsin,
northeastern Iowa,
and southeastern
Minnesota
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Trauma & Emergency
Center (TEC)
Level II Trauma
and Emergency
Center serves
over 30,000
patients/yr
18-bed unit staffed by 11 emergency medicine
physicians and 70 nurses, EMTs, paramedics,
and other personnel
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HAZARD VULNERABILITY ANALYSIS
(HVA)
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First Step - HVA
Our first step was to
conduct a Hazard
Vulnerability Analysis
Purpose of HVA:
identify factors that
could increase the
risk of a radiological
incident in the region
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HVA Results
• location on a major interstate highway;
• proximity to a nuclear reactor currently being
decommissioned
• proximity to U.S. Army’s Fort McCoy
• radioactive material use at local hospitals, universities,
industrial facilities, and government facilities
Potential radiological incidents related to these
factors include transportation accidents, worker
injuries, and terrorist actions.
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EVALUATION OF EXISTING SPACE AND
EQUIPMENT
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What Were We Starting
With?
An evaluation of
the existing
space and
equipment was
conducted in
collaboration with
outside experts in
chemical,
biological,
radiological, and
nuclear (CBRN)
response
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Outside Experts
Exchange program conducted with Frimley Park
Hospital NHS Foundation Trust in the United
Kingdom.

Similar to Gundersen Lutheran in size,
proximity to major transportation routes, and
proximity to a large military base

Frimley Park staff travelled to La Crosse in
Nov 2008 for a weeklong evaluation
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Evaluation
Activities
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Evaluation
Activities
• Frimley Park team met with staff from:
TEC
Emergency Medical Services
Security
Safety
Imaging
Radiation Safety
Telecommunications
Infection Control
• Evaluated:
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patient flow
existing Decontamination Room and Equipment
future needs
setup/deconstruction of portable Decon Tent
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Frimley Park Team
Recommendations
• Recommended designation of separate
pathways and entrances for contaminated and
non-contaminated ambulances and patients
• Additional recommendations were related to
deficiencies of existing Decontamination Room
• For each deficiency, a corrective action was
recommended
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Decontamination
Room
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Problems with
Existing Decon Rm
• Walls/ceiling vulnerable to water penetration and
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contaminant adhesion
Concrete flooring (slippery)
No separate ventilation system
No drainage to a water collection tank
No storage space for equipment and Personal
Protective Equipment (PPE)
Equipment not readily available
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Corrective Actions
• Recommendations for patient flow and water
collection tank implemented immediately
• Recommendations regarding radiation detection
and measurement equipment, PPE, and
decontamination equipment implemented during
project
• All recommendations integrated into planning for
construction of a new Critical Care Hospital
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Job Action Cards
• Final recommendation from Frimley Park
Hospital team was to use of Job Action Cards
into our response plan
• Concise, simple direction card for each person.
Allows each person to quickly understand their
role/tasks in an emergency situation
• Provided templates of cards used at Frimley
Park Hospital
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EQUIPMENT SELECTION AND
PURCHASE
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Equipment
Selection/Purchase
Grant for project used to purchase radiation
detection and measurement equipment:
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radiation detection system for TEC entrance
portable instrument for radioisotope
identification
survey meters
electronic dosimeters for staff
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Entrance Monitoring
An entrance monitor is necessary to detect the
presence of a radiation hazard.
• Key features for selecting a monitor:
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high sensitivity
rapid response time
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Entrance Monitor
Selected
Ludlum Measurements, Inc., Model 375-10 wallmounted area monitor with a sodium iodide
scintillation detector, $2189 each
 two alarm levels
 3 seconds response time
 AC power with 12 hr battery backup
 audible alarm, can also have strobe light and horn
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Ludlum Model 35710
• Wall mounted
• Continuous digital
readout
• Optional environmental
box for outdoor use
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Entrance Monitor
Installation
Purchased and installed two monitors (total cost $4378)
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Avoid Alarming for
Normal Patients!
• Didn’t want monitors alarming from diagnostic
Nuclear Medicine and Radiation Oncology seed
implant patients who are not a hazard
• TEC physicians and staff felt alarms from these
patients would cause them to disregard or turn
off systems
• Nice feature with Ludlum 375-10 system is that
Ludlum can calibrate it to not trigger for low
energy medical radioisotopes
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Low Energy
Discrimination
Radioisotopes excluded from detection:
Tc-99m, Tl-201, In-111, P-103, I-123 and I-125
Examples of radioisotopes above the threshold
which will be detected:
I-131, Cs-137, Co-60, Ba-133, F-18, Ga-67, Mo-99
Verified on-site
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Portable MultiChannel
Analyzer (MCA)
In addition to detecting the presence of
radiation, it is important to identify the
radioisotope.
Different radioisotopes have different
characteristics such as energy and half-life.
Need to know what you are dealing with to
appropriately treat patients and protect staff.
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Radioisotope
Identification
• Key features for selecting a radioisotope
identifier:
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accuracy
rapid response time
portability
ease of use
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MCA Selected
Berkeley Nucleonics Model 940-2-G SAM
Defender with a sodium iodide detector, $10038,
including 3 yr calibration, maintenance, upgrade,
and training program
 energy range of 18 keV to 3 MeV
 electronic isotope library
 can transfer data to a PC through a CompactFlash
card, Ethernet, or USB adapter
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Berkeley Nucleonics Model
940-2-G SAM Defender
• AC power or “AA” cell
batteries with 6 hr life
• weight 4.5 lbs
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Survey meters
Survey meters are lightweight, portable devices
used to detect the presence, location, and level of
radioactive contamination on patients
Also used to monitor staff, equipment, and facility
for contamination acquired during patient care and
decontamination
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Survey meters
• Key factors for selection of survey meters
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high sensitivity
ruggedness
ease of use
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Survey Meter Model
Selected
• Ludlum Measurements, Inc., Model 3 Survey
Meter with Model 44-9 Pancake Geiger-Mueller
Detector, $710 each
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4 second response time in Fast mode
Power is supplied by two “D” cell batteries with a
typical battery life of 2,000 hours
3.5 lbs
equipped with optional 1 uCi Cs-137 check source
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Ludlum Model 3 Survey Meter
with Model 44-9 Pancake GeigerMueller Detector
• Six meters were purchased for use in the TEC,
and one additional meter was purchased for the
Gundersen Lutheran MedLink AIR helicopter
(total cost $4970)
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Electronic
Dosimeters
Need to assess radiation dose received by staff
during patient care and decontamination.
Key features for selecting staff monitoring devices
 real-time dose display
 accuracy
 ruggedness
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Dosimeter Model
Selected
Global Dosimetry Solutions Model DMC 2000S
Electronic Dosimeter with silicon diode detector,
$550 each
 digital display of dose (0.1 - 1,000 mrem) and dose
rate ( 0.1 - 1,000 mrem/yr)
 energy range 50 keV to 6 MeV
 battery powered, typical battery life of 2,000 hrs
 weight 2.0 oz
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Global Dosimetry Solutions
Model DMC 2000S Electronic
Dosimeter
• Six dosimeters were purchased to augment two units
already present at the facility (total cost $3300)
• Size is similar to that
of a pager. Attaches
to clothing with
detachable clip
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Initial equipment costs
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Recurring equipment
costs
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RESPONSE PLAN
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Plan Development
• Template used was the State Expert Panel on
Radiation Emergencies report
• Had to customize template for our organization’s
specific management structure and
infrastructure
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Core Group
• A core group of individuals was selected to
develop the radiological incident response plan:
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Radiation Safety Officer
Hospital Safety Officer
Physician Chair of Emergency Medicine Dept
Managers for TEC, Emergency Medical
Services, Security, Facility Operations
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Initial Core Group
Meeting
• Initial Core Group meeting:
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define project objectives
set timeline
determine roles for Job Action Cards
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Next Steps
• Draft plan written. Job Action
Card made for each role.
• Not difficult since State
Experts Plan already had
procedures for personnel to
follow
• Just needed to determine who
at our facility would fill each
role
No need to reinvent
the wheel
Photo: creativecranes.com
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Job Action Cards
Job Action Card was
created for each role.
Incident Command System
Incorporated
Number of roles could
be reduced for smaller
facilities.
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Job Action Cards
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Concise
Large font
Brightly colored
Laminated
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Tabletop Exercise
• Core group reviewed the draft plan and assessed
it with a tabletop exercise.
• Followed steps on the Job Action Cards to
respond to a hypothetical radiological incident
• Improvements were made to draft plan after
feedback on workflow and responsibilities
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Other documents
and materials
In addition to the Job Action Cards, we included
the following materials into the plan:
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REAC/TS flowchart
CDC Fact Sheet for Physicians on Acute Radiation
Syndrome (ARS)
Info sheet on treatments for internal contamination
Radiological Incident FAQ sheet
Survey meter instruction card
Poster showing how to put on PPE
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REAC/TS Patient
Treatment Flowchart
• Flowchart from the Oak Ridge Institute for Science and
Education (ORISE) Radiation Emergency Assistance
Center/Training Site (REAC/TS)
• Shows decision-making steps, decontamination
procedures, and treatment of patients involved in a
radiological incident and is available on the REAC/TS
Website
• http://orise.orau.gov/reacts/combined-injury.htm
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REAC/TS Patient
Treatment Flowchart
• Colorful and easy to
read
• Matches State Expert
Panel recommendations
• Multiple copies printed
on 24” x 36” foam board
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ARS Fact Sheet for
Physicians
• CDC Fact Sheet for Physicians on Acute
Radiation Syndrome (ARS) describes the three
classic acute radiation syndromes and
cutaneous injury
• Includes tests for estimating radiation dose, and
instructions for triage and patient management.
• Available at CDC Radiation Emergency website
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Treatment for Internal
Contaminants
• Patients involved in a radiological incident may
have external contamination, internal
contamination, or both.
• Blocking and decorporation agents may reduce
internal uptake of radioactive materials or
increase their rate of excretion.
• Table 2, App 7, of State Expert Panel report
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Treatment for Internal
Contaminants
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Radiological Incident
FAQ Sheet
• Patients, family members, and the media have
concerns and questions during a radiological
incident.
• FAQ list (App 10 of the State Expert Panel
report) was modified for use at Gundersen
Lutheran Health System
 Revised comply with organizational policies on patient
education and staff communication with the media.
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FAQ Examples
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Survey Meter
Instruction Card
A concise instruction sheet
for use of the survey meters
was developed based on
App 6 to the State Expert
Panel report.
Laminated and attached to
each survey meter.
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Personal Protective
Equipment (PPE)
Donning Poster
Copies printed on
24” x 36” foam
board
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ADDITIONAL TOOLS/SUPPLIES
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Radiological
Incident Binder
• Three ring binder containing:
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Contact info for Radiation Safety
Staff
Job Action Cards
Radiological Incident Plan
and Associated Documents
• Copies kept at:
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TEC nurse’s station
Security office
Radiation Safety office
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Equipment Storage
Containers
Plastic storage
containers that could
be easily lifted and
moved were used to
store equipment and
PPE right in
Decontamination
room.
Subsequently obtained wheeled storage unit to hold all
containers. Easy to move out when Decon Rm needed.
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TRAINING
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Training
Key factors for selecting training materials and
methods:
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cost
time required
ease of use in an emergency situation (“just in time”
training)
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Training Program
Selected
• The 17-minute CDC video Radiological Terrorism: Justin-Time Training for Hospital Clinicians, was the primary
training tool.
• Intended for medical staff but found to be applicable to
non-medical staff too.
• Feedback indicated video made staff more comfortable
with providing care to a contaminated patient and
reduced their fear of radiation and radiation effects.
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Training
• Staff also received training on the specific steps
and actions in our Radiological Incident
Response Plan.
• Hands-on training provided to TEC staff in use of
radiation survey meters and response if the
alarms trigger on the area monitors at the TEC
entrances.
• Annual refresher training and updates done via
intranet course and in-person inservices.
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TESTING
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Testing
• Three exercises were performed to test the
Radiological Incident Response Plan.
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each exercise tested different parts of the plan.
drill observer recorded observations and
recommendations during exercise
drill photographer
Post-drill recommendations implemented and
retested in next exercise
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Exercise 1: U.S. Army
Operation Red Dragon
2009
• Operation Red Dragon conducted by U.S. Army
Reserve personnel.
• Focused on the military’s ability to deploy Army
Reserve chemical assets in a CBRN response
environment in coordination with local
community agencies and hospitals.
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Red Dragon
Scenario
Terrorist group detonates improvised explosive device–
shaped charge on a pressurized container aboard a barge
near the La Crosse festival site, releasing anhydrous
ammonia during a major morning concert and festival.
Terrorist group then targets the victims and the emergency
responder community by releasing a radiologic agent from
a nearby bridge.
Potential 28484 exposures, 1208 untreated fatalities, and
1342 total casualties, overwhelming medical and public
health authorities and decimating emergency responders.
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Operation Red Dragon
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Exercise 2:
Radiopharmaceutical courier
transportation accident
• Scenario: A courier vehicle delivering nuclear medicine
isotopes to area hospitals plunges over an embankment
on the interstate highway.
• First responders observe the “Caution – Radioactive
Materials” signs on crushed and wet packages. Notify
TEC they will arrive in 30 min with one non-ambulatory
patient with a fractured arm who may be contaminated
with radioactive materials.
• Limited drill. Ended when simulated patient brought into
Decontamination Room.
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Radiopharmaceutical
courier transportation
accident
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Exercise 3: 131I patient
• Scenario: Patient receives 100 mCi radioactive 131I for
treatment of thyroid carcinoma at another regional
hospital.
• An hour later, while returning home by car she develops
a severe headache, nausea, and vomiting. Her husband
pulls the car over and calls 9-1-1. First responders
arrive.
• Patient loses consciousness on the way to the hospital
and is taken directly to a treatment room. Police officer
from the scene is unaware that he is contaminated with
131I and triggers the TEC entrance radiation detector.
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I-131 Patient Accident
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STAFFING AND WORKLOAD
IMPLICATIONS
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Staffing/Workload
Implications
Staff were used in their existing job roles, and no
additional personnel were required for this project.
Staff time was required to:
• develop the plan and associated documents
• train staff
• develop and participate in the three exercises
89
Staffing/Workload
Implications
• Concise training methods resulted in 1-4 hour
training time for each participating TEC staff
member including exercises
• The most significant time burden was that of the
facility’s Radiation Safety staff. 80-100 total hrs
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CONCLUSIONS
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Factors for Success
• A plan champion (the Radiation Safety Officer)
and the core group of individuals who took
responsibility for developing and implementing
the plan were critical to the success of this
project.
• Incorporating use of the ICS provided sufficient
flexibility to adapt to any size of radiological
emergency
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Factors for Success
• Combination of video training, hands-on training,
and practicing actions in exercises was an
effective system of education for individuals with
differing learning styles.
• Clear, concise Job Action Cards received very
positive feedback from staff.
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Challenge
• Limitations in Gundersen Lutheran Health
System’s existing decontamination facilities were
a challenge.
• The lesson learned from this challenge is that
hazardous materials incident response should
be incorporated into planning new construction
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Challenge
• Conducting exercises was challenging because
an ER is busy with real patients.
• Consulting with emergency center staff to
determine the best time to conduct a drill was
useful.
• Conducting limited exercises to test specific
parts of the plan was better for ER staff than a 34 hr full drill
.
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Conclusions
• Successfully demonstrated that the Wisconsin State
Expert Panel on Radiation Emergencies report entitled
The Management of Patients in a Radiological Incident
issued in November 2007 provides a flexible template
that can be customized to fit the needs of individual
healthcare organizations.
• Cost of implementation was approximately $25,000, not
including staff time
• Readiness for appropriate response to an actual
radiological incident was substantially improved.
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FOR FURTHER INFORMATION
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For Further Information
• Copies of the Radiological Incident Response
Plan, Job Action Cards, and associated
documents developed for this project an be
obtained from:
Mary Ellen Jafari, MS, DABR, Radiation Safety Officer
Gundersen Lutheran Health System
1900 South Ave. Mail Stop C02-002
La Crosse, WI 54601
[email protected]
608-775-2933
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For Further Information
Jafari, ME. Radiological
Incident Preparedness for
Community Hospitals: A
Demonstration Project.
Health Phys. 99
(Supplement 2): S123S135; 2010
99
Additional Resources
US Dept of Health and Human Services
Radiation Emergency and Medical Management website
http://www.remm.nlm.gov/index.html
Oak Ridge Institute for Science and Education (ORISE)
Radiation Emergency Assistance Center/Training Site
(REAC/TS)
http://orise.orau.gov/reacts/
US Centers for Disease Control and Prevention (CDC)
Radiation Emergencies website
http://www.bt.cdc.gov/radiation/
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