Hospital Preparedness: A Pilot Program for Radiation Monitoring in Emergency Departments

1. Hospital 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

3. Disclaimer 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.

4. Project 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

5. 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

6. Why 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

7. Rationale for Selection of System • Technical features • Energy • Detector type • Alarm methodology and sensitivity • Human factors • Cost • Data management and networking

9. Laboratory Testing • AFFRI Low Dose Irradiation Facility • Optimize operational parameters • Test sensitivity • Construction of gantry • Sources • PC monitoring

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

18. 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

19. 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

21. Data Summary

22. Device Data: Summary

23. 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

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

25. 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

26. 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

27. 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) 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

28. 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

29. Drills • Essential for identifying gaps • PPE • Control zones • Surveying • Establishing background, documenting • Critical in increasing confidence and competence

30. 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

31. 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

32. 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 of increasing confidence and competence of staff • Simple messaging is most likely to succeed

33. 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

34. 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

35. 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

36. Contact Info: • CAPT Michael Noska • Michael.Noska@fda.hhs.gov • 240-276-3331 • Susan Eckert • Susan.e.eckert@medstar.net • 202-877-3113