Radiation Incident Addendum
This module was developed by the Johns Hopkins Evidence-based
Practice Center under Contract No. 290-02-0018 from the Agency for Healthcare
Research and Quality, Rockville, MD. The content of this module is intended
to provide guidance for hospital disaster drill evaluation and should not be
construed as representing standards of care or recommendations on how to respond
to specific types of disasters. No statement in this module should be construed
as an official position of the Agency for Healthcare Research and Quality or
of the U.S. Department of Health and Human Services.
Instructions: Attach to Incident Command, Decontamination, Triage, and Treatment Zone Modules for radiation drills.
Note: Circle
or check (_) as indicated. Y = Yes; N = No; U = Unclear;
NA = Not applicable
Observer: ______________________________________________________________ Date: ____/____/____
Observer title: ___________________________________________________________
Zone: __________________________________________________________________
Hospital: _______________________________________________________________
Period of time of evaluation: _____________ AM / PM (Circle one)
to _____________ AM / PM (Circle one)
|
Time Points
| Event |
Time |
RA1. Time that this zone became aware
that radiation-exposed victims were involved: (Circle one) |
AM / PM / U |
Comments (if comment refers to a specific item, give the item number):
|
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Information Flow
| Question |
Response |
RA2. How did this zone become
aware that radiation-exposed victims were involved? (Check all that apply) |
a. [ ] Informed by fire department
b. [ ] Informed by incident command center
c. [ ] Onsite alarm
d. [ ] Other (specify):
________________________________ |
RA3. Was the incident commander informed
that a radiation exposure was present? |
Y / N / U |
RA4. How was the incident
commander notified? (Check all that apply)
|
a. [ ] FAX sent
b. [ ] E-mail sent
c. [ ] Person-to-person contact
d. [ ] Telephone message
e. [ ] Unclear
f. [ ] NA
g. [ ] Other (specify):
________________________________ |
RA5. If the incident commander
was informed of a radiation exposure, how long after the radiation exposure
was suspected did notification occur? (Check one)
|
O < 30 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O Unclear |
| O NA |
RA6. Was the radiation safety officer
or designee informed that a radiation exposure was present? |
Y / N / U |
RA7. How was the radiation
safety officer or designee notified?(Check all that apply) |
a. [ ] FAX sent
b. [ ] E-mail sent
c. [ ] Person-to-person contact
d. [ ] Telephone message
e. [ ] Unclear
f. [ ] NA
g. [ ] Other (specify):
________________________________ |
RA8. If the radiation safety
officer or designee was contacted, how long after the radiation exposure
was suspected did notification occur? (Check one)
|
O < 30 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O Unclear |
| O NA |
RA9. Did the radiation safety
officer or designee provide an assessment of risk associated with the exposure?
|
Y / N / U / NA |
Items RA10-RA19 are intended for the Incident Command Zone observer only. Observers
in other zones should skip to item RA20.
| Question |
Response |
| RA10. Was the radiation safety
officer or designee informed that a radiation exposure was present? |
Y / N / U |
RA11. How was the local and/or
State health department notified? (Check all that apply) |
a. [ ] FAX sent
b. [ ] E-mail sent
c. [ ] Person-to-person contact
d. [ ] Telephone message
e. [ ] Unclear
f. [ ] NA
g. [ ] Other (specify):
________________________________ |
RA12. If the local and/or
State health department was informed, how long after the radiation exposure
was suspected did notification occur? (Check one)
|
O < 30 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O Unclear |
| O NA |
RA13. Was a hazardous materials
(HAZMAT) official informed that a radiation exposure was present? |
Y / N / U |
RA14. How was the HAZMAT official
notified? (Check all that apply) |
a. [ ] FAX sent
b. [ ] E-mail sent
c. [ ] Person-to-person contact
d. [ ] Telephone message
e. [ ] Unclear
f. [ ] NA
g. [ ] Other (specify):
________________________________ |
RA15. If a HAZMAT official
was informed, how long after the radiation exposure was suspected did notification
occur? (Check one) |
O < 30 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O Unclear |
| O NA |
RA16. Was occupational health
informed that a radiation exposure was present? |
Y / N / U |
RA17. How was occupational
health notified? (Check all that apply) |
a. [ ] FAX sent
b. [ ] E-mail sent
c. [ ] Person-to-person contact
d. [ ] Telephone message
e. [ ] Unclear
f. [ ] NA
g. [ ] Other (specify):
________________________________ |
RA18. If occupational health
was informed, how long after the radiation exposure was suspected did notification
occur? (Check one) |
O < 30 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O Unclear |
| O NA |
RA19. Were municipal wastewater
treatment officials notified? |
Y / N / U |
Comments (if comment refers to a specific item, give the item number):
|
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Materials and Supplies
| Question |
Response |
RA20. If prophylaxis for the
given agent was needed, was it available? |
Y / N / U / NA |
| RA21. Were specialized cleaning
supplies available for contaminated equipment? |
Y / N / U / NA |
Comments (if comment refers to a specific item, give the item number):
|
If using RADIATION INCIDENT ADDENDUM in the INCIDENT COMMAND
ZONE, STOP HERE, do not complete the rest of module.
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Zone Description
| Question |
Response |
RA22. Was the radiation decontamination
zone separate from the triage zone? |
Y / N / U |
| RA23. Was the radiation decontamination
zone separate from the treatment area? |
Y / N / U |
RA24-26. Was the integrity of the boundaries of the following zones
assessed by the use of radiation detectors? |
RA24. Radiation Decontamination |
Y / N / U / NA |
| RA25. Triage |
Y / N / U / NA |
| RA26. Treatment |
Y / N / U / NA |
RA27. Within the radiation
decontamination zone, were the areas designated as: (Check all that apply) |
a. [ ] Hot versus cold
b. [ ] Hot versus warm versus cold
c. [ ] No designations
d. [ ] Other (specify):
_________________________________ |
RA28. Was the decontamination
for radiation exposure performed within hot, warm, or cold areas? (Check all that apply) | a. [ ] Hot
b. [ ] Warm
c. [ ] Cold
d. [ ] Unclear
e. [ ] NA
f. [ ] Other (specify):
________________________________ |
Comments (if comment refers to a specific item, give the item number):
|
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Safety: Isolation Precautions
| Question |
Response |
Were the following available? |
| RA29. Dosimeters |
Y / N / U |
| RA30. Floor covering |
Y / N / U |
| RA31. Radiation signs |
Y / N / U |
| RA32. Radiation survey meters |
Y / N / U |
| RA33. Striped tape |
Y / N / U |
RA34. Radioactive and mixed
waste (Bio/Rad) disposal containers |
Y / N / U |
| RA35. Other (specify): _______________________________________ |
Y / N / U |
RA36. Did health care workers sign in and
out of the decontamination zone? |
Y / N / U |
RA37. Were entry and exit
times entered? (Check all that apply) |
a. [ ] Entry times entered
b. [ ] Exit times entered
c. [ ] No times entered
d. [ ] Unclear |
RA38. Were the records of entry and/or
exit times given to the radiation safety officer? |
Y / N / U |
| RA39. Were breaches in precautions observed?
(If breaches in precautions were observed, specify in comment box at end
of this section.) |
Y / N / U |
RA40. Were lists of exposed and nonexposed
victims generated? |
Y / N / U / NA |
RA41. Did the institutional safety officer
arrive in this zone to assess the activity? |
Y / N / U / NA |
Comments (if comment refers to a specific item, give the item number):
|
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Safety: Personal Protective Equipment (PPE)
| Question |
Response |
RA42. Was PPE needed to protect health care workers?
If needed, were these safety materials available for the health care workers? |
Y / N / U |
If safety materials were not available, circle "N"
in column "a" and go to the next row.
| Safety Materials |
a. Available? |
b. Used by staff? |
c. Adequate Supply? |
| RA43. Passive (negative pressure)
filtration (e.g., N95 or N99 masks) |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA44. Powered (positive pressure)
filtration (e.g., PAPR) |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA45. Self-contained breathing
apparatus |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA46. Level B or higher suits
(e.g., heat bound or serged seams) |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA47. Double latex gloves |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA48. Face-masks with shields |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA49. Waterproof gowns |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA50. Surgical caps |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA51. Waterproof shoe covers |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA52. Other (specify): _______________ |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA53. Other (specify): _______________ |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| RA54. Other (specify): _______________ |
Y / N / U/ NA |
Y / N / U/ NA |
Y / N / U/ NA |
| Question |
Response |
| RA55. Did you observe staff without PPE
interacting with contaminated victims? |
Y / N / U/ NA |
RA56. If the staff was interacting
with contaminated victims without PPE, what types of staff were they? (Check all that apply) |
a. [ ] Ancillary staff
b. [ ] Nurses
c. [ ] Physicians
d. [ ] Did not observe
e. [ ] NA
f. [ ] Other (specify):
__________________________________ |
RA57. Were dose rates to victims measured
or estimated? |
Y / N / U |
| RA58. Were dose rates to staff measured
or estimated? |
Y / N / U |
Comments (if comment refers to a specific item, give the item number):
|
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