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 Michael.Noska@fda.hhs.gov 240-276-3331

Susan Eckert Susan.e.eckert@medstar.net 202-877-3113