Hospital Preparedness: A Pilot
Program for Radiation Monitoring
in Emergency Departments
Susan E. Eckert, RN, MSN
Washingt...
This work was performed
under HHS Contract
HHSP2332006425OEC:
Pilot Program for Radiation
Monitoring in Emergency
Departme...
Project Overview
 Primary Purpose: To assess the
effectiveness of using radiation
monitors in hospital emergency
departme...
Project Goals
 Fulfill HHS’s ESF-8 responsibility for
medical and public health
emergency response, including
population ...
Why is protection needed?
 National Planning Scenarios 1 & 10
 Unknown/uncertain contamination
 Self-referring victims
...
Rationale for Selection of System
 Technical features
 Energy (keV)
 Detector type
 Alarm methodology and sensitivity
...
Laboratory Testing
 AFFRI Low Dose Irradiation Facility
 Optimize operational parameters
 Test sensitivity
 Constructi...
System Set-Up
 Area monitor configuration
 2 inch by 2 inch NaI scintillation detector
wrapped in a 1/32” (0.39mm) lead ...
Project Methodology
 Ludlum Area Monitors 375-10, configured
based on the AFRRI study, were installed
at the entrances of...
Project Methodology
 Additional testing performed to evaluate
the devices
 Check Source Testing
 Nuclear Medicine Patie...
Project Methodology
 Reference materials developed for clinicians:
 Quick Reference Tools
 Response guide (algorithm)
...
Project Methodology
 Reference materials developed for
clinicians:
 Tools
 Staff talking points
 Remote alarm signage
...
Project Methodology
 Drills conducted once training provided at
the 3 main sites
 Exercise materials developed based on:...
Project Methodology
 Toolkit created
 Included:
 Equipment
 All educational and reference materials
 Toolkit deployed...
Project Specifics
 Monitors mounted at ED entrances
 Total of 9 devices in 3 hospitals
 Devices have local alarms and r...
Software
 Pulls data from device
 Extensive testing and revisions
performed
 2 upgrades to existing program
 1 new rel...
Data Summary
Data Type Interval Site Collected
Min/Max/Avg
Background Readings
Daily-12/10/06-06/10/07 WHC/FSH/GUH
Alarm C...
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 10...
Device Data : ANOVA
 Evaluated:
 Among all 9 devices
 Among devices within each hospital
 Findings:
 Statistically si...
Device Data: Alarm Activity
 Evaluated number of false, positive and
unknown alarms for all 9 monitors over
the 6 month p...
Data Summary
 Devices work as anticipated
 Screen out most hospital isotopes,
screen in possible agents used in an
RDD
...
Impact in the Hospital Environment
 Installation
 Site selection: devices and fixed alarms
 Power and dataports
 Monit...
Staff Preparation- Not Labor Intensive
 Introduction to system
 Management of alarms
 Development of reference tools
 ...
Treat Patient
Pull PPE/Radiation Response Supplies
Recent Nuclear
Medicine
Procedure?
Locate and identify source
(Stop all...
Radiological Response
 Development and provision of
education on managing a
radiological event
 Differentiating small vs...
Drills
 Essential for identifying gaps
 PPE
 Control zones
 Surveying
 Establishing background, documenting
 Critica...
Lessons Learned
 Detection Devices worked as anticipated
 Screened out most hospital isotopes
 Screened in possible age...
Lessons Learned 2
 Detectors should be mounted at 5 foot height
not 3 feet
 Alarm notification at entrance portal PLUS i...
Lessons Learned 3
 There is enormous opportunity to
improve the management of a
radiological event by hospital
personnel
...
Lessons Learned 4
 Technical factors cannot be
considered in a vacuum (human
factors)
 Need to be aware of operational
e...
Project Summary
 Devised and validated a simple, low
cost system for radiation detection
following accidents or terrorist...
THANKS TO:
 Project Officer: Dr. George Alexander
 AFFRI Staff: LCDR John Crapo,
LT Anamarie Dent
 HHS Staff: Dr. Norm ...
Contact Info:
 CAPT Michael Noska
 Michael.Noska@fda.hhs.gov
 240-276-3331
 Susan Eckert
 Susan.e.eckert@medstar.net
...
Hospital Preparedness: A Pilot Program for Radiation ...
Hospital Preparedness: A Pilot Program for Radiation ...
Hospital Preparedness: A Pilot Program for Radiation ...
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  • Project took place from Sept 06 to Dec 07 – period of 15 months
    WHC first test, then rolled out to GUH, FSH
    WHC 908 beds
    FSH 329 beds
    GUH 609 beds
  • CHB 397 beds
    Mary washington 397 beds
  • Problem: How can you equip a hospital to detect radioactive contamination on its patients.
    This is a turnkey radiation detection toolkit that we develop for the Department of Health and Human Services.
    It contains everything an Emergency Department or hospital needs to detect a patient who is contaminated with radioactivity
    It contains, the detectors, instructions for their installation, the protocol the staff should follow if the detectors alarm, training material for the staff to learn the protocol, drills and exercises to test the system, and all the equipment necessary to carry this out (note the Geiger Counter)
    Our goal is to create a high capability military resource and national security asset right here in the nation’s capital.
    We have the knowledge, assets, talent, and commitment
  • Hospital Preparedness: A Pilot Program for Radiation ...

    1. 1. 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
    2. 2. This work was performed under HHS Contract HHSP2332006425OEC: Pilot Program for Radiation Monitoring in Emergency Departments
    3. 3. 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
    4. 4. 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
    5. 5. 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
    6. 6. Rationale for Selection of System  Technical features  Energy (keV)  Detector type  Alarm methodology and sensitivity  Human factors  Cost  Web based program
    7. 7. Laboratory Testing  AFFRI Low Dose Irradiation Facility  Optimize operational parameters  Test sensitivity  Construction of gantry  Sources  PC monitoring
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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
    18. 18. 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) RadationReading(uR/Hr) WHC1 WHC2 WHC3 FSH1 FSH2 FSH3 FSH4 GUH1 GUH2
    19. 19. 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
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. Treat Patient Pull PPE/Radiation Response Supplies Recent Nuclear Medicine Procedure? Locate and identify source (Stop all potential persons immediately) ED RADIATION ALARM RESPONSE GUIDE – QUICK REFERENCE ALARM Triage nurse responds Charge 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.
    25. 25. 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
    26. 26. Drills  Essential for identifying gaps  PPE  Control zones  Surveying  Establishing background, documenting  Critical in increasing confidence and competence
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. 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
    32. 32. 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
    33. 33. Contact Info:  CAPT Michael Noska  Michael.Noska@fda.hhs.gov  240-276-3331  Susan Eckert  Susan.e.eckert@medstar.net  202-877-3113
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