Title: Hospital Preparedness: A Pilot Program for Radiation Monitoring in Emergency Departments
1Hospital Preparedness A Pilot Program for
Radiation Monitoring in Emergency Departments
CAPT Michael A. Noska, MS, USPHS Dept. of Health
and Human Services/ Food and Drug
Administration Susan E. Eckert, RN,
MSN Washington Hospital Center/ ER One Institute
2 This work was performed under HHS Contract
HHSP2332006425OEC Pilot Program for Radiation
Monitoring in Emergency Departments
3Disclaimer
- The use and description of specific products in
this study does not imply endorsement of a
manufacturer by the Department of Health and
Human Services.
4Project Overview
- Primary Purpose To assess the effectiveness of
using radiation monitors in hospital emergency
department entrances - Secondary Purpose To provide ED clinicians and
staff with necessary tools and resources to mount
an initial response to a radiological event
5Project Goals
- Fulfill HHSs 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
6Why is protection needed?
- National Planning Scenarios 1 10
- Unknown/uncertain contamination
- Self-referring victims
- Surreptitious exposure
- Early Assessment
- Radiation type
- External vs. internal
- Contamination control
7Rationale for Selection of System
- Technical features
- Energy
- Detector type
- Alarm methodology and sensitivity
- Human factors
- Cost
- Data management and networking
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9Laboratory Testing
- AFFRI Low Dose Irradiation Facility
- Optimize operational parameters
- Test sensitivity
- Construction of gantry
- Sources
- PC monitoring
10System 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
11Project 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
12Project 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
13Project 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
14Project 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
15Project 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
16Project Methodology
- Toolkit created
- Included
- Equipment
- All educational and reference materials
- Toolkit deployed to
- Childrens Hospital Boston
- Mary Washington Hospital, Fredericksburg, VA
- Final revisions to materials completed
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18Project 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
19Software
- 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
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21Data Summary
22Device Data Summary
23Device 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
24 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
25Impact in the Hospital Environment
- Installation
- Site selection devices and fixed alarms
- Power and dataports
- Monitoring alarms remotely
- Supplementing manufacturers materials
- Sustainment
- Quality Assurance checks
26Staff 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
27ED RADIATION ALARM RESPONSE GUIDE QUICK
REFERENCE
ALARM Triage nurse responds Charge RN and MD
back up triage
Locate and identify source (Stop all potential
persons immediately)
No threat 1. Release person(s) 2.
Reset alarm 3. Debrief staff
Recent Nuclear Medicine Procedure?
Yes
No
- Notify Radiation Safety Officer.
- Establish control zone.
- Pull PPE radiation response supplies.
- To decon area for survey/decon.
Medically stable?
Yes
No
- Notify Radiation Safety Officer.
- Establish control zone.
- Address need to activate disaster plan.
Treat Patient Pull PPE/Radiation Response Supplies
28Radiological 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
29Drills
- Essential for identifying gaps
- PPE
- Control zones
- Surveying
- Establishing background, documenting
- Critical in increasing confidence and competence
30Lessons 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
31Lessons 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
32Lessons 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 of increasing confidence and competence
of staff - Simple messaging is most likely to succeed
33Lessons 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
34Project 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
35THANKS TO
- Project Officer Dr. George Alexander
- AFFRI Staff LCDR John Crapo,
- LT Anamarie Dent
- HHS Staff Dr. Norm Coleman
- Healthcare Partners Childrens Hospital-Boston,
Franklin Square Hospital, Georgetown University
Hospital, Mary Washington Hospital, Washington
Hospital Center - Industry Partners Atlantic Nuclear, Ludlum
Instruments
36Contact Info
- CAPT Michael Noska
- Michael.Noska_at_fda.hhs.gov
- 240-276-3331
- Susan Eckert
- Susan.e.eckert_at_medstar.net
- 202-877-3113