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. 2

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

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? 4

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

6. MOTIVATION 6

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 7

8. Contaminated Patients Individuals involved in such incidents may be contaminated with radioactive materials and, if injured, will require emergency medical treatment. 8 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. 9

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 10

11. INTRODUCTION 11

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 12

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. 13

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. 14

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

16. Trauma & Emergency Center (TEC) Level II Trauma and Emergency Center serves over 30,000 patients/yr 16 18-bed unit staffed by 11 emergency medicine physicians and 70 nurses, EMTs, paramedics, and other personnel

17. HAZARD VULNERABILITY ANALYSIS (HVA) 17

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 18

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. 19

20. EVALUATION OF EXISTING SPACE AND EQUIPMENT 20

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 21

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 22

23. Evaluation Activities 23

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

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 25

26. Decontamination Room 26

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 27

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 28

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 29

30. EQUIPMENT SELECTION AND PURCHASE 30

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 31

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 32

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 33

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

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

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 36

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 37

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. 38

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

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 40

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

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 42

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

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 44

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) 45

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 46

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 47

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 48

49. Initial equipment costs 49

50. Recurring equipment costs 50

51. RESPONSE PLAN 51

52. Plan Development Template used was the State Expert Panel on Radiation Emergencies report Had to customize template for our organization’s specific management structure and infrastructure 52

53. Core Group A core group of individuals was selected to develop the radiological incident response plan: Radiation Safety Officer Hospital Safety Officer Physician Chair of Emergency Medicine Dept Managers for TEC, Emergency Medical Services, Security, Facility Operations 53

54. Initial Core Group Meeting Initial Core Group meeting: define project objectives set timeline determine roles for Job Action Cards 54

55. Next Steps Draft plan written. Job Action Card made for each role. Not difficult since State Experts Plan already had procedures for personnel to follow Just needed to determine who at our facility would fill each role 55 Photo: creativecranes.com No need to reinvent the wheel

56. Job Action Cards Job Action Card was created for each role. Incident Command System Incorporated Number of roles could be reduced for smaller facilities. 56

57. Job Action Cards Concise Large font Brightly colored Laminated 57

58. Tabletop Exercise Core group reviewed the draft plan and assessed it with a tabletop exercise. Followed steps on the Job Action Cards to respond to a hypothetical radiological incident Improvements were made to draft plan after feedback on workflow and responsibilities 58

59. Other documents and materials In addition to the Job Action Cards, we included the following materials into the plan: REAC/TS flowchart CDC Fact Sheet for Physicians on Acute Radiation Syndrome (ARS) Info sheet on treatments for internal contamination Radiological Incident FAQ sheet Survey meter instruction card Poster showing how to put on PPE 59

60. REAC/TS Patient Treatment Flowchart Flowchart from the Oak Ridge Institute for Science and Education (ORISE) Radiation Emergency Assistance Center/Training Site (REAC/TS) Shows decision-making steps, decontamination procedures, and treatment of patients involved in a radiological incident and is available on the REAC/TS Website http://orise.orau.gov/reacts/combined-injury.htm 60

61. REAC/TS Patient Treatment Flowchart Colorful and easy to read Matches State Expert Panel recommendations Multiple copies printed on 24” x 36” foam board 61

62. ARS Fact Sheet for Physicians CDC Fact Sheet for Physicians on Acute Radiation Syndrome (ARS) describes the three classic acute radiation syndromes and cutaneous injury Includes tests for estimating radiation dose, and instructions for triage and patient management. Available at CDC Radiation Emergency website 62

63. Treatment for Internal Contaminants Patients involved in a radiological incident may have external contamination, internal contamination, or both. Blocking and decorporation agents may reduce internal uptake of radioactive materials or increase their rate of excretion. Table 2, App 7, of State Expert Panel report 63

64. Treatment for Internal Contaminants 64

65. Radiological Incident FAQ Sheet Patients, family members, and the media have concerns and questions during a radiological incident. FAQ list (App 10 of the State Expert Panel report) was modified for use at Gundersen Lutheran Health System  Revised comply with organizational policies on patient education and staff communication with the media. 65

66. FAQ Examples 66

67. Survey Meter Instruction Card A concise instruction sheet for use of the survey meters was developed based on App 6 to the State Expert Panel report. Laminated and attached to each survey meter. 67

68. Personal Protective Equipment (PPE) Donning Poster Copies printed on 24” x 36” foam board 68

69. ADDITIONAL TOOLS/SUPPLIES 69

70. Radiological Incident Binder Three ring binder containing: Contact info for Radiation Safety Staff Job Action Cards Radiological Incident Plan and Associated Documents Copies kept at: TEC nurse’s station Security office Radiation Safety office 70

71. Equipment Storage Containers Plastic storage containers that could be easily lifted and moved were used to store equipment and PPE right in Decontamination room. 71 Subsequently obtained wheeled storage unit to hold all containers. Easy to move out when Decon Rm needed.

72. TRAINING 72

73. Training Key factors for selecting training materials and methods: cost time required ease of use in an emergency situation (“just in time” training) 73

74. Training Program Selected The 17-minute CDC video Radiological Terrorism: Just- in-Time Training for Hospital Clinicians, was the primary training tool.video Radiological Terrorism: Just- in-Time Training for Hospital Clinicians Intended for medical staff but found to be applicable to non-medical staff too. Feedback indicated video made staff more comfortable with providing care to a contaminated patient and reduced their fear of radiation and radiation effects. 74

75. Training Staff also received training on the specific steps and actions in our Radiological Incident Response Plan. Hands-on training provided to TEC staff in use of radiation survey meters and response if the alarms trigger on the area monitors at the TEC entrances. Annual refresher training and updates done via intranet course and in-person inservices. 75

76. TESTING 76

77. Testing Three exercises were performed to test the Radiological Incident Response Plan. each exercise tested different parts of the plan. drill observer recorded observations and recommendations during exercise drill photographer Post-drill recommendations implemented and retested in next exercise 77

78. Exercise 1: U.S. Army Operation Red Dragon 2009 Operation Red Dragon conducted by U.S. Army Reserve personnel. Focused on the military’s ability to deploy Army Reserve chemical assets in a CBRN response environment in coordination with local community agencies and hospitals. 78

79. Red Dragon Scenario Terrorist group detonates improvised explosive device– shaped charge on a pressurized container aboard a barge near the La Crosse festival site, releasing anhydrous ammonia during a major morning concert and festival. Terrorist group then targets the victims and the emergency responder community by releasing a radiologic agent from a nearby bridge. Potential 28484 exposures, 1208 untreated fatalities, and 1342 total casualties, overwhelming medical and public health authorities and decimating emergency responders. 79

80. Operation Red Dragon 80

81. 81

82. Exercise 2: Radiopharmaceutical courier transportation accident Scenario: A courier vehicle delivering nuclear medicine isotopes to area hospitals plunges over an embankment on the interstate highway. First responders observe the “Caution – Radioactive Materials” signs on crushed and wet packages. Notify TEC they will arrive in 30 min with one non-ambulatory patient with a fractured arm who may be contaminated with radioactive materials. Limited drill. Ended when simulated patient brought into Decontamination Room. 82

83. Radiopharmaceutical courier transportation accident 83

84. 84

85. Exercise 3: 131 I patient Scenario: Patient receives 100 mCi radioactive 131 I for treatment of thyroid carcinoma at another regional hospital. An hour later, while returning home by car she develops a severe headache, nausea, and vomiting. Her husband pulls the car over and calls 9 ‑ 1 ‑ 1. First responders arrive. Patient loses consciousness on the way to the hospital and is taken directly to a treatment room. Police officer from the scene is unaware that he is contaminated with 131 I and triggers the TEC entrance radiation detector. 85

86. I-131 Patient Accident 86

87. 87

88. STAFFING AND WORKLOAD IMPLICATIONS 88

89. Staffing/Workload Implications Staff were used in their existing job roles, and no additional personnel were required for this project. Staff time was required to: develop the plan and associated documents train staff develop and participate in the three exercises 89

90. Staffing/Workload Implications Concise training methods resulted in 1-4 hour training time for each participating TEC staff member including exercises The most significant time burden was that of the facility’s Radiation Safety staff. 80-100 total hrs 90

91. CONCLUSIONS 91

92. Factors for Success A plan champion (the Radiation Safety Officer) and the core group of individuals who took responsibility for developing and implementing the plan were critical to the success of this project. Incorporating use of the ICS provided sufficient flexibility to adapt to any size of radiological emergency 92

93. Factors for Success Combination of video training, hands-on training, and practicing actions in exercises was an effective system of education for individuals with differing learning styles. Clear, concise Job Action Cards received very positive feedback from staff. 93

94. Challenge Limitations in Gundersen Lutheran Health System’s existing decontamination facilities were a challenge. The lesson learned from this challenge is that hazardous materials incident response should be incorporated into planning new construction 94

95. Challenge Conducting exercises was challenging because an ER is busy with real patients. Consulting with emergency center staff to determine the best time to conduct a drill was useful. Conducting limited exercises to test specific parts of the plan was better for ER staff than a 3- 4 hr full drill. 95

96. Conclusions Successfully demonstrated that the Wisconsin State Expert Panel on Radiation Emergencies report entitled The Management of Patients in a Radiological Incident issued in November 2007 provides a flexible template that can be customized to fit the needs of individual healthcare organizations. Cost of implementation was approximately $25,000, not including staff time Readiness for appropriate response to an actual radiological incident was substantially improved. 96

97. FOR FURTHER INFORMATION 97

98. For Further Information Copies of the Radiological Incident Response Plan, Job Action Cards, and associated documents developed for this project an be obtained from: Mary Ellen Jafari, MS, DABR, Radiation Safety Officer Gundersen Lutheran Health System 1900 South Ave. Mail Stop C02-002 La Crosse, WI 54601 mejafari@gundluth.orgmejafari@gundluth.org 608-775-2933 98

99. For Further Information Jafari, ME. Radiological Incident Preparedness for Community Hospitals: A Demonstration Project. Health Phys. 99 (Supplement 2): S123- S135; 2010 99

100. Additional Resources US Dept of Health and Human Services Radiation Emergency and Medical Management website http://www.remm.nlm.gov/index.html Oak Ridge Institute for Science and Education (ORISE) Radiation Emergency Assistance Center/Training Site (REAC/TS) http://orise.orau.gov/reacts/ US Centers for Disease Control and Prevention (CDC) Radiation Emergencies website http://www.bt.cdc.gov/radiation/ 100