hospital preparedness: a pilot program for radiation
TRANSCRIPT
Hospital Preparedness: A Pilot Program for Radiation Monitoring in Emergency Departments
Susan E. Eckert, RN, MSNWashington Hospital Center/
ER One Institute
CAPT Michael A. Noska, MS, USPHSDept. of Health and Human Services/
Food and Drug Administration
This work was performed under HHS Contract HHSP2332006425OEC: Pilot Program for Radiation Monitoring in Emergency Departments
Project Overview
Primary Purpose: To assess the effectiveness of using radiation monitors in hospital emergency department entrances Build upon work performed by AFRRI
Secondary Purpose: To provide ED clinicians and staff with necessary tools and resources to mount an initial response to a radiological event
Project Goals
Fulfill HHS’s ESF-8 responsibility for medical and public health emergency response, including population monitoring, decon, medical countermeasures, etc.
Provide early notification to hospital of contaminated patients for triage, treatment and response
Protect hospital staff and facilities
Why is protection needed?
National Planning Scenarios 1 & 10 Unknown/uncertain contamination Self-referring victims Surreptitious exposure
Radiations of concern Penetrating/non-penetrating External vs. internal
Contamination control
Rationale for Selection of System
Technical features Energy (keV) Detector type
Alarm methodology and sensitivity Human factors Cost Web based program
Laboratory Testing
AFFRI Low Dose Irradiation Facility Optimize operational parameters Test sensitivity Construction of gantry Sources PC monitoring
System Set-Up
Area monitor configuration 2 inch by 2 inch NaI scintillation detector
wrapped in a 1/32” (0.39mm) lead shield 300 keV discriminator
Based on anticipated hospital use of isotopes vs. agents used in RDD
Firmware set to ignore bursts of energy exceeding the discriminator threshold for 1 second
Response to X-Ray machine Voltage set by factory in response to Ba-133
Voltage set at 525V-575V
Project Methodology
Ludlum Area Monitors 375-10, configured based on the AFRRI study, were installed at the entrances of three Emergency Departments Washington Hospital Center (WHC) Franklin Square Hospital Center (FSH) Georgetown University Hospital (GUH)
Data collected daily at all sites for a 6 month period Minimum, maximum and average radiation levels Alarm conditions
Project Methodology
Additional testing performed to evaluate the devices Check Source Testing Nuclear Medicine Patient Trial
Reference materials developed for clinicians Procedures :
Receipt and Install of Equipment Establishing Background Radiation Levels Establishing Check Source Ranges Establishing-Setting Alarm Limits Quality Assurance Testing
Project Methodology Reference materials developed for clinicians:
Quick Reference Tools Response guide (algorithm) Isotopes that cause/do not cause an alarm PPE- don-doff procedure Geiger counter operations-performing a patient
survey
Education On-line/printed modules:
Geiger counter operations Performing a patient survey Pre-post tests
3D Simulations Geiger counter Area monitor
Project Methodology
Reference materials developed for clinicians: Tools
Staff talking points Remote alarm signage Dosimeter log QA documentation tool- area monitor Radiation survey patient documentation
tool
Project Methodology
Drills conducted once training provided at the 3 main sites Exercise materials developed based on:
Homeland Security Exercise and Evaluation Program (HSEEP) and AHRQ Drill Evaluation Tool
Objectives, outcome measures, scope of play, safety procedures, logistics, scenario, master event scenario list (MSEL) victim cards, player briefing, evaluation tool, after action report (AAR) and corrective action plan templates
Materials revised as needed
Project Methodology
Toolkit created Included:
Equipment All educational and reference materials
Toolkit deployed to: Children’s Hospital Boston Mary Washington Hospital,
Fredericksburg, VA Final revisions to materials
completed
Project Specifics
Monitors mounted at ED entrances Total of 9 devices in 3 hospitals Devices have local alarms and remote
alarms at central area Data transmitted from each device via
software every 5 seconds (2 seconds if alarm condition) Min/Max/Avg readings calculated daily QA check with Cesium-137 check source
performed weekly
Software
Pulls data from device Extensive testing and revisions
performed 2 upgrades to existing program 1 new release
Allows viewing from any site, multiple users to access data, user-friendly screens and queries
NOT tested fully Problems also experienced at pilot sites
Data Summary
Data Type Interval Site Collected
Min/Max/AvgBackground Readings
Daily-12/10/06-06/10/07 WHC/FSH/GUH
Alarm Condition Daily-12/10/06-06/10/07 WHC/FSH/GUH
QA Check Weekly-12/10/06-06/10/07 WHC/FSH/GUH
Response to Medical Isotopes
19 patients-Feb-Mar, 2007 WHC
Geometry Testing March 2007 WHC
Check Source Testing March 2007 WHC
Device Data: Summary
Daily Average Radiation Over Time by Monitor
0
1
2
3
4
5
6
7
8
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217
Time (Days)
Rad
atio
n R
eadi
ng (u
R/H
r)
WHC1
WHC2
WHC3
FSH1
FSH2
FSH3
FSH4
GUH1
GUH2
Device Data : ANOVA
Evaluated: Among all 9 devices Among devices within each hospital
Findings: Statistically significant differences between the
mean reading among all devices at 5% significance level
Statistically significant differences between the mean reading at devices within each hospital at 5% significance level
Device Data: Alarm Activity
Evaluated number of false, positive and unknown alarms for all 9 monitors over the 6 month period Included QA and other testing sources
Results: Devices alarmed as anticipated Alarms from unknown source relatively low
Range = 4-25 Highest # in 1 month= 5 Mean = 5.4 among all monitors
Data Summary
Devices work as anticipated Screen out most hospital isotopes,
screen in possible agents used in an RDD
Alarm conditions not overwhelming for ED environment/clinicians
Differences in readings expected based on background, building material, storage of items near monitors
Impact in the Hospital Environment
Installation Site selection: devices and fixed alarms
Power and dataports Monitoring alarms remotely Supplementing manufacturer’s
materials Sustainment
Quality Assurance checks
Staff Preparation- Not Labor Intensive
Introduction to system
Management of alarms
Development of reference tools 1 page maximum Laminated, wallet & poster size
Development of response algorithm
Treat PatientPull PPE/Radiation Response Supplies
Recent Nuclear Medicine
Procedure?
Locate and identify source(Stop all potential persons
immediately)
ED RADIATION ALARM RESPONSE GUIDE – QUICK REFERENCEALARM
Triage nurse respondsCharge RN and MD
back up triage
Medically stable?
No threat 1. Release person(s) 2. Reset alarm 3. Debrief staff
Yes
No
Yes
No
1. Notify Radiation Safety Officer.2. Establish control zone.3. Address need to activate disaster plan.
1. Notify Radiation Safety Officer.2. Establish control zone.3. Pull PPE radiation response supplies.4. To decon area for survey/decon.
Radiological Response
Development and provision of education on managing a radiological event Differentiating small vs. large events
Ensuring initial treatment steps clearly understood
Treat first, remove clothing, proper PPE Defining control zones: inside and outside Evaluating devices needed for mass casualties Hardwiring access to external resources
REMM, REAC/TS, WRAMC RAMT
Drills
Essential for identifying gaps PPE Control zones Surveying
Establishing background, documenting
Critical in increasing confidence and competence
Lessons Learned
Detection Devices worked as anticipated Screened out most hospital isotopes Screened in possible agents used in an RDD
Alarm conditions not overwhelming for an ED environment /clinicians
Natural alarms from hospital isotopes kept staff mindful (doctrine of daily routine)
Differences in background readings occurred secondary to location, building material and storage of items near monitors
Lessons Learned 2
Detectors should be mounted at 5 foot height not 3 feet
Alarm notification at entrance portal PLUS in main clinical arena Alarms both auditory and visual
Alarms activate 1 – 5 x a month from hospital isotopes I-131 usual cause of alarm
Level of knowledge of radiation emergencies by average health care provider: Low
Lessons Learned 3
There is enormous opportunity to improve the management of a radiological event by hospital personnel
Installation of the system had the unintended benefit on increasing confidence and competence of staff
Simple messaging is most likely to succeed
Lessons Learned 4
Technical factors cannot be considered in a vacuum (human factors)
Need to be aware of operational environment
Strong collaboration between physicists, hospital personnel and vendor
Protocols, SOPs and training
Project Summary
Devised and validated a simple, low cost system for radiation detection following accidents or terrorist events
Developed a deployable toolkit for hospital emergency response
Developed a rad training and response program for hospital personnel
THANKS TO:
Project Officer: Dr. George Alexander AFFRI Staff: LCDR John Crapo,
LT Anamarie Dent HHS Staff: Dr. Norm Coleman Healthcare Partners: Children’s Hospital-
Boston, Franklin Square Hospital, Georgetown University Hospital, Mary Washington Hospital, Washington Hospital Center
Industry Partners: Atlantic Nuclear, Ludlum Instruments
Contact Info:
CAPT Michael Noska [email protected] 240-276-3331
Susan Eckert [email protected] 202-877-3113