CHHS17/020

Canberra Hospital and Health ServicesOperational Procedure Inpatient Radioactive Iodine-131 Therapy: Booking and Administration Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 - Procedure Documentation Overview......................................................................2

Section 2 - Patient Journey Outline...........................................................................................3

Section 3 - Referral, Booking, Administration, Isolation, and Discharge Assessment...............4

1. Referral.......................................................................................................................... 4

2. Booking & Information...................................................................................................4

3. Administration............................................................................................................... 5

4. Isolation......................................................................................................................... 6

5. Discharge........................................................................................................................6

6. Incidents.........................................................................................................................7

Section 4 - Contact Details........................................................................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 9

Definitions, Acronyms & Abbreviations....................................................................................9

Search Terms.......................................................................................................................... 10

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Purpose

The purpose of this procedure is to outline the process for referral, booking, administration, isolation and discharge assessment of patients undergoing Radioactive Iodine-131 therapy as an inpatient of Canberra Hospital & Health Service (CHHS), in line with relevant legislation.

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Scope

This document applies to all Administration Officers, Medical Officers, Medical Physicists, Medical Physics Registrars (under supervision), Nuclear Medicine Scientists (NMS), Nuclear Medicine Science Students (under direct supervision), Nurses and Student Nurses (under direct supervision), who are involved in the care of patients requiring a hospital admission and isolation precautions for the duration of Radioactive Iodine-131 therapy (all patients receiving more than 600MBq [15mCi] of Radioactive Iodine-131).

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Section 1 - Procedure Documentation Overview

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Section 2 - Patient Journey Outline

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Section 3 - Referral, Booking, Administration, Isolation, and Discharge Assessment

1. Referrali. The referring specialist (typically an Endocrinologist) may contact Nuclear Medicine

to confirm an available date. They will then provide the following items to Nuclear Medicine1: A completed ‘Radioactive Iodine-131 Therapy Booking Worksheet’ Relevant medical history documents, as outlined on the Worksheet, including:

o Current medication listo Pathology & histopathology results (if performed privately)o Previous imaging results (if performed privately)o Thyrogen / Thyroxine withdrawal preparation sheet

ii. The referrer must also send a completed CHHS ‘Request for Admission’ (RFA) form to the Patient Flow Office, and forward a copy to Nuclear Medicine.

iii. All of these items must be received by Nuclear Medicine administration staff before the booking process begins.

iv. The referrer may provide the patient with a copy of the appropriate ‘Patient Information Letter’ to read through.

2. Booking & Information

i. The Nuclear Medicine administration staff will collate all of the information outlined above and begin filling out a ‘Radioactive Iodine-131 Booking Outline and Checklist’. When all items required have been received they will scan the information to RIS and allocate the booking in the Nuclear Medicine diary.

ii. The administration staff will contact the patient to confirm the date and address details and arrange a suitable time for a pre-admission consultation with the NM Team, at least one week prior to the therapy administration date. The appropriate ‘Patient Information Letter’ will be sent to the patient (if not already provided by Endocrinology).

iii. If the patient has any questions prior to the consultation, they may call the NMS during business hours.

iv. The administration staff will confirm the ‘RFA’ has been completed and scan to RIS, then forward the copy of the ‘RFA’ to the 14B CNC via internal mail or email.

v. The administration staff will email the pre-admission consultation appointment time and date and the administration time and date to the NM Specialist, the 14B CNC, and the NM Medical Physicist, and forward the patient file to the NM Specialist. The NM Specialist will review the file prior to the consultation and confirm the dose to be administered is appropriate2.

vi. During the pre-admission consultation, the patient will have an opportunity to ask questions about the process, and further information about the procedure to be performed, risks involved, and the restrictions which will apply after discharge2,3 will be discussed verbally.

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vii. The NMS will then order the radioactive Iodine-131 capsule/s and complete the ‘Booking Checklist’.

viii. The ‘Booking Checklist’ will be scanned onto RIS, and all the paper documentation stored until the date of the procedure.

ix. If the patient is from a non-English speaking background, an interpreter should be booked for both the pre-therapy consultation and the therapy administration. Refer to the Language Services Policy and Procedure (available on SharePoint) for more information.

3. Administrationi. Female patients aged 12-60yrs old only: The patient attends ACT Pathology the

afternoon before the therapy date to have β-HCG blood test4 completed, unless they have had a hysterectomy5.

ii. On the day of therapy, all patients need to fast from midnight. A small amount of water (up to 250ml) is allowed. Diabetic patients should be advised to maintain blood glucose levels where necessary with small amounts of glucose-rich food or solution (i.e. lollies) rather than meals.

iii. The patient arrives at ward 14B by 9am on Friday for admission.iv. Nursing staff orientate the patient to the ward and notify the endocrinology team,

who will then complete the admission. Specific nursing procedures for the isolation period are outlined in ‘Inpatient Radioactive Iodine-131 Care’. If there are any discrepancies between the general nursing guidelines and the Radioactive Iodine-131 procedures, the Radioactive Iodine-131 procedures must take precedence.

v. 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.

vi. 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 administration (Safety Guide, clause 4.3)7 and the required pathology results are available.

vii. The Nuclear Medicine team (NM Specialist, NM Scientist and NM Medical Physicist) will attend the ward when the admission process is completed, and meet with the patient in the therapy room (room 1 or 2 only)8.

viii. The Nuclear Medicine Specialist will explain the Radioactive Iodine-131 therapy procedure to the patient again, including any risks and side effects9. The Nuclear Medicine team will answer any further questions that the patient may have, and complete a ‘Consent to Treatment’ form.

ix. The NMS will complete the Administration Checklist, scan to RIS (Radiology Information System) and place the Checklist in the patient chart.

x. The NM Specialist will give the capsule to the patient to swallow with a drink of water. The patient remains fasting for a further two (2) hours6.

xi. The NM team will place Radiation warning signage on the door of the patient’s room immediately prior to administration of the Radioactive Iodine-131, and this must remain in place for the duration of admission10.

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xii. 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’, available on the Policy Register.

4. Isolationi. The patient remains in the isolation room for the duration of the weekend.ii. Nursing procedures for this time are outlined in ‘Inpatient Radioactive Iodine-131

Therapy: Care and Discharge’, available on the Policy Register.iii. Radiation signage must stay in place on the door at all times.iv. Visitors are highly discouraged. It is important to keep ‘close contact’11 to a minimum

after the therapy dose has been administered. No one – staff, family or other patients – should spend more than a maximum of 15 minutes per day within 1 metre of the patient. A distance of more than 2 metres should be maintained whenever possible if it is necessary to be within the room. Where possible, consultation with the NM Specialist, RSO (Radiation Safety Officer) or NM Medical Physicist (all via switch) should occur prior to visitors attending the treatment room.

5. Dischargei. A Nuclear Medicine 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 NM Medical Physicist will complete the ‘Internal Radionuclide Therapy Treatment Sheet’13, and inform the nursing staff when the patient is ready to be discharged.

ii. Normal discharge procedures can be followed at this time by the nursing staff and endocrinology team.

iii. After the patient has been discharged and left the room, the NM Medical Physicist will return to monitor the room for radioactive contamination prior to cleaning15.

iv. The ‘Early Discharge of a Radioactive Iodine-131 Patient’ procedure outlines the procedure to be followed if the patient wishes to be discharged early, against advice16.

Discharge to another facilityi. If the patient is being transferred to another care institution, details of the patient’s

radioactive status must accompany them, and must include the following details17: Date, time and activity of radioactive Iodine-131 administration Nursing precautions to be followed when caring for the patient Contact details for the hospital for further questions, specifying that the NM

Specialist (on duty or on call) should be contacted in the first instance2, 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.

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A copy of this procedure and the Discharge Information Card completed by Medical Physics would be sufficient to meet this requirement.

6. Incidentsi. ‘In life-threatening situations, the patient’s medical management will always take

precedence over radiation safety considerations’ (Safety Guide, clause 4.5)Please refer to the Inpatient Radioactive Iodine-131 Therapy Clinical Procedure for further information on Emergency Medical Care.

ii. Dealing with Spills and Medical Emergencies are also detailed in the ‘Inpatient Radioactive Iodine-131 Care’ Procedure. Because the patient’s bodily fluids are all potentially radioactive, any unexpected spill of bodily fluids is a radioactive spill. All spills from these patients are considered major spills, and require an incident report18.

iii. ‘Early Discharge of a Radioactive Iodine-131 Patient’ and ‘Death of a Radioactive Iodine-131 Patient19’ Procedures are available separately on SharePoint.

iv. In all instances, the NM Specialist on duty or on call is available 24/7 through the switchboard as the first contact20. The RSO must also be notified (through switch) in the event of an emergency.

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Section 4 - Contact Details

Nuclear Medicine Specialist on duty ext 45 757Nuclear Medicine Specialist on call via 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 duty ext 44 345Nuclear Medicine Scientists on call via switch

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Implementation

The procedure will be implemented using the following: Discussion at team meetings Inclusion in staff orientation processes Dissemination through the CACHS Clinical Governance Committee

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1.

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Related Policies, Procedures, Guidelines and Legislation

Legislation and Standards ARPANSA 2014 – Fundamentals - Protection against Ionising Radiation. Available at

http://arpansa.gov.au/publications/codes/rpsF-1.cfm 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 http://arpansa.gov.au/publications/codes/rps14.cfm

Recommendations for the Discharge of Patients Undergoing Treatment with Radioactive Substances (2002) – ARPANSA

Safety Guide for Radiation Protection in Nuclear Medicine (2008) – ARPANSA (referred to as the ‘Safety Guide’. Available at http://arpansa.gov.au/publications/codes/rps14_2.cfm

National Safety and Quality Health Service (NSQHS) Standards, available at https://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/ o Governance for Safety and Quality in Health Service Organisationso Partnering with Consumerso Patient Identification and Procedure Matching

Radiation Act 2006 (Australian Capital Territory). Available at http://www.legislation.act.gov.au/a/2006-33/

Manuals CHHS Radiation Safety Manual – Nuclear Medicine

Policies and Procedures CHHS Operational Procedure Inpatient Radioactive Iodine-131 Therapy Consent and Treatment Policy Consent and Treatment SOP Consent and Treatment: Children or Young People SOP Consent and Treatment: Capacity and Substitute Decision Makers SOP TCH Clinical Handover Policy TCH Clinical Record Management Policy TCH Discharge Planning Policy TCH SOP - Discharge Summary Completion TCH SOP - Clinical Record Documentation TCH SOP - Medical Officer Clearance TCH SOP - Medication Supply on Discharge TCH SOP - Patient – Ward admission, Discharge and Transfer

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References

1. Safety Guide, clause 3.32. Safety Guide, clause 3.23. Safety Guide, clause 4.4.84. The Code, clause 3.2.7(b)5. Safety Guide, clause 5.36. EANM Guidelines for radioiodine therapy of differentiated thyroid cancer7. Safety Guide, clause 4.3 and clause 4.4.2, and the Code, clause 3.1.7(b)8. Safety Guide, clause 4.4.49. Safety Guide, clause 4.4.2, and the Code, clause 3.2.610. Safety Guide, clause 4.4.1011. Safety Guide, clause 4.4.812. Recommendations for discharge (RPS4), clause 2.1 and clause 2.413. Recommendations for discharge (RPS4), clause 2.214. Recommendations for discharge (RPS4), clause 315. Safety Guide, clause 4.4.10, and Annex H16. Safety Guide, clause 4.4.1017. Recommendations for discharge (RPS4), clause 2.818. The Code, clause 3.1.1119. The Code, clause 3.1.3220. Safety Guide, clause 4.5

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Definitions, Acronyms & Abbreviations

NM – Nuclear Medicine NMS – Nuclear Medicine Scientist NM MP – Nuclear Medicine Medical Physicist NM Team – consists of a Nuclear Medicine Specialist, a Nuclear Medicine Scientist and a

Nuclear Medicine Medical Physicist RFA- Request for Admission PIL – Patient Information Letter CNC – Clinical Nurse Consultant ‘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) – ARPANSA

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Search Terms

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Radioiodine, I131, Nuclear Medicine, RAI, Iodine, Radioactive, I-131, Iodine-131, Iodine 131

Disclaimer: 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 Amended Section Amended Approved By

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