Patients sent to other hospitals following the administration of therapeutic radioiodine - practical experiences from the Mersey Region.

1. Patients Sent to Other Hospitals
Following the Administration of
Therapeutic Radioiodine
Practical Experiences from the Mersey
Region
Matt Ward, Integrated Radiological
Services, Liverpool.
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

2. Overview (1) – Administering Site
• City Centre Hospital - Specialist Centre for I-131 therapies.
• Large NM departmental team with dedicated RPA services
attending several times per week (mainly supporting high dose
ablations).
• 350-450 non-carcinoma patients/yr treated as outpatients, 1-2/yr
as inpatients.
• Of these non-carcinoma outpatients, about one every 1-3 years is
notified as returning to another hospital following administration
(pre-existing condition/care).
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

3. Overview (2) - Receiving Hospital
• Large DGH approximately 20 miles
from Liverpool.
• Approx. 500 beds.
• Work with IR includes main, A&E,
cardio and specials x-ray, one fulltime gamma camera, on-site
radiopharmacy.
• EPR2010 permitted site.
• 2-3 RPS appointments for each
modality.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

4. A Routine Case....
• Receiving hospital RPS in DGH Gamma Camera
notified of patient returning to site. The
patient was already under the care of, and
referred from, the DGH in question.
• Patient had all NM treatments at city centre
site (I-131 specialist) so did not attend DGH
NM dept., but returned to a ward at the DGH
some distance from nearest RPS/Dept.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

5. A Routine Case....(2)
• Nurses on Ward at DGH received telephone and
written instructions from Physics MPE/RPS.
Good follow-up in terms of after care and
acknowledgement between these services.
• Standard “RP” pack issued to nursing team –
includes dosimeters, controlled area warning
signs, local rules, essential MPE, RP and RW
contact details.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

6. A Routine Case....(3)
• Frequent RPA-MPE contact on city centre site
and designated weekly contamination
monitoring team ensures that surveys can
quickly be adjusted in line with patient
numbers.
• Service includes declaring areas nondesignated (when satisfactory), suitable waste
monitoring and advice.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

7. And then suddenly...
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

8. A Not-so-Routine Case....
• Message
from
waste
contractor to Trust: Receipt
of active waste.
• No consignment details.
• Caught by site checks prior
to incineration.
• Contractor’s own RWA
estimated 17+ GBq I-131.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

9. A Not-so-Routine Case (2)
• Initial message from Trust waste services relayed
to administering site MPE.
• The MPE then notified the EA, IRS as RPA/RWA,
Nuclear Medicine RPS as a matter of urgency.
• RPS – Gamma Camera waste store (small) was
reviewed – everything there was logged (Tc-99m
sharps, small volumes), no record of additional
material being generated nor disposed of.
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

10. A Not-so-Routine Case (3)
• ID checks on the waste containers (4) confirmed
traceability to the I-131 patient ward.
• Review of CRIS showed patient administration
details (740 MBq).
• Where did the 17 GBq value come from?
• Time to visit the incinerator...
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

11. Location, Identification,
Quantification...
Trust FM staff “Is
this a public health
incident? “
Waste contractor staff “We
want to move this waste, it’s
way past our own permit
conditions”
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

12. Location, Identification,
Quantification...(2)
•
Waste contractor’s measurements involved crude
site monitoring (first level alert, Mini 900 series
monitor).
•
This was followed by their own RWA employing
spectral analysis and additional count rate data.
•
IRS Mini 900, Mini Rad 1000 and SmartIon measurements undertaken at various distances &
geometries.
•
For similar instruments - Count rates were in
reasonable agreement.
•
Corrections for count rate-activity and dose rate
to activity showed total waste activity did not
exceed 50% of administered total (best estimate,
some 170 MBq across four containers).
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

13. Activity Estimates
Estimated I-131 Activity (MBq)
Waste Site Activity Estimates
Date/Time (Days)
IPEM Radiation Protection in Nuclear
Medicine Study Day – February 2014

14. Next...
• Waste contractor was now happy to complete
their processing – production of retrospective
consignment note from DGH and continued
decay storage agreed.
• Quantification allowed dose estimates to be
generated for staff handling the waste at
every point from DGH to incinerator – no
IRR99 (public) limits breached.
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

15. EA Response
• EA Inspector arranged a site visit to the DGH.
Heads of Risk & Safety, Facilities Management,
RPS, RWA and Radiology present.
• DGH permit was reviewed in the context of this
incident - not just from the tabulated activity
values, waste transfer conditions, but an explicit
review of expectations of The Employer (and
therefore lines of management).
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

16. EA Response
• Commitment to improve given from Trust
management.
• Openness and suitably thorough investigation
recognised.
• Decision to report with observations and
recommendations, not to fine or prosecute.
IPEM Radiation Protection in Nuclear
Medicine Study Day– February 2014

17. Improvements
• Suitability of patient to return? Referrer, Practitioner, MPE
and RPA/RWA – An MDT approach, built in to the workflow.
• Suitability of facilities – RPA to verify and advise directly –
often easy for clinicians and nursing services to say
“yes....(probably)” or before final ward has been confirmed.
• RP vigilance & tighter processes – the DGH is an infrequent
host. However, this means that day 0, 1, 3, 5 visits are
manageable (and required). RP awareness not “routine”
for non-specialists.
IPEM – Radiation Protection in Nuclear
Medicine Study Day – February 2014

18. Contributing Factors – The Real World
• Changing patient condition.
• Nursing shift patterns.
• Annual leave.
• Late changes of final ward location at DGH.
• Warm weather – concerns re: hygiene, patient, staff
and public comfort – a keenness to maintain a clean
environment.
IPEM Radiation Protection in Nuclear
Medicine Study Day – February 2014