Radiological Incident Preparedness for Community Hospitals: A Demonstration Project

1. Radiological Incident Preparedness for Community Hospitals: A Demonstration Project Mary Ellen Jafari, MS, DABR Radiation Safety Officer Gundersen Lutheran Health System La Crosse, Wisconsin

2. 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.

3. Topics • Motivation & Introduction • Hazard Vulnerability Analysis (HVA) • Evaluation of Existing Capability • Equipment Purchase • Response Plan • Training • Testing • Staffing/Workload Implications • Conclusions

4. 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?

5. How should your staff to react to a radiological incident? Like this? Or like this?

6. motivation

7. Motivation • The potential for an incident involving injured patients and radioactive materials is growing due to: • industrial and medical use of radioisotopes • worldwide increase in terrorist activities • renewed interest in nuclear energy

8. 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)

9. 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.

10. 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

11. INTRODUCTION

12. 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

13. Topics Covered in State Expert Panel Report • 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.

14. 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.

15. Gundersen Lutheran Health System Headquartered in La Crosse, WI Serves patients throughout 19 counties in western Wisconsin, northeastern Iowa, and southeastern Minnesota

16. 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

17. HAZARD VULNERABILITY ANALYSIS (HVA)

18. 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

19. 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.

20. EVALUATION OF EXISTING SPACE AND EQUIPMENT

21. 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

22. 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

23. Evaluation Activities

24. Evaluation Activities • Frimley Park team met with staff from: TEC Emergency Medical Services Security Radiation Safety Safety Telecommunications Imaging Infection Control • Evaluated: • patient flow • existing Decontamination Room and Equipment • future needs • setup/deconstruction of portable Decon Tent

25. 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

26. Decontamination Room

27. Problems with Existing Decon Rm • Walls/ceiling vulnerable to water penetration and 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

28. 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

29. 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

30. EQUIPMENT SELECTION AND PURCHASE

31. Equipment Selection/Purchase Grant for project used to purchase radiation detection and measurement equipment: • radiation detection system for TEC entrance • portable instrument for radioisotope identification • survey meters • electronic dosimeters for staff

32. Entrance Monitoring An entrance monitor is necessary to detect the presence of a radiation hazard. • Key features for selecting a monitor: • high sensitivity • rapid response time

33. Entrance Monitor Selected Ludlum Measurements, Inc., Model 375-10 wall-mounted 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

34. Ludlum Model 357-10 • Wall mounted • Continuous digital readout • Optional environmental box for outdoor use

35. Entrance Monitor Installation Purchased and installed two monitors (total cost $4378)

36. 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

37. 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

38. 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.

39. Radioisotope Identification • Key features for selecting a radioisotope identifier: • accuracy • rapid response time • portability • ease of use

40. 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

41. Berkeley Nucleonics Model 940-2-G SAM Defender • AC power or “AA” cell batteries with 6 hr life • weight 4.5 lbs

42. 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

43. Survey meters • Key factors for selection of survey meters • high sensitivity • ruggedness • ease of use

44. Survey Meter Model Selected • Ludlum Measurements, Inc., Model 3 Survey Meter with Model 44-9 Pancake Geiger-Mueller Detector, $710 each • 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

45. Ludlum Model 3 Survey Meter with Model 44-9 Pancake Geiger-Mueller 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)

46. 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

47. 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

48. 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

49. Initial equipment costs

50. Recurring equipment costs