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

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) 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

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 full- time 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

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

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

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 non- designated (when satisfactory), suitable waste monitoring and advice. IPEM – Radiation Protection in Nuclear Medicine Study Day – February 2014

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

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

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

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

Location, Identification, Quantification... IPEM Radiation Protection in Nuclear Medicine Study Day– February 2014 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”

Location, Identification, Quantification...(2) IPEM Radiation Protection in Nuclear Medicine Study Day– February 2014 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).

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

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

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

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

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

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