Radiological Incident Preparedness for Community Hospitals: A Demonstration Project

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.

3
Topics

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

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?

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

6
motivation

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

8
Contaminated Patients

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

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 wont
  necessarily know if a radiation hazard exists.

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

11

• INTRODUCTION

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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

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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.

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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.

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Gundersen Lutheran Health System

• Headquartered in
• La Crosse, WI
• Serves patients throughout 19 counties in western
  Wisconsin, northeastern Iowa, and southeastern
  Minnesota

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Trauma Emergency Center (TEC)

• Level II Trauma and Emergency Center serves over
  30,000 patients/yr

18-bed unit staffed by 11 emergency medicine
physicians and 70 nurses, EMTs, paramedics, and
other personnel
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• HAZARD VULNERABILITY ANALYSIS (HVA)

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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

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HVA Results

• location on a major interstate highway
• proximity to a nuclear reactor currently being
  decommissioned
• proximity to U.S. Armys 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.

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• EVALUATION OF EXISTING SPACE AND EQUIPMENT

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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

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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

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Evaluation Activities

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Evaluation Activities

• Frimley Park team met with staff from
• TEC Emergency Medical Services
• Security Radiation Safety
• Safety Telecommunications
• Imaging Infection Control
• Evaluated
• patient flow
• existing Decontamination Room and Equipment
• future needs
• setup/deconstruction of portable Decon Tent

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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

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Decontamination Room
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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

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

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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

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• EQUIPMENT SELECTION AND PURCHASE

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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

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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

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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

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Ludlum Model 357-10

• Wall mounted
• Continuous digital
• readout
• Optional environmental
• box for outdoor use

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Entrance Monitor Installation

• Purchased and installed two monitors (total cost
  4378)

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Avoid Alarming for Normal Patients!

• Didnt 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

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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

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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.

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Radioisotope Identification

• Key features for selecting a radioisotope
  identifier
• accuracy
• rapid response time
• portability
• ease of use

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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

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Berkeley Nucleonics Model 940-2-G SAM Defender

• AC power or AA cell batteries with 6 hr life
• weight 4.5 lbs

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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

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Survey meters

• Key factors for selection of survey meters
• high sensitivity
• ruggedness
• ease of use

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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

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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)

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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

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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

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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

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Initial equipment costs
50
Recurring equipment costs

51

• RESPONSE PLAN

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Plan Development

• Template used was the State Expert Panel on
  Radiation Emergencies report
• Had to customize template for our organizations
  specific management structure and infrastructure

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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

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Initial Core Group Meeting

• Initial Core Group meeting
• define project objectives
• set timeline
• determine roles for Job Action Cards

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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

No need to reinvent the wheel
Photo creativecranes.com
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Job Action Cards

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

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Job Action Cards

• Concise
• Large font
• Brightly colored
• Laminated

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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

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 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

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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

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REAC/TS Patient Treatment Flowchart

• Colorful and easy to read
• Matches State Expert Panel recommendations
• Multiple copies printed on 24 x 36 foam board

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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

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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

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Treatment for Internal Contaminants

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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.

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FAQ Examples

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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.

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Personal Protective Equipment (PPE)Donning Poster

• Copies printed on 24 x 36 foam board

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• ADDITIONAL TOOLS/SUPPLIES

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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 nurses station
• Security office
• Radiation Safety office

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Equipment Storage Containers

• Plastic storage containers that could be easily
  lifted and moved were used to store equipment and
  PPE right in Decontamination room.

Subsequently obtained wheeled storage unit to
hold all containers. Easy to move out when Decon
Rm needed.
72

• TRAINING

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Training

• Key factors for selecting training materials and
  methods
• cost
• time required
• ease of use in an emergency situation (just in
  time training)

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Training Program Selected

• The 17-minute CDC video Radiological Terrorism
  Just-in-Time Training for Hospital Clinicians,
  was the primary training tool.
• 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.

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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.

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• TESTING

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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

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Exercise 1 U.S. Army Operation Red Dragon 2009

• Operation Red Dragon conducted by U.S. Army
  Reserve personnel.
• Focused on the militarys ability to deploy Army
  Reserve chemical assets in a CBRN response
  environment in coordination with local community
  agencies and hospitals.

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Red Dragon Scenario

• Terrorist group detonates improvised explosive
  deviceshaped 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.

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Operation Red Dragon

81

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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.

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Radiopharmaceutical courier transportation
accident

84

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Exercise 3 131I patient

• Scenario Patient receives 100 mCi radioactive
  131I 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 131I and triggers
  the TEC entrance radiation detector.

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I-131 Patient Accident

87

88

• STAFFING AND WORKLOAD IMPLICATIONS

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

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
  facilitys Radiation Safety staff. 80-100 total
  hrs

91

• CONCLUSIONS

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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

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.

94
Challenge

• Limitations in Gundersen Lutheran Health Systems
  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

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

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.
  

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• FOR FURTHER INFORMATION

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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_at_gundluth.org 608-775-2933

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For Further Information

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

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/