How One Urology Clinic Successfully Sets Up a Hot Lab for Radioligand Therapy Program - William Oresick
October 6, 2023
Specialized laboratories, which are called hot laboratories, are specially designed and equipped to handle radioactive materials of high activity, including plutonium and transplutonium elements. The handling of lutetium presents special radiation protection and safety because of its high specific activity and radiotoxicity. Therefore, the planning, design, construction, and operation of hot laboratories must meet stringent safety, containment, ventilation, shielding, criticality control, and fire protection requirements. In a detailed conversation with Phillip Koo, Bill Oresick discusses the innovative use of space in his urology clinic for Radioligand Therapy (RLT) programs. Dr. Oresick reveals that a preexisting procedure room is designated for radiopharmaceuticals two days per month. The room is easily converted into a "hot lab" with minimal modifications, such as reinforced cabinetry and a lock, as per regulations. The room also features a standard injection chair and a supply cart, both of which can be wheeled out to maximize space efficiency. Dr. Oresick elaborates on the additional equipment needed when they expanded to administer Lutetium-177, including a second "hot trash" and a syringe pump. He emphasizes the importance of a nuclear medicine tech for room preparation and radiation surveys. The setup allows for quick patient turnover, with each session taking around 30 to 45 minutes, making it a highly efficient model for RLT programs.
Biographies:
William Oresick, MHA, CMD, Director, Clinical Services, Cancer Centers, Summit Health, New Jersey
Phillip J. Koo, MD, Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona
Biographies:
William Oresick, MHA, CMD, Director, Clinical Services, Cancer Centers, Summit Health, New Jersey
Phillip J. Koo, MD, Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona
Read the Full Video Transcript
Phillip Koo: So, Bill, space is always a big issue when it comes to starting an RLT program. I noticed a very unique and novel setup here at your facility. Can you talk us through the space?
Bill Oresick: Of course. This is one of our preexisting procedure rooms that we had in our urology clinic. On a given day, this might be used for other urology procedures, but we designate it for our radiopharmaceutical program two days per month. So, all we really had to do to convert it from a procedure room into a "hot lab" was to add this reinforced cabinetry. We do have a lock on it, of course, as is necessary per regulations, but inside you can see it's pretty simple. We have our "hot trash," which is where we decay our used material and equipment. We have some lead blocks that we can use to shield anything we need to, and then this is where we'll also keep some of our used pigs until they're ready for pickup. So, as you can see, nothing major needed, no reinforcement, no extra lead lining. Everything is already shielded and it's very simple.
We also added this chair, a standard injection chair. It can be wheeled in and out so they don't have to give up that space on days when we're not doing procedures. We also just added a supply cart, which again, can be wheeled out if we needed the space back on non-urology days. And then we do have some equipment that takes up our counter space. We don't like this to move, but as you can see, it's not a huge burden.
Phillip Koo: Great. So when we're talking about the equipment, this is a facility where you're used to doing Radium-223 procedures.
Bill Oresick: Yes.
Phillip Koo: When you got the license to also administer Lutetium-177, what were the additional pieces of equipment you needed to purchase?
Bill Oresick: We did get actually a second "hot trash" just so we could have more room to decay anything that's hot after the procedure and we did purchase a syringe pump. That was per the physician's personal preference, though, that's not necessary for everybody.
Phillip Koo: Right. So it's interesting, you have this space that for two days, you mentioned, are used for injections. The other three days it's used for just normal clinic or procedure purposes. Can you talk to how you're able to sort of make that transition to maximize the efficiency of this room?
Bill Oresick: Yeah, so really like I said, the two days per month, we have it blocked off schedule-wise. We won't have anything else going on in this room on the urology schedule. We'll have our nuclear medicine tech come in early in the morning. She'll prep the room. As you can see, she puts down chux anywhere that there's a potential for spill. She'll do all her prep. We also wrap the bathroom. We do have an adjoining bathroom, which is key for the setup, so that if a patient does have to void and if, let's say they're leaking, they're not having to go through the entire department like that.
Phillip Koo: I imagine you do a radiation survey before and after each?
Bill Oresick: Correct. Correct. So again, at the end of the day, she'll do her entire survey of all personnel, hands, equipment that was used in the entire room, and the traditional cleanup.
Phillip Koo: So Bill, walk us through some of the key pieces of equipment that you have here.
Bill Oresick: Sure. So as I said, we had an existing Radium-223 program. So we had a lot of this equipment already. So we already had our Geiger counter, our L-block, our dose calibrator, et cetera. We did have to add this syringe shield, which accommodates the larger syringe that's used for PLUVICTO. It's a little bit thicker than the one that we had previously for Radium-223, just due to the increased size of the vial. So this will protect the physician's hands during injection. It is a longer injection, close to 10 minutes, so that's very important for us.
We also had to get a larger dipper, and in addition to that, we also made the decision to buy a syringe pump and a syringe shield. Now that's physician preference. That's not necessary. That was the only piece that was a little bit on the expensive side. Most of these other items are of minimal cost.
Phillip Koo: Great. So you could use an injector or you could do a handheld injection. Is that correct?
Bill Oresick: Correct.
Phillip Koo: Using a shield.
Bill Oresick: Correct, exactly. So, the physician holding this in their hand, you want this additional shielding to protect them as much as possible, but the automatic injector just takes some of the human error out of the injection process.
Phillip Koo: Given this setup that you have here, how do you create a template to accommodate the patients at your practice?
Bill Oresick: So we typically would schedule about 30 to 45 minutes per patient. It really isn't a long turnaround, so obviously we need a little bit of time in the morning, usually about an hour for the nuclear medicine tech to get the room set up and get everything ready. But then, when each patient comes back, a lot of the time is sort of just getting the IV started, making sure the vein is good and they're ready to go. Like I said, the actual push itself should be 10 minutes or less and then a little bit of observation before they're out of here. We're not seeing a huge volume of patients to the level that we would need to accommodate multiple at the same time. Usually one morning every two weeks we can do three or four patients, no problem, is our typical volume.
Phillip Koo: Great. And how much time to turn around the room?
Bill Oresick: Not much at all. I mean, we can really be in and out the next 10 or 15 minutes between patients.
Phillip Koo: Great.
Phillip Koo: So, Bill, space is always a big issue when it comes to starting an RLT program. I noticed a very unique and novel setup here at your facility. Can you talk us through the space?
Bill Oresick: Of course. This is one of our preexisting procedure rooms that we had in our urology clinic. On a given day, this might be used for other urology procedures, but we designate it for our radiopharmaceutical program two days per month. So, all we really had to do to convert it from a procedure room into a "hot lab" was to add this reinforced cabinetry. We do have a lock on it, of course, as is necessary per regulations, but inside you can see it's pretty simple. We have our "hot trash," which is where we decay our used material and equipment. We have some lead blocks that we can use to shield anything we need to, and then this is where we'll also keep some of our used pigs until they're ready for pickup. So, as you can see, nothing major needed, no reinforcement, no extra lead lining. Everything is already shielded and it's very simple.
We also added this chair, a standard injection chair. It can be wheeled in and out so they don't have to give up that space on days when we're not doing procedures. We also just added a supply cart, which again, can be wheeled out if we needed the space back on non-urology days. And then we do have some equipment that takes up our counter space. We don't like this to move, but as you can see, it's not a huge burden.
Phillip Koo: Great. So when we're talking about the equipment, this is a facility where you're used to doing Radium-223 procedures.
Bill Oresick: Yes.
Phillip Koo: When you got the license to also administer Lutetium-177, what were the additional pieces of equipment you needed to purchase?
Bill Oresick: We did get actually a second "hot trash" just so we could have more room to decay anything that's hot after the procedure and we did purchase a syringe pump. That was per the physician's personal preference, though, that's not necessary for everybody.
Phillip Koo: Right. So it's interesting, you have this space that for two days, you mentioned, are used for injections. The other three days it's used for just normal clinic or procedure purposes. Can you talk to how you're able to sort of make that transition to maximize the efficiency of this room?
Bill Oresick: Yeah, so really like I said, the two days per month, we have it blocked off schedule-wise. We won't have anything else going on in this room on the urology schedule. We'll have our nuclear medicine tech come in early in the morning. She'll prep the room. As you can see, she puts down chux anywhere that there's a potential for spill. She'll do all her prep. We also wrap the bathroom. We do have an adjoining bathroom, which is key for the setup, so that if a patient does have to void and if, let's say they're leaking, they're not having to go through the entire department like that.
Phillip Koo: I imagine you do a radiation survey before and after each?
Bill Oresick: Correct. Correct. So again, at the end of the day, she'll do her entire survey of all personnel, hands, equipment that was used in the entire room, and the traditional cleanup.
Phillip Koo: So Bill, walk us through some of the key pieces of equipment that you have here.
Bill Oresick: Sure. So as I said, we had an existing Radium-223 program. So we had a lot of this equipment already. So we already had our Geiger counter, our L-block, our dose calibrator, et cetera. We did have to add this syringe shield, which accommodates the larger syringe that's used for PLUVICTO. It's a little bit thicker than the one that we had previously for Radium-223, just due to the increased size of the vial. So this will protect the physician's hands during injection. It is a longer injection, close to 10 minutes, so that's very important for us.
We also had to get a larger dipper, and in addition to that, we also made the decision to buy a syringe pump and a syringe shield. Now that's physician preference. That's not necessary. That was the only piece that was a little bit on the expensive side. Most of these other items are of minimal cost.
Phillip Koo: Great. So you could use an injector or you could do a handheld injection. Is that correct?
Bill Oresick: Correct.
Phillip Koo: Using a shield.
Bill Oresick: Correct, exactly. So, the physician holding this in their hand, you want this additional shielding to protect them as much as possible, but the automatic injector just takes some of the human error out of the injection process.
Phillip Koo: Given this setup that you have here, how do you create a template to accommodate the patients at your practice?
Bill Oresick: So we typically would schedule about 30 to 45 minutes per patient. It really isn't a long turnaround, so obviously we need a little bit of time in the morning, usually about an hour for the nuclear medicine tech to get the room set up and get everything ready. But then, when each patient comes back, a lot of the time is sort of just getting the IV started, making sure the vein is good and they're ready to go. Like I said, the actual push itself should be 10 minutes or less and then a little bit of observation before they're out of here. We're not seeing a huge volume of patients to the level that we would need to accommodate multiple at the same time. Usually one morning every two weeks we can do three or four patients, no problem, is our typical volume.
Phillip Koo: Great. And how much time to turn around the room?
Bill Oresick: Not much at all. I mean, we can really be in and out the next 10 or 15 minutes between patients.
Phillip Koo: Great.