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Hospital Activities


Activate Hospital Incident Command System and the Pre-arranged Response Plan


  • Hospital Incident Command System should be activated
  • Teams should practice regularly in coordination with other regional medical facilities, and civilian authorities such as fire and rescue, police, Hazmat, city and county executives and health departments.

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Develop a Hospital Medical Response Team 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]


Radiological Emergency Medical Response Team Members

Role Responsibilities
Radiation safety officer
  • Primary individual responsible for radiologic monitoring
  • Assists emergency department and triage staff in determination of the classification of victims
  • Provides guidance and preparation of decontamination space
  • Directs and conducts survey, monitoring, and decontamination
  • Estimates risk by measurement of dose rate,
  • Documents and records all measurements
  • Conveys information of dose and risk to medical caregivers
  • Directs collection of blood and other biologic samples that might be required
  • Considers obtaining informed consent before allowing ED staff to work in high or very high dose rate areas
  • Directs monitoring radiation doses of patients and response personnel (issuing badges to all workers in moderate to high dose rate areas)
  • Assesses contamination of areas used in the administration of care to patients
  • Reports of level of risk to clinicians and medical caregivers
  • Considers reclassifying dose rate each hour and rotating staff if indicated
Emergency department personnel: physicians/nurses
  • Primary individuals responsible for the care of the patient is the emergency department medical director or, if unavailable, the emergency department physician assigned to trauma cases.
  • Physician is responsible for assuring that medical and surgical care is administered in a timely and effective manner.
  • Nurse is usually the primary individual responsible for initial activation of the radiation event hospital protocol is usually the emergency department nurse supervisor.
  • Nurse supervisor is responsible for assuring that the various aspects of the pre-approved radiation event protocol are properly implemented.
Nuclear medicine personnel
  • Assists the Radiation Safety Staff in the collection, storage, and analysis of samples, provide assistance and routine monitoring of personnel and equipment in the decontamination area
  • Assists in the analysis of area and personnel contamination wipe tests, provide assistance in the monitoring of emergency transportation vehicles, and perform other duties related to radiation safety and protection, as directed by the radiation safety officer.
Hospital safety/security coordinator
(Administrator on call)
  • Oversees the security operation to restrict unauthorized personnel from entering the hospital radiation decontamination area or other critical areas of the hospital,
  • Notifies state or federal officials if the situation requires assistance in excess of the hospital’s capacity
  • Assigns adequate personnel at the entrance of the hospital to restrict entry to the hospital to only those persons that are required for either operation of the hospital or implementation of the radiation disaster protocol
  • Directs incoming ambulances to the proper hospital entrance as directed by the emergency department physician, radiation safety officer, or designees
  • Secures the emergency medical services vehicle and prevents removal from hospital grounds until cleared by radiation safety staff, and reserves designated routes as needed.
Nursing staff
  • Provides staffing in the emergency department, operating room, and elsewhere in the hospital
  • Assists in decontamination, treatment, and psychological support of victims under the direction of radiation safety staff, emergency department staff, and hospital staff
Physician and Allied Health specialists with relevant expertise who must be part of the response teams
  • Radiation Oncologists
  • Medical Oncologists/Hematologists
  • Pediatric Oncologists
  • Psychiatrists
  • Blood Bank personnel
  • Psychologists
  • Social Workers
  • Trauma and Burn Care
  • Pulmonary
  • Toxicology
  • Pharmacy
Engineering/ housekeeping staff
  • Organizes and sets up decontamination area
  • Provide plastic-lined waste containers and other supplies as needed in the emergency department for decontamination, with assistance from operating room personnel, radiation oncology personnel, and laboratory personnel will assist as indicated, following the radiation protocol and direction of radiation safety staff
  • Will remove nonessential items of furniture from the decontamination area before arrival of the accident victims. They will participate in space clean-up as directed by radiation safety staff.
Public Information Officer
  • Releases approved incident information to the public, media
Security
  • Secures hospital grounds, perimeter, ED access, contaminated and uncontaminated areas of the ED, and hospital including Radiology, OR etc.

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Equip an Emergency Department for Decontamination 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]

  • Special equipment used for the care of contaminated patients beyond the scope of the usual emergency department inventory should be kept in a storage area (i.e., cabinet) marked "Hazardous Materials Equipment."
  • Adequate supplies should be stored to manage a "large disaster", with sufficient supplies to protect and assist all the personnel who are expected to participate.
  • This area should be located within close proximity of the emergency department.
  • The key for entering this area should be held in a secure location. An inventory list should be placed inside the cabinet. The appropriate staff person in the ED and the radiation safety team should know where this is.
  • All monitoring equipment and radiation signs should be inspected and inventoried annually.

Suggested Supply List for Decontamination of Victims in the Emergency Department

Category Supplies
Clothing Complete protective clothing for each member of the decontamination team:
  • Tyvek® coveralls
  • Surgical gloves
  • Shoe coverings
  • Surgical masks
  • Surgical caps
Detection equipment
  • Personnel dosimeters (pocket ionization type)
  • Thermoluminiscent dosimeters
  • Film badges
  • Geiger-Mueller meters (2) - Ludlum Model #5 with pancake probe (stored in nuclear medicine department)
Decontamination equipment
  • Cotton applicators
  • Large plastic bags (collection of clothes)
  • Adhesive tape and labels
  • Large towels
  • Soft scrub brushes
  • Plastic sheets
  • General cleansing agents: chlorine bleach, radiac wash (not to be used for patient decontamination), soap
  • Radiation warning signs
  • Copy of radiation accident standard protocol
  • Assorted pens
  • Specimen bottles (with and without heparin and ethylenediamine tetraacetic acid)
  • Kitty litter
  • Emesis basins
  • Fifty (50) feet of rope
  • Plastic tarpaulin or other plastic coverings for the floor

See also: Patient Decontamination: Recommendations for Hospitals (PDF - 124 K) (The Hospital and Healthcare System Disaster Interest Group and the California Emergency Medical Services Authority, July 2005, EMSA #233, Radiological Contamination, pages 11-16)

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Hospital Approach to Patients Presenting after a Nuclear Detonation


Hospital Approach to Patients Presenting after a Nuclear Detonation (Algorithm)

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Techniques of Contamination Control 1,2


The Goals of Contamination Control are to Prevent the Spread of Radioactive Materials from

  • The patient: In most circumstances the victim will be the source of the contamination; however, in rescue and extrication, some contamination may have been transferred to others.
  • The rescue personnel
  • The gurney and equipment used in patient care (stethoscope, BP cuff, etc.)
  • The ambulance

This contamination can be transferred to:

  • Care providers as they touch or move the patient to correct the medical problem
  • The equipment used to assess the patient's condition and to treat the medical emergency
  • The surrounding area (treatment gurney, floor, etc.)
  • In rare cases where dust or powders are present, the air could contain radioactive particles

Preparing the Treatment Area for Contamination Control

  • If possible, select a treatment room near an outside entrance. Clear the area of visitors and patients. Remove or cover equipment that will not be needed during emergency care of the radiation accident victim.
  • Several large plastic-lined waste containers will be needed. The treatment table should be covered with several layers of waterproof, disposable sheeting. Plastic bags in all sizes will be needed and should be readily available.
  • Survey instruments should be checked and ready for use before the patient arrives. Background radiation levels should be documented.
  • The treatment team should be prepared to meet the patient at the ambulance where the patient can be transferred to the prepared treatment gurney.

Covering Floor Areas

  • Rolls of brown wrapping paper or butcher paper three to four feet wide can be unrolled to make a path from the ambulance entrance to the decontamination room. Ordinary cloth sheets or square absorbent pads can be used if paper is unavailable. Whatever the floor covering, it should be taped securely to the floor. This route should then be roped off and marked to prevent unauthorized entry. The floor of the decontamination room or treatment area should be covered in a similar way if time allows. This will make cleanup of the area easier.
  • A control line should be established at the entrance to the decontamination room. A wide strip of tape on the floor at the entrance to the room should be marked clearly to differentiate the controlled (contaminated) from the non-controlled (uncontaminated) side.

Control Ventilation

  • While it may be desirable that the room, or rooms, have either a ventilation system that is separate from the rest of the hospital or a means of preventing the unfiltered exhaust air of the radiation emergency area from mixing with the air that is distributed to the rest of the hospital, there is very little likelihood that contaminants will become suspended in air and enter the ventilation system. Hence, no special precautions are advised. (Ref.: AMA. A Guide to the Hospital Management of Injuries Arising from Exposure to or Involving Ionizing Radiation. 1984).

Techniques of Contamination Control

  • Set up a controlled area large enough to hold the anticipated number of victims.
  • Prevent tracking of contaminants by covering floor areas and monitoring at exits of controlled areas.
  • Restrict access to the controlled area.
  • Monitoring anyone or anything leaving the controlled area.
  • Use strict isolation precautions, including protective clothing and double bagging.
  • Use a buffer zone or secondary control line for added security.
  • Control waste by using large, plastic-lined containers for clothing, linens, dressings, etc.
  • Control ventilation.
  • Change instruments, outer gloves, drapes, etc., when they become contaminated.
  • Use waterproof materials to limit the spread of contaminated liquids; for example, waterproof aperture drapes.

If Radioactive Contamination Is Discovered After Patient Has Been Admitted

  • Continue attending to the patient's medical needs.
  • Secure entire area where victim and attending staff have been.
  • Do not allow anyone or anything to leave area until cleared by the radiation safety officer.
  • Establish control lines, and prevent the spread of contamination.
  • Completely assess patient's radiological status.
  • Personnel should remove contaminated clothing before exiting area; they should be surveyed, shower, dress in clean clothing, and be resurveyed before leaving area.

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Operating Room Safety Guidelines 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]

  • A victim of a radiation accident who requires either emergency surgery or surgery at a later date who has been exposed only to external radiation but no contamination requires no special care in the operating room.
  • For those accident victims who require emergency surgery and who might be externally or internally contaminated with radioactive materials, the staff of the operating room should take the following precautions to minimize the spread of contamination.
  • A conventional operating room can be used, provided that there is adequate room to accommodate additional personnel along with the standard operating room staff.
  • Everything within the operating room (i.e., operating table, smaller tables, and floor) should be covered with disposable plastic coverings.
  • Routine antisepsis measures ensure adequate protection of the operating room staff against contamination.
  • Unless otherwise instructed by the radiation safety officer (RSO), there is no danger of contamination to the anesthesia and breathing equipment. Other items (i.e., surgical equipment and instruments, and gloves) should be frequently changed to avoid the spread of contamination. An adequate supply of surgical equipment should be present (i.e., triplicate).
  • Equipment should be monitored, surveyed, and wipe-tested by the RSO or his/her designee after use. Contaminated items will be placed in a container and stored in the nuclear medicine department. Areas of gross bodily contamination will be delineated and, if possible, covered with a plastic covering before surgery.
  • If an area of bodily contamination is to be surgically incised, it should be washed with normal saline, Betadine, and/or hydrogen peroxide (according to preference of attending surgeon). For persistent contamination, consultation with the RSO might be appropriate regarding the use of diethylenetriaminepentaacetic acid (DTPA) (1 ampule of DTPA per 100 mL of water) or other chelating agent.
  • Contaminated tissue removed from the victim should be placed in an appropriately labeled container and stored in the nuclear medicine department or other area of the hospital designated to be appropriate for storage of radioactive waste. The RSO should be notified of the location and type of stored tissue.
  • Upon completion of the surgical procedure, the RSO or his/her designee will survey and wipe-test the remaining surgical equipment, surgical garb, and the plastic coverings of the operating room floor to ascertain contamination. Any items that are found to be contaminated will be placed in a container and transported to the nuclear medicine department for storage until adequately decayed. All personnel should be monitored with a standard Geiger-Mueller meter before exiting the operating room suite.

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Imaging Suite Safety Guidelines 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]

  • After all clothing has been removed and gross decontamination has occurred, the patient can be X-rayed .
  • If the patient is sufficiently decontaminated to be removed from the decontamination area, radiographic procedures can be performed within the emergency department or radiology department.
  • If the treating physician believes that moving the patient from the decontamination area is unsafe, radiography can be performed with use of a portable X-ray unit.
  • If the patient's condition warrants, radiographic procedures can be performed before complete decontamination.

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Security Planning 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]

  • It is imperative that the decontamination area be kept physically isolated from the remainder of the hospital.
  • Entry into and exit from this area must be restricted, and it must be assured that no contamination is transferred from this area to the remainder of the hospital.
  • Appropriately trained security officers must be present in sufficient numbers to control the perimeter of the hospital, the entrance to the ED or the hospital's external decontamination area, access and egress from any contaminated areas within the hospital, any treatment areas, the admission areas, the x-ray suite, the OR, the morgue, if contaminated personnel are there.
  • Before entry into any potentially contaminated areas, personnel must don the appropriate protective clothing and wear personnel radiation monitoring devices.
  • Upon exit from the decontamination area, the protective clothing must be removed and considered contaminated. It shall be placed in a plastic-lined trash container for subsequent disposal or decay.
  • In addition, all personnel must survey their hands, feet, and clothing before leaving the decontamination area with a survey meter, ensuring that they are not contaminated.

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After a Radiation Event: Managing Contaminated Areas, Personnel, and Equipment 1


Adapted from Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]

  • Before leaving the decontamination area or after completion of handling and decontamination of victims of a radiation accident, all personnel of the medical triage team and equipment used will be surveyed by radiation staff.
  • At the end of the event or work shift, personal monitoring devices will be provided to the radiation safety officer for processing.
  • The victims must also be surveyed by the radiation safety officer or designee.
  • If precise dosimetry is not immediately available, radiation safety staff will estimate patient and staff dosimetry.
  • The radiation safety officer and security personnel will determine the best route to be used in transporting patients who might not be fully decontaminated to various treatment areas of the hospital.
  • The decontamination space and other spaces in contact with contaminated victims will be surveyed and wipe-tested for contamination and decontaminated as needed.
  • Radiation safety staff will direct decontamination of emergency transport vehicles, operating room, and elevators as needed.
  • Hospitalized victims with persistent contamination will be surveyed daily and assessed for potential spread of contamination.
  • Bed linen, bedclothes, and supplies will be bagged and surveyed.
  • Personnel radiation monitoring devices carried by members of the team will be collected and analyzed.
  • The radiation safety staff will identify these monitors and record exposures as available.
  • All contaminated items will be bagged, labeled, and stored in the appropriate storage area under the direction of the radiation safety staff.
  • No person or equipment shall be allowed to exit from the decontamination area without appropriate monitoring.

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Crisis Standards of Care

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References


  1. Dainiak N et al. Development of a statewide hospital plan for radiologic emergencies. Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):16-24. [PubMed Citation]
  2. Managing Radiation Emergencies: Hospital Emergency Care (REAC/TS)
  3. Training of Hospital Staff to Respond to a Mass Casualty Incident (Evidence Report/Technical Assessment Number 95, AHRQ Publication No. 04-E015-2, July 2004)
  4. Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism (NCRP Commentary No. 19), National Council on Radiation Protection and Measurements, Bethesda, MD, December 2005. Purchase required; see Free Overview (PDF - 219 KB).
  5. Becker, S.M. Emergency Communication and Information Issues in Terrorism Events Involving Radioactive Materials (PDF - 89 KB). Biosecurity and Bioterrorism. 2004;2(3): 195-207.[PubMed Citation]
  6. Patient Decontamination: Recommendations for Hospitals (PDF - 124 K) (The Hospital and Healthcare System Disaster Interest Group and the California Emergency Medical Services Authority, July 2005, EMSA #233, Radiological Contamination, pages 11-16)
  7. Bushberg JT, Miller KL. Hospital Responses to Radiation Casualties (PDF - 141 KB) (Health Physics Society, 2004)
  8. Bushberg JT, Kroger LA, Hartman MB, Leidholdt EM Jr, Miller KL, Derlet R, Wraa C. Nuclear/radiological terrorism: Emergency department management of radiation casualties. J Emerg Med. 2007 Jan;32(1):71-85. [PubMed Citation]
  9. Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident (PDF - 527 KB) (HHS/CDC, December 2003)
  10. Radiological Attack — Radiological Dispersal Devices (PDF - 127 KB) (The California Emergency Medical Services Authority)
 

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