SPARTANBURG REGIONAL HEALTHCARE SYSTEM
POLICY STATEMENT
TITLE: Radiological Emergency Management Plan
PURPOSE: The purpose of these procedures is to assure proper handling of medical emergencies that involve contamination of the patient with radioactive materials. In any medical emergency, including those involving radioactive contamination, life-threatening injuries must receive immediate attention; however, in addition to saving life, the primaryobjectives of radiation emergency plan should be the radiation protection of the hospital staff, patients, and visitors and prevention of contamination and damage to the hospital facility
ORIGINATION DATE: / KEYWORDS:Code Gamma , Radiological Emergency, Dirty Bomb
09/14/99
REVISION DATES:
11/04/04 / REVIEW DATES:
11/0/04, 07/12/05
RESPONSIBILITY:Radiation Safety Committee & Safety Division: Emergency Management
PLAN:
-TABLE OF CONTENTS / PageA. / Introduction ...... / 1
1. / Purposel
2. / Definitions ...... / 6
a. External Exposure ...... / 6
b. Internal Exposure ...... / 6
c. External Contamination ...... / 6
B. / Radiation Emergency Alert ...... / 6
1. / Information Collection ...... / 6
2. / Personnel Notification ...... / 7
3. / Radiation Emergency Area Preparation ...... / 7
C. / Radiation Emergency Area (REA)...... / 7
1. / Deflnition ...... :...... / 7
a. Receiving Route ...... / 7
b. Treatment/Decontamination Area ......
~ / 8
c. Control Point ...... / 8
2. / Location of REA ...... / 8
a. Primary REA ...... / 8
(1) Receiving Route ...... / 8
(2) Decon/Treatment Area ...... :..... / 8
(3) Control Point ...... / 8
b. Alternate REA ...... / 8
(1) Receiving Route ...... / 8
(2) Treatment/Decon Area ...... / 8
(3) Control Point ...... / 8
3. / Preparation of REA ...... / 8
4. / REA Regulations ...... / 9
5. / REA Supplies and Equipment ...... ……… / 9
D. / Protective Clothing and Personnel Dosimeters ...... / 10
1. Kinds ...... / 10
2. / Conditions Requiring ...... / 10
3. / Removing Contaminated Clothing ...... / 7
4. / Clearance Procedures ...... / 7
5. / Use of Dosimeters ...... / 8
E. / Patient Decontamination ...... / 8
1. / Patient Decon Procedures ...... / 9
a. Principles ...... / 9
b. Measures taken before decontamination ...... / 10
c. Decontamination Techniques ...... / 11
(1) General...... / 11
(2) Wounds ...... / 12
(3) Body Orifices ...... / 12
(4) Skin ...... / 13
d. Limits of Personnel External Radiation Exposure ...... / 14
F. / Sample Taking ...... / 14
1. General ...... / 14
2. / Principles ...... / 14
3 / Techniques & Indications ...... / 16
a. External Contamination ...... / 16
b. Internal Contamination ...... / 16
c. External Exposure ...... / 16
4. / Reminders ...... / 17
G. / Personnel Responsibilities ...... :...... / 17
1. / ED Charge Nurse ...... / 17
2. / ED Nursing Control Point Officer ...... / 17
3. / REA Nurse ...... / 18
4. / ED Male Attendant ...... / 19
5. / ED Unit Secretary ...... / 19
6. / ED Physician ...... / 19
7. / Nuclear Medicine Technologist ...... / 20
8. / Radiation Safety Officer (RSO) ...... / 20
9. / Radiation Oncology ...... / 21
10 / Radiology (X-Ray Department / 21
11 / Nursing Director (or Assistant / 22
12 / Extreme Medical Emergencies / 22
13 / Switchboard / 24
14 / Security / 24
15 / Maintenance / 25
Housekeeping / 25
EMS/Rescue Personnel / 25
-APPENDIX
I.REA Information Form
II.Notification List
111.Consultation Assistance List
IV.Radiation EmergencyAccident Supplies
V.Decontamination Supply List
Sample taking Supplies
-ATTACHMENTS
A.Location of Radiation Monitoring Equipment
B.Control Point Record of Assigned Personnel Monitors
C.Patient Decontamination Record
D.Emergency Department Map
F. REA Follow-up Report
SUMMARY OF ACTION FOR RADIOACTIVE EMERGENCIES
SPARTANBURG REGIONAL MEDICAL CENTER
Radiation Emergency Plan
Activation of PlanEC Shift Coordinator
NotificationEC Unit Secretary / Switchboard
Preparing REA AreaEC Shift Coordinator will designate
EvaluationREA Nurse
EC Physician / RSO
RSO / Safety Officer
MonitoringRSO / trained designee
Radiology (If RSO is not present)
Sample takingRSO/Nuclear Medicine Physician
EC Physician,
REA Nurse,
Nuclear Medicine Technician
DecontaminationREA Nurse - HERT
Evaluation of Decontamination (repeat)RSO/Nuclear Medicine Physician
Evaluation of Medical StatusEC Physician or designee
Treatment/DischargeEC Physician, RSO, Nuclear Medicine Physician, REA Nurse
Clean-up/Clearing/MonitoringRSO, Nuclear Medicine Physician, Nuclear Medicine Tech., REA Nurse
Third party contractor service as needed
SPARTANBURG REGIONAL MEDICAL CENTER RADIATION EMERGENCY PROCEDURES
1..Definitions -There are three major types of radiation exposure, which may cause injury. These types of radiation exposure may occur together.
a.External Radiation Exposurefrom a source external to the body (x-rays, gamma rays, neutrons):
Expect in extremely rare circumstances, this type of exposure will present no radiation hazard to attending personnel. These patients should be treated as normal emergencies unless instructed otherwise by the Radiation Safety Officer/Nuclear Medicine Physician.
b.Internal Contamination of the surface of the body of contact with transferable radioactive materials.
An individual whose clothing, skin, and/or wounds are contaminated with radioactive material may present a radiation hazard to attending personnel in the absence of adequate procedure to prevent that spread of the contaminant, or control the radiation exposure in the event of radioactive shrapnel wound.
B.RADIATION EMERGENCY ALERT (CODE GAMMA)
When it has been established that a radioactive medical emergency patient is to arrive at the hospital, a radiation Emergency Alert will to into effect. The Radiation Emergency Alert consists of three (3) actions to be taken to prepare the hospital and the staff to handle contaminated emergency patients.
1.Information Collection
2.Personnel Notification
3 .Preparation of Radiation Emergency Area
1.Information Collection(see Appendix 1)
When notification of the radiation emergency is received the following information should be obtained from the individual who is giving the warning:
a.Who is calling
b.Number of patients
c. Type of radiation accident (external exposure, internal exposure,external contamination)
d.Degree of injuries, if known
e.Contamination of injuries, if known
f.Decontamination efforts taken, if any
g.Special equipment required
h.Expected arrival time
I.Type of transportation
2.Personnel Notification (see Appendix II)
Immediately past collecting the necessary information the following should be notified:
a.The EC Shift Coordinator will notify the switchboard by dialing 3333. The EC Unit secretary shall notify the Emergency Manager or the Nursing Supervisor
b.The Emergency Center Physician will activate physician recall as needed.
c.The Emergency Center Unit Secretary will notify the Emergency Manager, Safety Officer, Trauma Coordinator and Director of Emergency Services.
d.The Switchboard will notify the following:(Appendix III)
l. Nuclear Medicine M-F 8am-4:30pm(ext.6166)
After 4:30pm, notify On-Call Nuclear Medicine Tech.
2. SRMC Medical Physicist/RSO
3. Chief of Nuclear Medicine (Physician)
4. Security
5. Environmental Services
6. Facilities
3.Radiation Emergency Area Preparation
If the emergency involves radioactive contamination, a Radiation Emergency Area must be established in which the patient(s) will be treated and decontaminated.
C.RADIATION EMERGENCY AREA (REA)
1 .Definitions -The Radiation Emergency Area (REA) is that portion of the hospital where radioactivity contaminated accident victims will be received, treated, and decontaminated. It incorporates each of the parts listed below.
a.The Receiving Route is that part of the hospital over which the contaminated patient ravels to reach the Treatment/Decontamination Area. It starts with the transport vehicle and includes outside walkways, the hospital entrance, corridors, and elevators used.
b.The Treatment/Decontamination Area is the room(s) earmarked for treating and decontaminating the patient.
c.The Control Point is the sole point at which attending personnel may enter or leave the REA. Any egress from the area will require monitoring as described herein. In the case two (2) Control Points
are established, those entering by one Control Point should exist through the same point to aid in recording monitoring results.
2.Location of Radiation Emergency, (see Attachment E)
a.Primary REA -This area will be used first to care for radiation Emergency patients (capacity 4-5 patients). Ropes
and "Caution - Radioactive Materials" signs will be erected as listed:
(1) to close rear entrance including transport vehicle and transport personnel on Emergency Center EMS entrance.
(2) to close trauma elevator and secure Chest Pain doors nearest the EMS entrance.
(3) secure Radiology room on back EC corridor across from DECON Rooms 21 & 22
(4) secure Pediatric / Urgent Care access
(5) post security at safe distance to secure perimeter
(6) if Operating Room is to be utilized, the charge nurse in the OR will be notified and a room will be assigned.
Receiving Route The radiation emergency patient will be admitted via the Emergency Center Decon room 21 & 22 through the back door into the REA. Treatment and decontamination procedures will be completed as indicated by the patient's condition.
The Treatment/Decontamination Area This will include Decon rooms # 21 & 22 treatment and decontamination area and room assigned by OR charge nurse if surgery is necessary.
The Control Point will be located in the Emergency Department corridor at Room # 16 and the pantry & shower door & CU door (side toward panty).
b. Alternate REA As of 1994 no Alternate REA is available in Surgery.
3.Preparation of REA -The Emergency Centershift coordinator will assign personnel as indicated to prepare area, may utilize Hospital Emergency Response Team (HERT),Environmental Services, Facilities, and security have areas of responsibilities and should be notified promptly of expected radiation emergency patients;
a.Remove any unnecessary supplies, equipment, or obstructions from Radiation Emergency Area
b. Cover floor of REA with brown paper
c. Assemble supplies and equipment in the treatment/decontamination area.
d.Rope off area and post radiation signs.
e.Security shall prohibit unauthorized entrance into the area (entrance allowed only through control point). Security will also clear EMS entrance of unnecessary traffic and direct transporting vehicle to the alternate entrance of the Emergency Center. (EMS/Rescue personnel involved in transporting the patient cannot leave this
area until cleared by the RSO/SO.) Blockades shall be deployed on ramp after entrance of transporting vehicle(s).
f.Appoint a control point officer from Emergency Center staff to secure supplies, make phone calls, etc. The Radiation Safety Officer/Nuclear Medicine Physician, the Nuclear Medicine Technician, or the person designated by them will also be control point technician utilizing equipment to monitor and authorize any entrance and exit from the REA.
g. Prepare for handling patients by donning protective clothing and personal monitors.
4.REA REGULATIONS
a.Only hospital staff directly involved in the treatment/decontamination of the patient(s) are authorized in the REA.
b.All personnel admitted to the REA after a patient has arrived must wear protective clothing and personnel monitor.
c.Entrance into and exit from the REA is through the Control Point only.
d.Anyone leaving the REA must take off the outer layer of protective clothing by monitored and found free of contamination. Transport personnel must also be found free of contamination before being released.
e.No supplies, tools, samples or other articles may leave the REA unless cleared by the Radiation Safety Officer/Nuclear Medicine Physician. (This includes the transportation vehicle(s). EKG, x-ray machines, etc.).
f. Patients may leave the REA only on a clean stretcher transported over fresh protective floor covering and only after both patient and stretcher have been monitored and found to be free of contamination.
g. REA may be re-opened only by the Radiation Safety Officer/Nuclear Medicine Physician following decontamination and clearance survey.
h.Decontamination and/or disposal of contaminated articles will be conducted under the direction of the Radiation Safety Officer/Nuclear Medicine Physician.
5.REA Supplies and Equipment
The supplies and equipment needed to handle a radiation emergency will be kept in the EP locker in EMS vestibule. (A list of the supplies and equipment is given in Appendix IV & V.) Following use, the list should be consulted for replenishment.
D.PROTECTIVE CLOTHING AND PERSONNEL DOSIMETERS
Protective clothing is issued at the Control Point to prevent personnel from becoming contaminated with radioactive material.
1.Kinds of Protective Clothing
a.Standard Protective Clothing -consists of the same items normally used by surgeons in the Operating Room, i.e., a scrub suit, surgical gown, latex gloves, a surgical mask, cap and regular Operating Room shoe covers. (Located Room # 21 - accessible by key.)
b.Full Protective Clothing -consists of coveralls, a hood, vinyl footwear or shoe protectors, rubber gloves and respirator ("half-mask").
2.Conditions Requiring Protective Clothing
a.All work within the REA requires protective clothing, independent of the degree of contamination present on the patient or his clothing.
Standard protective clothing will suffice in all cases where gross decontamination has been performed (i.e., when very little loose contamination is present), or where the contamination is confined to a relatively small area.
Without specific instruction to the contrary standard protective clothing may be assumed to suffice. When the Radiation Safety Officer/Nuclear Medicine Physician Judges the use of full protective clothing necessary, mask and gown will be removed, coveralls put on over the scrub suit and hood, respirator, rubber gloves, and shoe protectors donned to replace the items removed.
(2)Full protective clothing is only necessary when the patient has a relatively large amount of removable contamination on body and clothing.
For complete protection taping of full protective clothing around the hood, at the writs, ankles, and back of gown should be carried out. (For this purpose tape is available.) If necessary for the shower the patient, staff members caring for the patient must be in full protective clothing.
Contaminated Protective Clothing
a. On completion of their activities in the treatment/Decontamination Room(s), personnel will take off their layer of protective clothing in the following order.
1. Remove tape and hood, if any
2. Remove gown or coveralls, turning them inside out
3. Remove shoe covers one at a time, stepping out of the contaminated area with the uncovered shoe.
4. Remove gloves, mask and cap
5. Disposable garments go into plastic trash container and non-disposable into plastic laundry bag located with the REA.
b. After removal of the outer layer personnel will proceed to the Conntrol Point, have their dosimeters removed and be monitored for any contamination.
Clearance Procedures
a.In case no contamination is found personnel may put on their normal clothing. After a final check at the Control Point, they will be cleared to enter the uncontrolled hospital area.
b.In case persons are found to be contaminated, they will take a shower, be monitored again and, if free from contamination, be supplied with disposable garments, and proceed as describe above.
5.Use of Dosimeters
a.Dosimeters will be available at the Control Point to all personnel entering the Radiation Emergency Area and assigned as needed by the Radiation Safety Officer/Nuclear Medicine Physician.
b.Dosimeters are of three (e) types:
Direct reading dosimeters ("pen-dosimeters"), which are supplied to all personnel.
(2)Badge dosimeters which may be supplied to specific personnel.
Ring dosimeters, which are only supplied to surgeons (and their assistant, if any) in case they have to remove highly radioactive foreign bodies.
c.Dosimeters are to be worn:
(1)above the sternum,clipped to the scrub suit (pen and badge dosimeters), i.e., under the outer layer of the protective clothing.
(2) on the ring finger of the right hand (or the left hand, if surgeon/assistant is left-handed) under the glove (ring dosimeters).
d.Upon leaving the Radiation Emergency Area the wearer should surrender his/her dosimeters to the Control Point attendant, who will record the assignment of dosimeters as well as pen dosimeter readings according to the form contained in Attachment B. The pen dosimeters may be re-issued if not contaminated. Film and ring monitors will be retained in a low-background radiation area for later processing.
E.PATIENT DECONTAMINATION
1.General -These procedures cover general patient decontamination procedures and supplies. The supply list identifies all items necessary for proper decontamination of radioactivity contaminated patient.
2.Patient Decontamination Procedures
a. Principles
The objectives of decontamination are:
(a)to prevent injury caused by the presence of radioactive substances on the body.
(b)to prevent the spread of contamination over and into the patient.
(c)to protect attending personnel from becoming contaminated themselves or (in extreme cases) from being exposed to a source of radiation.
(2)Although decontamination should be started as soon as possible primary attention should be given to the alleviation of life-threatening conditions created by traumatic injury.
Decontamination is essentially the physical removal of radioactive dirt from the skin, wounds or body orifices. Most decontaminates contain detergents or other chemical agents to facilitate this removal. Therefore, most decontaminates are suitable for decontamination of the intact skin only and are not appropriate for wound cleansing or irrigation of body orifices.
(4)Decontamination is performed:
(a)From the highest level of contamination to the lowest
(b)Starting with the simplest procedure (e. g., soap and water) to more complicated procedures.
(c)With due regard to contamination of wounds body orifices, etc. (see below for specific guidelines).
(5) Usually the effect of decontamination is greatest in the earliest stages, i.e., most of the radioactive material is removed during the first decontamination effort. Continued decontamination may show diminishing effectiveness. At some point, a decision has to be made to either accept some residual contamination, or proceed with the use of more potent decontaminate (more specific guidelines below).
b.Measures to be taken before decontamination
(1)Assuming the gross decontamination has been performed at the site of the accident it can be expected that the residual contamination is minor and/or that serious contamination is
minor e.g., around and in a wound. Before decontamination the following steps should be taken:
(a)Judge whether the patient's condition requires immediate intervention; if so, proceed, covering the contaminated area with a plastic drape or a towel;
(b)obtain a briefing as to the contamination status of the patient, and as to the specific measures to be taken by attending personnel with regard to their protection. if it was an industrial accident the plant health physicist is an excellent source.
(c)monitor the patient with the radiation survey instrument:
Hold the probe about 2 inches from the patient, taking care not to touch. the patient with the probe thus contaminating it and rendering it useless.
Scan the entire body, marking the areas of contamination and recording the finding on the Patient Decontamination Record Sheet. (attachment C)
(iii)Decide in which order skin decontamination shall be performed (starting with the highest contaminated area).
(d)Inspect wounds and decide whether further wound decontamination or treatment can safely be postponed until completion of skin decontamination.
(e)Make a decision as to whether certain samples should be taken (see Procedures for Sample Taking for further details).
(2)In case on decontamination has been performed (most likely because of an urgent need for emergency surgical treatment):