Inpatient Radioactive Iodine -131 Therapy Clinical Procedure



Canberra Hospital and Health ServicesClinical Procedure Inpatient Radioactive Iodine-131 Therapy: Care and Discharge Contents TOC \o "1-3" \h \z \u Contents PAGEREF _Toc475440296 \h 1Purpose PAGEREF _Toc475440297 \h 2Scope PAGEREF _Toc475440298 \h 2Section 1 - Procedure PAGEREF _Toc475440299 \h 21.Room Preparation PAGEREF _Toc475440300 \h 22.Administration PAGEREF _Toc475440301 \h 23.Isolation PAGEREF _Toc475440302 \h 34.Visitors PAGEREF _Toc475440303 \h 35.Nursing Care PAGEREF _Toc475440304 \h 36.Emergency Medical Care PAGEREF _Toc475440305 \h 47.Discharge PAGEREF _Toc475440306 \h 4Discharge to another facility PAGEREF _Toc475440307 \h 58.Incidents PAGEREF _Toc475440308 \h 5Bodily Fluids / Radioactive Spills PAGEREF _Toc475440309 \h 5Section 2 - Contact Details PAGEREF _Toc475440310 \h 6Implementation PAGEREF _Toc475440311 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc475440312 \h 6References PAGEREF _Toc475440313 \h 7Definitions, Acronyms & Abbreviations PAGEREF _Toc475440314 \h 8Search Terms PAGEREF _Toc475440315 \h 8PurposeThe purpose of this procedure is to outline the process to be followed when providing care to a patient admitted to the Canberra Hospital and Health Services (CHHS) for radioactive Iodine-131 therapy.Back to Table of ContentsScope This document applies to all Administration Officers, Medical Officers, Medical Physicists, Medical Physics Registrars, Nuclear Medicine Scientists (NMS), Nuclear Medicine Science Students, Nurses and Student Nurses under direct supervision, who are involved in the care of patients requiring an admission for the duration of Radioactive Iodine-131 therapy (all patients receiving more than 600MBq [15mCi] of Radioactive Iodine-131). Back to Table of ContentsSection 1 - ProcedureRoom PreparationThe patient will present to Ward 14B by 9am on Friday. The nursing staff and Endocrinology registrar will follow routine admission procedures to admit the patient to room 1 or 2 only1 (the ‘therapy room’). The room will need to be supplied with the following:At least 4 red-lined garbage binsAmple 600ml water bottlesSufficient linen for 3-4 daysSmall, medium and large glovesExcess furniture should be removed from the therapy room. Only a bed, chair, phone and over-bed trolley are required. Radiation signage 2 must be displayed in the door display frame at all times.Administration Nursing staff will notify the NMS by phone (ext 44 345) once admission is complete. The NMS will liaise directly with the Team Leader in 14B if there are any delays in this process.The NMS will liaise with the NM Specialist and NM Medical Physicist, ensure the radioactive Iodine-131 dose has been checked by at least two members of the NM Team and is ready for administration3 and the required pathology (including β-HCG) results are available.The Nuclear Medicine team (NM Specialist, NMS and NM Medical Physicist) will attend the ward when the admission is complete. The team will meet with the patient in the therapy room. The Nuclear Medicine Specialist will explain the Radioactive Iodine-131 therapy to the patient, including any risks and side effects4. The Nuclear Medicine team will answer any questions that the patient may have and ask the patient to sign a ‘Consent to Treatment’ form accessible from the Clinical Forms Register prior to swallowing the capsule/s.The patient swallows the capsule with a drink of water and remains fasting for a further two (2) hours5.The NMS will complete the Administration Checklist, scan to RIS (Radiology Information System) and place the Checklist in the patient chart.Radiation warning signage will be placed on the door of the patient’s room immediately prior to administration, and must remain in place for the duration of admission.The NM Medical Physicists will return 20 minutes after administration, to conduct the first radiation survey. The patient should not void their bladder prior to this survey. Survey results are recorded in the ‘Internal Radionuclide Therapy Treatment Sheet’, accessible from the Clinical Forms Register.Isolation The patient remains in the therapy room for the duration of the weekend.Radiation Signage must remain in place on the door at all times.It is important to keep ‘close contact’ to a minimum 6 after the therapy dose has been administered. No one – staff, family or other patients – should spend more than 15 minutes per day within 1 metre of the patient. A distance of more than 2 metres should be maintained whenever possible. Where possible, consultation with the NM Specialist, RSO or NM Medical Physicist (all via switch) should occur prior to visitors attending the treatment room.Visitors Visitors should be discouraged. However, they may be allowed for brief periods7. The maximum period of time for any visitor is 15 minutes per day, and they should stay more than 2 metres from the patient. A brief period of close contact is allowed, for example a hug. Pregnant women and children under the age of 10 are not permitted to visit.Nursing Care Essential nursing procedures should still be done, as quickly as practical8. Gloves should be worn for any patient contact, or contact with isolation room surfaces. Communication should be via the room phone where possible / practical. Time spent in the room with the patient should be minimised as far as possible. Radiation monitoring equipment provided near the door to the therapy room should be used.Medications- Patients are discouraged from bringing and taking their own medications, as per CHHS Medication Management Policy available from the Policy Register. Regular medications should be recorded in the patient’s medication chart and provided by CHHS.Meals 9 are provided on disposable cups, plates and cutlery, which are not to leave the room without a radiation contamination survey being completed by Medical Physics. If necessary, patients may bring their own meals, which are to be stored in the general access fridge (NOT in the patient’s room fridge) for reheating and delivery by the nursing staff. Food which is stored in the patient’s room after the time of therapy dose administration cannot be removed from the room without a radiation contamination survey being completed by Medical Physics.Emergency Medical Care “In life-threatening situations, the patient’s medical management will always take precedence over radiation safety considerations” (see clause 4.5, Safety Guide) During an emergency medical situation, only essential staff should be involved. All other staff should remain more than 2 metres away from the patient. 10 If possible and practical, staff should not spend more than 15 minutes within 1 metre of the patient. If other staff are available to take over, this may be a feasible option. Gloves and gowns should be worn, and staff should be aware that the patient’s bodily fluids are potential radioactive contaminants. If an emergency situation arises, or the medical condition of the patient deteriorates, the Nuclear Medicine Specialist and Radiation Safety Officer must be contacted (via the switchboard) as soon as possible.Non-urgent investigations or interventions should be postponed wherever possible, until the Medical Physics team has cleared the patient for discharge. Discharge A Medical Physicist will return to Ward 14B on Monday morning to measure and document the amount of radiation being emitted from the patient. If it is below the legal limits (36uSv/hr at 1m, equivalent to 600MBq) the patient may be discharged home. The Medical Physicist will complete the ‘Internal Radionuclide Therapy Treatment Sheet’ 11. The Medical Physicist will fax the form to Nuclear Medicine to be scanned into RIS, then file the form in the patient chart.The Medical Physicist will inform the nursing staff when the patient is ready to be discharged, ensure the patient has a copy of the Radiation Precautions (sent with the Patient Information Letter), and provide the patient with a ‘Radioactive Iodine-131 Discharge Information’ card 12. Normal discharge procedures can be followed at this time by the nursing staff and endocrinology team.The NMS will visit or contact the patient by phone to confirm the follow-up scan date and time (if required). After the patient has been discharged, the NM Medical Physicist will return to monitor the room for radioactive contamination prior to cleaning 13. Once the room is considered safe to clean, the Medical Physicist will remove the radiation warning signage, replace it with a notice for the cleaning staff, and inform the nursing staff that the room is available for general use.The ‘Early Discharge of a Radioactive Iodine-131 Patient’ procedure available from the Policy Register outlines the procedure to be followed if the patient wishes to be discharged early, against medical advice 14.Discharge to another facilityIf the patient is being transferred to another care institution, details of the patient’s radioactive status must accompany them, and must include the following details 15:Date, time and activity of radioactive Iodine-131 administrationNursing precautions to be followed when caring for the patientContact details for the hospital for further questions, specifying that the NM Specialist (on duty or on call) should be contacted in the first instance, via the Canberra hospital switchboard. The NM Specialist may then refer the query to the RSO (on duty or on call), the NMS (on duty or on call), or to the NM Medical Physicist (during business hours, available through the RSO after hours), as necessary.A copy of this procedure and the Discharge Information Card completed by Medical Physics would be sufficient to meet this requirement.IncidentsBecause the patient’s bodily fluids are all radioactive, any unexpected spill of bodily fluids is a radioactive spill (see below). All spills from these patients are considered major spills, and require an incident report 16.‘Early Discharge’ of a Radioactive Iodine-131 Patient’ and ‘Death of a Radioactive Iodine-131 Patient’ 17 Procedures will be available on the Policy Register. In all instances, the NM Specialist on call is available 24/7 through the switchboard as the first contact 18. The RSO (Radiation Safety Officer) must also be notified (through switch) in the event of an emergency.Bodily Fluids / Radioactive SpillsPregnant or breastfeeding staff should not be involved in dealing with a major spill, due to the likelihood of increased exposure. The following steps should be followed:Remove all unnecessary people from the area of the spillIf anyone requires medical attention, attend to their needs, calling a MET call if requiredContact the NM Specialist on duty or on call and the RSO (both via switch) for immediate assessment and advice, via the switchboard. They will provide initial advice and arrange to attend if necessary. They may also contact the NMS on duty or on call, and/or the NM Medical Physicist, as required.The NMS Manager, NM Specialist and the RSO must be notified of the incident.A RIskMan report should be completed. If a surface, substance, or material is contaminated with more than 100 times the exemption level for that radioactive material, ARPANSA must be notified by the RSO.Refer to the Radiation Safety Manual – Nuclear Medicine on the Policy Register for further information.Back to Table of ContentsSection 2 - Contact DetailsNuclear Medicine Specialist on duty ext 45 757Nuclear Medicine Specialist on callvia switchRadiation Safety Officer (24hrs)via switchNM Medical Physicist (business hours)ext 45 300NM Medical Physicist (out of hours, via RSO) via switchNuclear Medicine Scientists on dutyext 44 345Nuclear Medicine Scientists on callvia switchBack to Table of ContentsImplementation The procedure will be implemented using the following:Discussion at team meetings, including Medical Physics, Nuclear Medicine and ward 14BInclusion in staff orientation processesDissemination through the CACHS Clinical Governance Committee Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislation and StandardsARPANSA 2014 – Fundamentals - Protection against Ionising Radiation. Available at RPS 4 - Discharge of patients undergoing treatment with radioactive substances. Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008) – ARPANSA (referred to as ‘The Code’). Available at Recommendations for the Discharge of Patients Undergoing Treatment with Radioactive Substances (2002) – ARPANSASafety Guide for Radiation Protection in Nuclear Medicine (2008) – ARPANSA (referred to as the ‘Safety Guide’. Available at National Safety and Quality Health Service (NSQHS) Standards, available at Governance for Safety and Quality in Health Service OrganisationsPartnering with ConsumersPatient Identification and Procedure MatchingRadiation Act 2006 (Australian Capital Territory). Available at ManualsCHHS Radiation Safety Manual – Nuclear MedicinePolicies and ProceduresCHHS Operational Procedure Inpatient Radioactive Iodine-131 TherapyConsent and Treatment PolicyConsent and Treatment SOPConsent and Treatment: Children or Young People SOPConsent and Treatment: Capacity and Substitute Decision Makers SOPTCH Clinical Handover PolicyTCH Clinical Record Management PolicyTCH Discharge Planning Policy TCH SOP - Discharge Summary CompletionTCH SOP - Clinical Record Documentation TCH SOP - Medical Officer Clearance TCH SOP - Medication Supply on Discharge TCH SOP - Patient – Ward admission, Discharge and Transfer Back to Table of ContentsReferencesSafety Guide, clause 4.4.4Safety Guide, clause 4.4.10Safety Guide, clause 4.3Safety Guide, clause 4.4.2EANM Guidelines for radioiodine therapy of differentiated thyroid cancerSafety Guide, clause 4.4.8Safety Guide, clause 4.4.10Safety Guide, clause 4.4.10Safety Guide, clause 4.4.10Safety Guide, clause 4.5Recommendations for discharge (RPS4), clause 2.4Recommendations for discharge (RPS4), clause 2.212. Recommendations for discharge (RPS4), clause 3Safety Guide, clause 4.4.10Safety Guide, clause 4.4.10Recommendations for discharge (RPS4), clause 2.8The Code, clause 3.1.11The Code, clause 3.1.32Safety Guide, clause 4.5Back to Table of ContentsDefinitions, Acronyms & AbbreviationsNM – Nuclear Medicine NMS – Nuclear Medicine ScientistNM MP – Nuclear Medicine Medical PhysicistNM Team – consists of a Nuclear Medicine Specialist, a Nuclear Medicine Scientist and a Nuclear Medicine Medical PhysicistRFA- Request for AdmissionPIL – Patient Information Letter‘Safety Guide’ - Safety Guide for Radiation Protection in Nuclear Medicine (2008) – ARPANSA‘The Code’ - Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008) – ARPANSABack to Table of ContentsSearch Terms Radioiodine, I131, Nuclear Medicine, RAI, Iodine, Radioactive, I-131, Iodine-131, Iodine 131Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
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