Hospital Preparedness: A Pilot Program for Radiation Monitoring in Emergency Departments Susan E. Eckert, RN, MSN Washington Hospital Center/ ER One Institute CAPT Michael A. Noska, MS, USPHS Dept. 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, userfriendly screens and queries NOT tested fully Problems also experienced at pilot sites
Data Summary Data Type Interval Site Collected Min/Max/Avg Background 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 Radation Reading (ur/hr) 8 7 6 5 4 3 2 1 0 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) 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
ED 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) Recent Nuclear Medicine Procedure? Yes No threat 1. Release person(s) 2. Reset alarm 3. Debrief staff No Medically stable? Yes 1. Notify Radiation Safety Officer. 2. Establish control zone. 3. Pull PPE radiation response supplies. 4. To decon area for survey/decon. No Treat Patient Pull PPE/Radiation Response Supplies 1. Notify Radiation Safety Officer. 2. Establish control zone. 3. Address need to activate disaster plan.
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