HCPro.com - Hospital Safety Center

OSHA adds GHS to Hazard Communication Standard

Fri, 01 Jun 2012 04:00:00 GMT

OSHA adds GHS to Hazard Communication Standard

Expected revisions align with United Nations global chemical labeling system to improve worker safety

It was only a matter of time, but OSHA has officially revised its Hazard Communication Standard to include the Globally Harmonized System (GHS) of Classification and Labelling of Chemicals. The change was expected to be announced this year after OSHA submitted the change to the Office of Management and Budget in October 2011. GHS adoption has been on OSHA's agenda for more than six years.

"Exposure to hazardous chemicals is one of the most serious dangers facing American workers today," Secretary of Labor Hilda L. Solis said in a press release. "Revising OSHA's Hazard Communication Standard will improve the quality, consistency and clarity of hazard information that workers receive, making it safer for workers to do their jobs and easier for employers to stay competitive in the global marketplace."

OSHA expects the revised standard to prevent roughly 585 injuries and illnesses each year, and improve productivity for businesses that regularly handle, store, and use hazardous chemicals, with a cost savings of $32.2 million for businesses that periodically update safety data sheets (SDS) and labels. Complete implementation of the changes is expected by 2016; however, employers have until December 2013 to train employees on the system's new requirements.

Hospitals are one of the primary businesses affected by the revision of the Hazard Communication Standard, which has been troublesome for healthcare facilities even before this change. OSHA lists it as the third most frequently cited standard from October 2010 to September 2011. Switching to the new GHS system should ultimately make it easier for hospitals to protect employees who regularly work with hazardous chemicals, says Bruce Cunha, RN, MS, COHN-S, employee health and safety manager at Marshfield (Wis.) Clinic.

"I'm usually moderately critical of OSHA and their new rules, but I think this is a good, positive rule," he says. "I think it will help employees-it makes it easier for them to understand the hazards of a chemical, and [the change] makes for a much better rule."

Training employees

Employee training, on both the laboratory and clinical side, is the most immediate compliance need that safety officers should focus on, says Kenneth Weinberg, BA, MSc, PhD, an environmental health, safety, and toxicology consultant with Safdoc Systems, LLC, in Stoughton, Mass. Weinberg, who was previously the director of safety at Massachusetts General Hospital in Boston, says clinical staff in particular might experience challenges with hazard communication training.

"I believe this is going to be very confusing and a difficult transition for hospital people," he says. "I don't think they got the Hazard Communication Standard to begin with."

Even though hospitals have until December 2013 to train employees, safety officers should begin thinking about how they will incorporate initial training into their curriculum. Safety officers should provide initial notification of the change and the basic aspects of the GHS system through internal newsletters or emails, Weinberg says.

At Marshfield Clinic, Cunha says he typically trains employees annually on hazard communication requirements. This year he plans to expand the training program to include additional components that cover the new revisions.

"In the past, you were required to provide hazard communication training upon hire and repeat if you found employees were not following the rules or if there was a change in your process," he says. "With GHS, you need to add in training on the rule changes to ensure employees understand the new system. I don't believe that is going to be a big deal."

According to Cunha, the health system had planned to revamp its computer training program in June, which would allow the system to integrate any required changes to its hazard communication training.

Even though hazard communication training is only required upon employment, Weinberg suggests incorporating it into fire safety training so employees get at least a basic review each year.

Reorganizing your chemical inventory

One way to decrease the burden of the Hazard Communication Standard is to go through your facility's chemical inventory and weed out any chemicals that are no longer used. This cuts down on the number of hazards and the number of GHS SDSs you need to have on file.

"I think if you're going to go through all this, why not do a review of your chemical inventory and do a clean sweep of your chemicals?" Cunha says. "It amazes me every time we've done clean sweeps in our facility and we still find things we shouldn't have anymore."

The standard change also provides an opportunity to separate any mixtures that may have unique hazards, Weinberg says.

Each chemical should have a corresponding material safety data sheet (MSDS), and manufacturers should be preparing to send new GHS-compliant SDSs to hospitals for each chemical.

"It's the manufacturer's responsibility to do that, but as the user, it's your responsibility to have those material safety data sheets on hand. The other caveat to that is if you had a guy that worked for you 12 years ago, he's not going to know the new material safety data sheets, so you need to have the new ones as well as the old ones," Weinberg says.

Healthcare facilities should also review their hazard communication plans. The revised OSHA standard won't necessarily force a hospital to drastically change its plan, but many hospitals' existing plans already have compliance problems when survey time rolls around. Incorporating a review of your plan along with the other changes should help bolster the overall effectiveness of your program.

"My honest observation is there probably aren't a lot of hospitals that are truly in compliance with the hazard communication program-that have their data sheets, that have a chemical inventory list, that are keeping up with that list, that are evaluating new products when they come in and training employees," Cunha says. "I have my doubts. Unfortunately hospitals tend to lag behind a little bit in the general industry category."

Chemical labeling and SDS

The switch to the GHS system means manufacturers will also have to switch the labels on their chemical containers. These labels will feature pictograms that provide a summary of the hazards, readable by anyone regardless of language.

Although the responsibility of producing these labels falls largely on the shoulders of the manufacturer, hospitals should provide information to their employees on how to interpret them. Some chemicals will also be reclassified under the GHS system.

"When we move to the GHS, I really do feel it's going to make it safer for employees," Cunha says. "Now they can pick up a bottle and they don't have go get the data sheet for more information. You're going to be able to pick up the bottle regardless of what language it's in wherever you are in the world, and you should have a pretty good idea as to what the hazards are and what you need to do to protect yourself."

In addition to appropriate education, safety officers should provide signage, particularly in laboratories, to help employees quickly recognize the corresponding symbols.

Another change with the GHS system involves new SDS forms. Fortunately, these are not very different from the existing MSDS forms, Cunha says. Both include much of the same information, although they are structured slightly differently. (For more information on GHS safety data sheets, See "Minimum information necessary for a GHS safety data sheet" on p. 5.)

"I did a seminar on this and one of the questions was, 'Do we have to get rid of all our data sheets and now get the new ones?' " Cunha says. "And the answer is, you should be getting those new data sheets as they are being manufactured anyway."

One slight caveat that may affect larger hospitals is that any lab producing items for outside entities needs to provide an SDS, Cunha says. For example, one of the labs at Marshfield Clinic does 24-hour urine tests that include a preservative. Those tests need to be accompanied by a data sheet when they are sent out, and once the OSHA revisions take full effect in 2016, the data sheets should be replaced by the GHS SDS forms.

"If you have a large laboratory and you have outreach or outside clients and you're supplying them with formalin containers, you have to provide them with a data sheet since you're the supplier," Cunha says. "That's something that most hospitals might want to look at. Does your lab provide any chemicals to any of your outside customers?"

Higher priority on a newer standard

New standard revisions usually mean more focus from surveyors, and this standard is likely to follow the same trend. "I think they are probably going to want to take a look at hazard communication since it is a new regulation change-I think they will ask a little bit more about it," Cunha says. "Are we going to see more fines because there aren't written programs? Yeah, probably; OSHA's been on a big enforcement kick lately."

But this regulatory change isn't nearly as onerous as a new standard, since many of the same requirements are still in place. Hospitals still need to document compliance in two main areas: hazard communication plan and employee training.

"When an OSHA inspector comes in, one of the first things they do is go through all your written standards, so if you don't have a written hazard communication standard, you get dinged," Weinberg says. "Then they are going to start to check about training and how you can prove you did the training, so if you don't have that, you get dinged. And now it's a revised regulation, so it's like bloodborne pathogens when it first came up. What they are going to do is target bigger hospitals like the UCLAs and NYUs and Mass Generals because those are the ones to make examples of."

Take the guesswork out of complying with the newly modified OSHA Hazard Communication Standard and PPE requirements

Changes to the OSHA Hazard Communication (HazCom) Standard through adoption of the Globally Harmonized System (GHS) of Classification and Labelling of Chemicals, and the new Enforcement Guidance for Personal Protective Equipment in General Industry, are two of the most significant changes from OSHA this year. The HazCom/GHS changes will require critical compliance and training adjustments for healthcare facilities. OSHA is also currently citing businesses for personal protective equipment (PPE) enforcement guidance violations under the February 2011 changes to the requirements.

In HCPro's 90-minute audio conference from June 2011, "HazCom/GHS and PPE Enforcement: Understanding the New Requirements for OSHA Compliance in Healthcare," healthcare industry experts discuss how these changes affect your workplace, provide a timeline for implementation, and offer tools to help you train your staff. You'll be able to:

Determine how the proposed changes to the HazCom standard will affect your organization
Establish a timeline for implementation and staff training
Understand the new PPE enforcement guidance and how it specifically relates to healthcare
Implement a compliant hazard assessment program

Visit www.hcmarketplace.com/prod-9593 for more information and to listen to the on-demand program.

CMS adopts sections of 2012 Life Safety Code

Fri, 01 Jun 2012 04:00:00 GMT

CMS adopts sections of 2012 Life Safety Code

Memo: CMS accepting waivers on four sections of the Life Safety Code, providing leeway for corridor clutter

A Centers for Medicare & Medicaid Services (CMS) memo released in March offers some flexibility for healthcare facilities in terms of Life Safety Code® (LSC) compliance, particularly when it comes to corridor clutter and combustible decorations.

The memo states that CMS will immediately allow hospitals to adopt four sections of the 2012 LSC, also known as National Fire Protection Association 101. CMS is looking at eventually adopting the entire 2012 edition of the code, but is allowing hospitals to adopt these sections now through a waiver process. The sections address the following issues:

Previously restricted items that can now be placed in exit corridors
The recognition that a kitchen is not a hazardous area and can be open to an exit corridor under certain circumstances
The installation of direct-vent gas fireplaces and solid fuel burning fireplaces
The installation of combustible decorations

CMS decided to adopt these 2012 LSC changes early in order to appease strong lobbying groups representing nursing homes, says Brad Keyes, CHSP, a consultant with Keyes Life Safety Compliance.

"Apparently, owners of nursing homes want to design new structures with some amenities that you may find in a retirement home, or perhaps even in a nice home," Keyes says.

While most of the changes benefit nursing homes, the changes were made under the general category of "healthcare occupancy," meaning that they will also apply to hospitals. This will offer some leeway in comparison to the 2000 LSC that was fully adopted by CMS, says Steven MacArthur, safety consultant for The Greeley Company, a division of HCPro, Inc., in Danvers, Mass.

"CMS is cherry-picking some of the more useful and influential standards, and allowing hospitals and nursing homes to take advantage of the more flexible 2012 requirements for things such as corridor storage and the presence of combustible decorations in the care environment, both which had very limited application based on the 2000 edition of the Life Safety Code, which is the current enforcement document," MacArthur says.

More flexibility with corridor space and decorations

Of the four changes, corridor clutter and combustible decorations are the most applicable to the hospital environment. Fireplaces and kitchens open to the corridor are issues more commonly found in nursing home environments rather than the traditional healthcare setting.

Historically, corridor clutter has been a notorious compliance problem for hospitals, but the new requirements allow for slightly more leeway, particularly with wheeled equipment, Keyes says. Wheeled equipment is permitted to be left unattended in the corridor for more than 30 minutes, provided:

The equipment does not reduce the clear unobstructed corridor width to less than 5 feet.
The fire safety plan addresses the relocation of wheeled equipment during a fire emergency. The plan must identify where the wheeled equipment will be relocated.
The wheeled equipment is limited to equipment that is in use, medical emergency equipment not in use, and patient lift and transport equipment. Beds are not considered transport equipment or emergency medical equipment, so they will not be allowed in corridors.

Fixed seating may be installed in corridors that are at least 8 feet wide, but it cannot project more than 2 feet into the corridor. Fixed seating must also be attached to the wall or floor and cannot be installed on both sides of the hallway. There are size limitations and requirements regarding sprinkler systems as well.

In terms of decorations, the 2012 LSC moves from no combustible decorations outlined in the 2000 edition, to allowing 20% of the wall, ceiling, and doors to be covered with combustible decorations in non-sprinklered smoke compartments.

"That amount goes up to 30% in smoke compartments fully protected with automatic sprinklers; and will be allowed to go up to 50% of wall, ceiling, and doors to be covered in patient sleeping rooms that do not exceed more than four patients, in a smoke compartment fully protected with automatic sprinklers," Keyes says.

The waiver process

The Social Security Amendment Act of 1965, which created the Medicare and Medicaid programs, requires any healthcare facility receiving CMS funding to comply with the LSC. Since CMS has currently adopted the 2000 edition of the LSC, it is not allowed to simply adopt a portion of the 2012 edition.

"If an organization cannot comply with a certain LSC requirement, and the resolution of that LSC deficiency would be considered a significant hardship to do so, the organization is allowed to submit a request to CMS to waive that portion of the LSC, which means they do not have to comply with it, if approved," Keyes says.

The March CMS memo is unique because the agency is straightforwardly saying that a healthcare facility requesting a waiver does not need to demonstrate an unreasonable hardship to comply with the four sections of the 2012 code.

"That makes sense, and if there was a hardship, then they just need to fall back onto the 2000 edition, which does not allow these four changes," Keyes says.

MacArthur suspects that hospitals will have to ensure their facilities have full sprinkler protection in order to prove they are in compliance with the 2012 LSC requirements.

"The memorandum doesn't provide a great deal of specific information, so this is a course that will likely have to be plotted as we go," he says.

The benefits of staying with the 2000 LSC

Although the four sections of the 2012 LSC allow for more leeway concerning decorations and corridor clutter, it may be more of a headache to apply for a waiver rather than simply staying within the confines of the more constrictive 2000 LSC requirements. The memo does not require hospitals to switch to the 2012 LSC-it merely gives them the option to do so if they choose.

Keyes says if he were a safety officer at a hospital, he would not be interested in pursuing a waiver request because allowing staff members to leave unattended medical equipment in corridors forms bad habits, even if the equipment does not reduce the corridor to less than 5 feet. "My experience with staff is they will either intentionally or unintentionally abuse the restrictions of this new rule," Keyes says. "Give them an inch and they will take a mile."

Additionally, training staff members to recognize the nuances of the 2012 LSC can be onerous. For example, recognizing medical equipment that is not in use versus in storage can be difficult.

"Unless the medical equipment in storage has plastic bags over them, then it's pretty difficult to say whether it's in storage or not in use," Keyes says. "If you can't tell, how do you expect a surveyor to know?"

Submitting a waiver also means your fire plan needs to clearly state where wheeled equipment will be relocated. A plan that states the equipment will be put in a vacant patient room is not effective since there may be circumstances during an emergency where all patient rooms are full.

In the end, submitting waivers to adopt the 2012 LSC changes may be more work than they are worth, Keyes and MacArthur say.

Double-gloving can be both safe and effective

Fri, 01 Jun 2012 04:00:00 GMT

Double-gloving can be both safe and effective

AORN shows that double-gloving, particularly with an indicator glove, offers more protection during surgery

A study published by the Association of periOperative Registered Nurses (AORN) in March focused on the benefits of double-gloving during surgery, a practice that has been endorsed by many associations as a means to significantly reduce healthcare worker exposure to bloodborne pathogens.

The results were published after a 24-month investigation by researchers examining the effect of using inner indicator gloves and the detection of tears or perforations during surgery.

Although many organizations already support double-gloving during surgery, this study lends additional support to the practice's safety and efficacy, says Denise Korniewicz, PhD, RN, FAAN, dean and professor at the College of Nursing at the University of North Dakota in Grand Forks.

"I think when you have the data that we presented where you can actually demonstrate that you have more safety resulting from use of double-gloving, I think it does give more credence to standards and a set policy," she says.

Double-gloving has become more commonplace in recent years, Korniewicz adds, particularly because more organizations are publishing recommendations as part of their policy statements or clinical guidelines. Healthcare workers are particularly compliant with these recommendations when they are working with high-risk patients who are known hepatitis or HIV carriers. Now, it's become clearer that double-gloving provides additional safety and equal effectiveness regardless of the patient.

Using indicator gloves

The use of indicator gloves is particularly effective when double-gloving, as evidenced in the published study.

Indicator gloves are a different color than the outer glove, which makes it easier to recognize a tear or perforation. The study found that the frequency of changing gloves during surgery was significantly higher among healthcare providers who wore dark-colored gloves under light-colored gloves versus those who wore two pairs of gloves that were the same color. Approximately 69% of participants who wore indicator gloves changed their gloves during a procedure.

"It's automatic," Korniewicz says. "It's like, 'Oh, wow, I've breached the glove and I should change it.' When you use two white gloves or two blue gloves, that's harder to detect, and I think that's the advantage of having the color coding. When you see something right away, you do it right away."

Researchers found that healthcare workers expressed positive feedback about indicator gloves because they were able to see perforations right away rather than discovering them after the surgery was over. As a result, many workers said they felt safer when double-gloving.

Changing attitudes

One of the common complaints from surgeons about double-gloving is that it hinders hand sensitivity and dexterity. However, previous studies have shown that position is no longer the majority opinion, especially since manufacturers now make better-fitting surgical gloves. As a result, surgeons are much more accepting of double-gloving than they have been in the past.

"[Gloves] are more flexible than they were in the past, so when you wear two gloves it's not nearly as burdensome," Korniewicz says. Additionally, healthcare facilities have created more awareness through their annual bloodborne pathogens training, and more professional organizations include double-gloving in their recommendations. (For a summary of recommendations, see "Professional recommendations for double-gloving" sidebar on p. 9.)

"I think when the professional organizations move forward and say it's safer, that's when behavior changes," says Korniewicz. "I don't think it's because of one or two research studies that change automatically happens; I think it takes a while in practice."

Professional recommendations for double-gloving

The Association of Surgical Technologists published Recommended Standards of Practice for Gowning and Gloving, which recommends double-gloving for all surgical procedures based on a review of five major studies that revealed the following:

There is no difference in the number of perforations between a single pair of gloves and the outer glove when a healthcare worker double-gloves; however, the number of perforations in the innermost glove is significantly reduced during double-gloving
There is no difference in the number of perforations to the innermost glove when double-gloving as compared to wearing a single pair of orthopedic gloves
When the innermost glove is colored when double-gloving, it is considerably easier to detect perforations to the outer glove, but the detection of perforations of the innermost glove does not increase
Wearing glove liners between the two gloves when double-gloving significantly reduces the number of perforations to the inner glove
Wearing an outer cloth glove over the inner glove significantly reduces perforations to the inner glove
There was no difference in the number of perforations to the innermost glove when wearing steel-weave gloves compared to standard double-gloving

If a sharps injury does occur, double-gloving reduces the amount of exposure to blood or body fluid since it is being wiped or stripped off of the instrument as it passes through the first glove.

In 2004, the American College of Surgeons addressed the use of double-gloving in an article published in the Journal of the American College of Surgeons. The authors indicated that perforation rates were as high as 61% among thoracic surgeons and 40% among scrub nurses. Subsequently, double-gloving reduced the risk of exposure to patient blood as much as 87% when the outer glove was punctured, and the volume of blood on a suture needle was reduced as much as 95% when passing through two glove layers. However, the authors noted that there is still widespread perception among surgeons that double-gloving reduces hand sensitivity and dexterity.

Overall, a large body of literature and data suggests double-gloving is safe and effective, thus supporting the practice.

A number of other organizations, including the Centers for Disease Control and Prevention, the Association of periOperative Registered Nurses, and the American Academy of Orthopedic Surgeons, also support the use of double-gloving and offer recommendations and support for the practice.

Past disasters give clues into the recovery process

Fri, 01 Jun 2012 04:00:00 GMT

Past disasters give clues into the recovery process

Managing a large-scale disaster can be difficult enough, but without long-term recovery plans, your hospital is doomed from the start

When you look back at the major disasters of the last decade, a few come to mind right away. The 10-year anniversary of 9/11 was last September; Hurricane Katrina struck in 2005; and most recently Joplin, Mo., was destroyed by a category EF5 tornado that virtually wiped out the local hospital. Overseas, Japan is still feeling the impact of a deadly tsunami that struck early in 2011.

Major disasters like these can ravage a community for months or even years, but once healthcare facilities have returned to normal operations, their experience provides a learning opportunity for other hospitals, particularly when it comes to disaster recovery.

Hospitals need to strike a balance between mitigating the immediate effects of a disaster in order to treat the surge of patients and moving forward to return to normal operations. These are decisions that are typically made by facility managers along with hospital leadership, says Mary Comerio, a professor of architecture at UC Berkley College of Environmental Design and an internationally recognized expert on disaster recovery.

"You are coping and you have a plan on how you're going to get back into operation," she says. "It's a two-pronged approach. If you just cope with the emergency and you're not dealing with the long term, you're shooting yourself in the foot."

Recovery begins on day one

The immediate aftermath of a disaster will throw every process off balance, and the following 24 hours will focus mostly on minimizing the damage, setting up triage units, and safely caring for existing patients.

But during that time, facility managers and emergency managers should start to think about how their decisions will affect operations in the future.

"I think the sacred saying of most people in any local government or emergency management is that 'recovery begins on day one;' this is when you have to start planning your long-term recovery even while you're coping with the immediate impact," Comerio says.

Initially, the main priority is ensuring safety for all patients. This often involves a review of basic facility issues such as:

Power
Emergency generators
Lights
Water
Evacuation or closure of units
Communication

Long-term repairs, particularly architectural or design repairs, should also be evaluated at this time, with the understanding that major damage could take years to fix due to all of the needed permits, engineering evaluations, and-of course-financing. For example, Charity Hospital in New Orleans took nearly five years to get back to normal operations after being devastated by Hurricane Katrina.

"All of those things take time, and I think people are often unfortunately a bit naïve about understanding why you can't just snap your fingers and make it better," Comerio says.

Recovery planning

Planning for immediate disaster management is often the primary focus for hospitals, but those plans should also include plans and goals for long-term recovery. "A lot is going to be happening simultaneously, and people need to have plans in place on how to deal with all those things," Comerio says.

Sometimes even the most unexpected issues can cause major long-term problems. For example, a healthcare complex in New Zealand had to shut down entire buildings and evacuate patients after an earthquake. There was no visible structural damage to the complex, but the earthquake shook the fuel in the emergency tanks, disturbing some of the ducts and sealing off the tanks so the emergency generators were inoperable. The facility had to first evacuate the buildings, and then get the tanks inspected and repaired, Comerio says.

Although all disasters are unique, incorporating long-term recovery options into disaster drills and exercises provides some preparation for the real event. For example, designing scenarios where an entire wing is wiped out allows strategic thinking on how the event will affect the hospital and the time frame for rebuilding.

However, the most important part of recovery planning is deciding who gets to decide.

"You can't always solve all of those things ahead of time, but you really need a structure in place so there is a clear hierarchy of who is making decisions and why," Comerio says. "That's really critical. It sounds silly but it's really important."

These responsibilities should be incorporated into the hospital's incident command chart. One or two hospital leaders should be charged with making the final decisions during disasters, with a team of staff members who can contribute to the decision process.

Learning from the past

Healthcare facilities can learn a lot from past disasters, particularly concerning the recovery process. One of the primary issues that communities have learned in the aftermath of a catastrophe is that without reliable healthcare, residents will quickly flee.

"This was really a significant lesson from Hurricane Katrina with the closure of Charity Hospital," Comerio says. "Universities are trying to restart and companies are trying to rebuild their businesses, and their workers are saying, 'I'm not going to stay here without any healthcare. If there is no hospital in this community, I'm not going to put my family at that kind of risk.' "

This issue is particularly important in rural areas that rely on a single healthcare facility. If a disaster impedes the facility's ability to safely operate, the entire community needs to prioritize getting the hospital up and running before the population leaves.

In urban areas, healthcare facilities need to collaborate to look at where their major losses are and how they can work together to serve the health needs of the population while also rebuilding devastated facilities.

"In San Francisco, where earthquakes are inevitable, there could be one on the Hayward Fault or there could be one on the San Andreas Fault," Comerio says. "Depending on where an earthquake happens, some facilities will be more impacted than others, so understanding that local network and understanding how you can redirect and reorganize services within [those constraints] is critical in terms of planning."

One very specific lesson that has become clear from past disasters: Elevators will inevitably fail. Comerio says elevator failure can be an enormous strain on emergency management processes. Even if they're not broken, something may go off track on a cable and it may take time to have the elevators inspected and reset.

"[Elevator failure] is something that hospitals have to plan for and they don't," she says. "It's amazing how they never think of this, but it happens in almost every single disaster."

Briefings on Hospital Safety, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

OSHA adds GHS to Hazard Communication Standard

Expected revisions align with United Nations global chemical labeling system to improve worker safety

Training employees

"I believe this is going to be very confusing and a difficult transition for hospital people," he says. "I don't think they got the Hazard Communication Standard to begin with."

According to Cunha, the health system had planned to revamp its computer training program in June, which would allow the system to integrate any required changes to its hazard communication training.

Even though hazard communication training is only required upon employment, Weinberg suggests incorporating it into fire safety training so employees get at least a basic review each year.

Reorganizing your chemical inventory

The standard change also provides an opportunity to separate any mixtures that may have unique hazards, Weinberg says.

Each chemical should have a corresponding material safety data sheet (MSDS), and manufacturers should be preparing to send new GHS-compliant SDSs to hospitals for each chemical.

Chemical labeling and SDS

In addition to appropriate education, safety officers should provide signage, particularly in laboratories, to help employees quickly recognize the corresponding symbols.

Higher priority on a newer standard

Take the guesswork out of complying with the newly modified OSHA Hazard Communication Standard and PPE requirements

Determine how the proposed changes to the HazCom standard will affect your organization
Establish a timeline for implementation and staff training
Understand the new PPE enforcement guidance and how it specifically relates to healthcare
Implement a compliant hazard assessment program

Visit www.hcmarketplace.com/prod-9593 for more information and to listen to the on-demand program.

CMS adopts sections of 2012 Life Safety Code

Memo: CMS accepting waivers on four sections of the Life Safety Code, providing leeway for corridor clutter

Previously restricted items that can now be placed in exit corridors
The recognition that a kitchen is not a hazardous area and can be open to an exit corridor under certain circumstances
The installation of direct-vent gas fireplaces and solid fuel burning fireplaces
The installation of combustible decorations

CMS decided to adopt these 2012 LSC changes early in order to appease strong lobbying groups representing nursing homes, says Brad Keyes, CHSP, a consultant with Keyes Life Safety Compliance.

"Apparently, owners of nursing homes want to design new structures with some amenities that you may find in a retirement home, or perhaps even in a nice home," Keyes says.

More flexibility with corridor space and decorations

The equipment does not reduce the clear unobstructed corridor width to less than 5 feet.
The fire safety plan addresses the relocation of wheeled equipment during a fire emergency. The plan must identify where the wheeled equipment will be relocated.
The wheeled equipment is limited to equipment that is in use, medical emergency equipment not in use, and patient lift and transport equipment. Beds are not considered transport equipment or emergency medical equipment, so they will not be allowed in corridors.

The waiver process

"That makes sense, and if there was a hardship, then they just need to fall back onto the 2000 edition, which does not allow these four changes," Keyes says.

MacArthur suspects that hospitals will have to ensure their facilities have full sprinkler protection in order to prove they are in compliance with the 2012 LSC requirements.

"The memorandum doesn't provide a great deal of specific information, so this is a course that will likely have to be plotted as we go," he says.

The benefits of staying with the 2000 LSC

Additionally, training staff members to recognize the nuances of the 2012 LSC can be onerous. For example, recognizing medical equipment that is not in use versus in storage can be difficult.

In the end, submitting waivers to adopt the 2012 LSC changes may be more work than they are worth, Keyes and MacArthur say.

Double-gloving can be both safe and effective

AORN shows that double-gloving, particularly with an indicator glove, offers more protection during surgery

The results were published after a 24-month investigation by researchers examining the effect of using inner indicator gloves and the detection of tears or perforations during surgery.

Using indicator gloves

The use of indicator gloves is particularly effective when double-gloving, as evidenced in the published study.

Changing attitudes

Professional recommendations for double-gloving

There is no difference in the number of perforations between a single pair of gloves and the outer glove when a healthcare worker double-gloves; however, the number of perforations in the innermost glove is significantly reduced during double-gloving
There is no difference in the number of perforations to the innermost glove when double-gloving as compared to wearing a single pair of orthopedic gloves
When the innermost glove is colored when double-gloving, it is considerably easier to detect perforations to the outer glove, but the detection of perforations of the innermost glove does not increase
Wearing glove liners between the two gloves when double-gloving significantly reduces the number of perforations to the inner glove
Wearing an outer cloth glove over the inner glove significantly reduces perforations to the inner glove
There was no difference in the number of perforations to the innermost glove when wearing steel-weave gloves compared to standard double-gloving

If a sharps injury does occur, double-gloving reduces the amount of exposure to blood or body fluid since it is being wiped or stripped off of the instrument as it passes through the first glove.

Overall, a large body of literature and data suggests double-gloving is safe and effective, thus supporting the practice.

Past disasters give clues into the recovery process

Managing a large-scale disaster can be difficult enough, but without long-term recovery plans, your hospital is doomed from the start

Recovery begins on day one

But during that time, facility managers and emergency managers should start to think about how their decisions will affect operations in the future.

Initially, the main priority is ensuring safety for all patients. This often involves a review of ba

IAHSS releases security design guidelines

Mon, 07 May 2012 18:20:00 GMT

New guidelines provide resource for security directors and design teams during building and renovation

Security directors who feel out of the loop when it comes to building and renovation projects finally have a resource to lean on.

In March, the International Association for Healthcare Security and Safety (IAHSS) released Design and Renovation Guidelines for Healthcare Facilities, with security-specific guidance for projects ranging from new facility construction to renovation of high-risk areas of hospitals, including the ED, pharmacy, and infant and pediatric units. (See IAHSS General Guidelines? on p. 3 for an excerpt of the official guidelines.)

Download the PDF (link above) to read the entire Healthcare Security Alert issue.

Training mitigates risks of norovirus outbreak

Tue, 01 May 2012 04:00:00 GMT

Training mitigates risks of norovirus outbreak

Study shows norovirus outbreaks among top risks

A norovirus outbreak may enter a hospital unnoticed, but can quickly transform into a hospital's worst nightmare, potentially forcing the shutdown of entire units to prevent the spread of infection.

For years it was unknown just how prevalent norovirus and other outbreaks were, but a study published in the February issue of the American Journal of Infection Control shows that such outbreaks are becoming increasingly common, particularly in nonacute settings like rehabilitation units and behavioral health.

A two-part electronic survey was sent to members of the Association for Professionals in Infection Control and Epidemiology. The survey gathered 822 responses representing 386 outbreak investigations.

According to the study, nearly 60% of the outbreaks were caused by four organisms:

Norovirus (18%)
Staphylococcus aureus (17%)
Acinetobacter (14%)
Clostridium difficile (10%)

Furthermore, 22.6% of the investigations reported unit or department closure, most often associated with norovirus.

These numbers offer a new baseline for norovirus incidence that hadn't been established previously, says Emily Rhinehart, RN, MPH, CIC, CPHQ, lead author of the study and vice president of global loss prevention at Chartis Insurance in Atlanta.

"It's difficult to know the frequency prior to this publication because no one had done a study like this, so we had no data about what was causing outbreak investigations in U.S. hospitals," Rhinehart says. "We had reports of individual outbreaks, and of course there are a number of reports of norovirus outbreaks, but no one did the sampling to find out the frequency. I don't think we can say it's new data, but we have really only recognized norovirus as a cause of healthcare-associated infection for around 10 years."

Although norovirus outbreaks are difficult to prevent entirely, the high likelihood of an outbreak should force hospitals to consider quick methods of containment once they start seeing signs and symptoms.

Spreading awareness

The survey statistics offer a new perspective on where norovirus outbreaks cause the most danger. According to the data, outbreaks are more likely to occur in rehab or behavioral health units, which usually receive less infection control attention than higher-risk areas like organ transplant units or the ICU, where many patients are immunocompromised.

"Infection preventionists aren't usually thinking about outbreaks occurring in those areas," Rhinehart says. "These are people that are generally there for a longer period of time and tend to interact with each other a little more."

Spreading norovirus awareness to the staff is also crucial in recognizing and containing an outbreak. Nurses or doctors need to know what to look for in order to identify potential carriers before the outbreak spirals out of control. If multiple employees show symptoms of norovirus, nurses should alert both the employee health manager and the infection preventionist.

"If nurses see more than one patient with vomiting and diarrhea, and it's not the reason for admission, they should alert the infection preventionists immediately," Rhinehart says. "The only way to detect it is being alert for its possibility, seeing more [people with symptoms] than you think you should see, and then bringing it to someone's attention."

According to the CDC, symptoms of norovirus include nausea, vomiting, diarrhea, and stomach cramping. Patients may occasionally experience low-grade fever, chills, headache, muscle aches, and tiredness. Diarrhea is more common in children, whereas vomiting is more common in adults, with symptoms lasting for one or two days.

Protecting employees

Hospitals should develop a sick leave policy for staff members who exhibit norovirus symptoms. The CDC's 2011 Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings indicates that hospitals should exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, frequent hand hygiene should be reinforced, particularly after patient contact.

Additionally, nonessential staff, students, and volunteers should be excluded from areas that contain a norovirus outbreak.

Just-in-time training

The best way to prepare for a norovirus outbreak is to train staff members ahead of time with disaster scenariosor tabletop exercises involving a wide variety of hospital employees.

An incident command system set up for a norovirus outbreak is also important. See p. 5 for a tool that provides a guide to how a hospital command center should be structured.

Sometimes, however, hospitals are caught unprepared, or staff members need refresher training in dealing with norovirus patients. In these cases, "just-in-time" training can provide quick, succinct information for nurses and environmental services workers on how to contain an outbreak and protect themselves from contamination, says Kristine Sanger, BS, MT(ASCP), hospital disaster exercise coordinator at the Center for Preparedness Education in Omaha, NE, which has created and published just-in-time training guidelines for norovirus outbreaks.

"If you had the luxury of training in advance, of course that's the best scenario, but the just-in-time training tool is really written with the mind-set that if you need quick training, it's a short and concise training tool that people can take a look at and flip through," Sanger says.

She recommends bundling the tools on laminated half-sheets of paper so they are easy to hand out and quick to read during an outbreak.

"I think really the gist of having this training tool is having an opportunity to redistribute this material quickly and in an easily readable format that doesn't get bogged down with policy information," Sanger says.

Involving environmental services

Environmental services employees are important during any disaster or emergency, but in a norovirus outbreak they are crucial, Sanger says. Unfortunately, these employees are often left out from disaster planning, leaving most of the response to doctors and nurses who need to quickly triage patients. "I could get on my soapbox and shout out to the world that environmental services is important in any hospital, but I think that [in regards to] norovirus, they are absolutely essential personnel," she says.

The Center's just-in-time training offers specific recommendations for environmental services regarding norovirus issues. For example, the following guidelines apply when cleaning up after a vomiting incident:

Always use wet, versus dry, cleaning methods to minimize the spread of airborne particles (using vacuums may lead to further surface contamination)
Use single-use cleaning equipment and supplies whenever possible
Clean and disinfect any equipment that is not discarded
Following a vomiting incident in kitchens, buffet, or drink service areas, discard all exposed or unwrapped foods within a 25-foot radius
The following PPE is suggested for environmental services workers to protect themselves from infection:
- Tyvek® overalls
- Boot covers
- Gloves (not vinyl)
- Mask
- Eye protection
- Hair covering (optional)

Sanger recommends also including environmental and food services supervisors and managers during preplanning exercises.

"They have a lot of input," she says. "They are affected by these plans that say, 'Environmental services are going to do this,' but no one tells them that they are needed to do it."

Educating employees on why they need to take extra precautions outside of their normal job responsibilities will help them further understand their role in containing an outbreak, Rhinehart says.

"If there is a unit closure, they might be asked to come in and change the curtains," she says. "[Norovirus] isn't necessarily transmitted on the curtains, but it gives you a fresh unit so when you readmit patients you're not concerned there would be any reservoir of bacteria in the environment."

Tabletop exercises

One of the most effective methods of preparation, without the intensity of a full-blown disaster drill, is tabletop exercises. These lower-intensity drills, in which staff gather around a table to discuss and brainstorm what needs to be done in case of an outbreak, offer the chance for multiple departments to work together on one scenario, allowing varied perspectives on how the disaster will affect each department.

In the past, especially with norovirus outbreaks, Sanger says she has incorporated the public health department and other community entities, like local colleges that may experience an outbreak. "It was great information sharing, and whenever you do something like that, you actually have a name and a face and you're building some connections with people you don't normally work with," she says. "In the event there is an outbreak, you already have those communications and those relationships set up and you don't have to work so hard backpedaling and trying to figure out who to contact."

The following are a few keys to a successful tabletop exercise:

Include everyone who might be affected by the disaster. In the case of a norovirus outbreak, you should include departments such as environment and food services in addition to healthcare workers.
Bring everyone into a room, explain the disaster scenario, and provide relevant questions.
Break up into small groups (roughly five per group). The groups can be formed one of two ways:
- Have each group consist of everyone from the same department (e.g., place nurses at one table, doctors at another table, etc.)
- Mix the groups so they include one person from each department
Have the groups answer each of the questions in the scenario. Once everyone is finished, reconvene in a large group for a grand facilitated discussion.

"If we find some problems-and I promise you we find problems every time we do this-then we have to categorize that as something we need to address," Sanger says. "Maybe not right now, because we have a lot of problems we want to solve at this point, but in the long term this is something we need to address."

After-action procedures

One crucial step that many facilities forget-or neglect-is after-action evaluations and reports. These reports document the actions that occurred in response to an event, such as an outbreak, often identifying some key follow-up actions to improve the response to the next event. Hospitals tend to lag in this area because once one disaster is over, another priority quickly crops up to take its place.

"Everybody has priorities, and usually the priority is put out the fire and then put out the next fire and the next fire," Sanger says. "That is just systematically how people run. [After-action reports] are just not something that becomes a priority all the time."

The Joint Commission has emphasized the need for after-action reports, but not all hospitals are Joint Commission-accredited.

The real benefit of after-action reports following a disaster is that it gives planners and managers a chance to step back and look at what went well and what didn't. This information should be documented in a formal report, which can be used to refine response procedures.

"Once you finish that document, you need to continue to follow up with your safety committee, or whatever committee addresses these plans, and make sure they are improved upon," Sanger says. "The idea should be, 'Let's avoid the same problems we just had.' "

From a liability perspective, hospitals need to keep accurate records of patients who were at the hospital during an outbreak and employees who may have been infected, along with documentation that summarizes the actions taken and who was involved in decision-making, Rhinehart says.

Once the outbreak is under control, safety and infection prevention should collaborate to write a report on what was successful and what should be handled differently.

Staff reluctant to respond to radiological disaster

Tue, 01 May 2012 04:00:00 GMT

Staff reluctant to respond to radiological disaster

Healthcare worker survey highlights fears about dirty bomb incident

Fear of the unknown is a common phobia among all demographics. For healthcare workers, the unknown usually comes in the form of a disaster.

High on the list of healthcare fears is a radiological disaster or the threat of a "dirty bomb," which combines conventional weapons with the dispersal of radioactive material-a possible weapon of choice for terrorist organizations.

A radiological incident, whether an attack or an accident, would overload nearby healthcare systems with patients exposed to radiation. Although such an attack has not occurred on U.S. soil, its potential risk level has landed the scenario among the federal government's c.

A recent survey administered at Johns Hopkins Hospital indicated that more than one-third of workers (39%) were not willing to respond in the event of a dirty bomb attack. Only 73% of staff members were willing to respond if required. The results of the survey were published in the October 2011 issue of PLoS ONE (a Public Library of Science journal). In February, the study was evaluated by the Faculty of 1000 (F1000), which identifies and evaluates the most important articles in biology and medical research.

"The nuclear threat is real given the increased activity of global terrorist organizations, lax security of nuclear material, and a rise in illicit trafficking of radioactive materials," the F1000 evaluation reads. "An effective medical response requires the concerted efforts of an entire medical infrastructure that includes every member of a hospital, especially if the healthcare needs may last for many months."

One of the primary reasons healthcare workers may be tentative about responding to a radiological threat is that so little is understood regarding the ideal method of worker response, says Daniel Barnett, MD, MPH, researcher at the Johns Hopkins Preparedness and Emergency Response Research Center in Baltimore, and coauthor of the study.

"Radiation is a very poorly understood threat, as evidenced in this particular study," Barnett says. "Gaps in knowledge and gaps in training are very much causative of this unwillingness to respond."

The study highlights a need for hospital preparedness teams to focus specifically on radiological attacks, to improve their own policies and procedures, and to help healthcare workers understand their role during the response phase of such an incident.

Training and education

Survey respondents included employees from a variety of demographics, including nurses, doctors, surgeons, and technicians. Nurses-who were less willing than physicians to respond to a dirty bomb attack-may be the most important demographic since they are the largest cohort of healthcare providers in the United States. If nurses fail to respond, it could have a drastic impact on hospitals' ability to handle a surge of patients during a radiological event, Barnett says.

There are two main reasons why healthcare workers are less inclined to report during a dirty bomb incident, according to Barnett:

Concern for safety in the workplace
Inability to do their job correctly

To alleviate these fears, hospitals need to focus on role-specific training that emphasizes various job categories and responsibilities during a radiological disaster. "I think that would go a long way toward enhancing that sense of job efficacy," Barnett says. "We found in this study that having a sense that you can do your job effectively is a critically important modifier of willingness to respond."

Unlike natural disasters, which occur multiple times each year throughout the country, a radiological attack has never occurred in the United States, so many healthcare workers don't know what to expect, says Nelson Chao, MD, MBA, professor of medicine and immunology and division chief of cellular therapy/blood and marrow transplant at Duke University in Durham, NC. Chao also authored the F1000 evaluation.

Although this lack of familiarity makes training and preparing more difficult, it also means employee education is imperative to help nurses and doctors understand their role as well as the safety precautions that are put in place.

"I think all hospitals have had some drills and attempted to address some of these issues, but clearly there is nothing to fall back on as far as experience to help with drills, so it sure does make it more difficult that way," says Chao.

A radiological attack is much more of a psychological risk than a physical one, Barnett says. The first step for hospitals should be to debunk myths or misperceptions staff members have about their own safety or how radiation is spread.

"I think that will go a long way toward ensuring employees feel they can comfortably come to work, knowing that simple barrier precautions in the case of a dirty bomb allows for safety in the work environment," he says.

Setting staff straight can often be achieved through simple educational efforts, Chao says. A basic understanding of what radiation is, how it works, and how it is transmitted can ease the minds of employees who are wondering how the hospital plans to keep them safe.

Building a radiological plan

Because there are no historical references to fall back on, it's important that hospitals put in extra effort to plan for a dirty bomb threat. Hospitals should have specific radiation response plans in place that include coordination with local health agencies and community partners.

For example, decontamination procedures are imperative when dealing with radiation exposures. Affected patients should go through a decontamination process outside of the facility.

"Once you have contaminated individuals [in the ED], it's no longer an emergency department, it's a decontamination facility," Barnett says. "So it's very important that decontamination happen prior to entry of affected individuals into the hospital ED."

Similar to natural disasters, your hospital's location makes a difference in how you plan for and manage a radiological attack. Urban areas are terrorist targets, so hospitals in large cities should be prepared for a surge of patients exposed to radiation, or will be forced to operate with fewer resources if their own facility is affected.

Barnett notes that rural hospitals should make their own plans to provide support for surrounding urban areas if needed.

"Although urban areas may be more at risk in terms of the actual physical impact of such an event, rural areas are the locales where people from urban areas would evacuate to," he explains. "It's important for rural hospitals to be familiar with these threats so they know what to and how to prepare should an event happen in an urban area."

A dirty bomb incident in a major city like Washington, DC, or New York City would likely involve national agencies as well, Chao says.

"It would probably incapacitate that area and surrounding areas, so it would require a fairly large-scale response nationally or at least regionally," he says.

In the short term, hospitals should also consider cross-training employees so that in the event of a dirty bomb or radiological emergency, even if there are fewer employees, they will be able to perform a variety of roles, augmenting the hospital's response capacity.

Establishing a culture of readiness

To increase the number of healthcare workers willing to respond to a radiological event, hospitals need to focus on their work culture and the message it sends to employees.

The Johns Hopkins survey found that individuals who were willing to work extra hours in response to a threat were also far more willing to respond initially. Additionally, those who perceived their colleagues were more apt to respond were in turn much more likely to respond.

"So establishing a culture of readiness and willingness to go above and beyond routine duties is critical for hospitals, and I actually think that's the area that is ripe for further research," Barnett says.

He notes that the survey found punitive measures, such as punishing employees for refusing to work longer hours or work during a disaster, to be less effective. A better option involves long-term positive culture change, establishing an environment where people have a sense that their colleagues will respond to a disaster and they should too.

Healthcare facilities can start this process by integrating certain principles and expectations regarding disaster response into their mission statement. "I think that would be a very important culture-changing measure, and I think it needs to be a top-down culture change. It has to start at the top, and it really has to permeate throughout all levels of the hospital's organizational chart," Barnett says.

Human resources can also be involved by including specific responsibilities in job descriptions for new hires, which would outline duties during a disaster. "Our sense from this study and other work we have done is that a lot of employees don't necessarily understand what their individual roles and responsibilities would be during a specific event," Barnett says. "That can be a real barrier towards response."

National planning scenario: Step-by-step response to a radiological event

The Office of the Assistant Secretary for Preparedness and Response (ASPR), a division of the U.S. Department of Health and Human Services, has assembled a list of the top national planning scenarios, ranging from a nuclear attack to pandemic influenza. Number three on that list is a radiological attack involving a radiation dispersal device or "dirty bomb."

In the scenario, a dirty bomb is detonated in three separate, but regionally close, moderate to large cities. ASPR expects 180 fatalities, 270 injuries, and 20,000 detectable contaminations at each site. Approximately 10,000 people would evacuate to shelters and safe areas, while hundreds of thousands would self-evacuate from major urban areas in anticipation of future attacks.For the purposes of triaging patients, it's important to understand the difference between radiation exposure and contamination. Exposure (or irradiation) occurs when radiation penetrates tissue, even without physically contacting radioactive material. The victim is not radioactive in this scenario.

Contamination occurs either externally or internally when radioactive material comes in contact with a person. External contamination can be radioactive material on a person's clothes, hair, or skin, while internal contamination occurs when radioactive material enters the body through inhalation, ingestion, or absorption through skin or wounds.

Victims of contamination should go through a decontamination process. External decontamination simply involves removing the person's clothing and shoes and washing skin and hair with soap and water. Internal decontamination involves normal body cleansing mechanisms. Laxatives or chelating compounds may be used to speed up this process, or blocking agents can be administered to inhibit uptake of radioactive materials, depending on the nature of the chemical.

Hospital officials should have some guidance as to the kind of chemical they may be dealing with in order to take the appropriate steps for decontamination. As always, patients should be triaged and decontaminated outside of the hospital so as not to risk exposing other patients and staff members.

Source: ASPR.

Even outside the ED, workplace violence a risk

Tue, 01 May 2012 04:00:00 GMT

Even outside the ED, workplace violence a risk

Violent outbursts aren't restricted to one unit

Workplace violence prevention initiatives traditionally focus specifically on the ED, and with good reason: Statistically, ED staff members see the highest number of potentially violent patients.

But what happens when those patients are transferred to other floors? The risk for violence is still present, but without the appropriate training, doctors and nurses on that floor may not be able to recognize that risk before it's too late.

Violent outbursts can come from many sources-patients, family members, and even coworkers. Nor does violence restrict itself to the ED. As such, it requires healthcare facilities to place more emphasis on protecting nurses in places like med-surg, telemetry, step-down, and neonatal ICUs.

One reason staff members outside of the ED may be seeing more potentially violent patients is that more state psychiatric facilities are underfunded or shutting down, leaving community hospitals to manage the overflow of psychiatric patients, says Christine Pontus, MS, RN, COHN-S, associate director of the Massachusetts Nurses Association in Canton.

"[Psych patients] are coming in for various reasons, and often a med-surg nurse-not to say they aren't very competent as nurses-they aren't trained to be psych nurses, and sometimes they don't have the staffing they need, so the nurse is very vulnerable," Pontus says.

Even though high-risk areas like the ED do need focused attention, safety officers and security directors can't neglect other hospital units where random acts of violence can occur.

Internal versus external violence

Nurses and doctors should be aware of potential violence from two sources: externally, from patients, family members, or visitors; or internally, from coworkers or even their family members. (A recent incident at a Connecticut hospital, in which one employee shot two others, is an example of internal violence. Learn more about what you can do to prevent a similar incident at your facility in this month's Healthcare Security Alert insert.)

Overflow of domestic violence into the workplace is one issue that is becoming more prevalent, says Randy Spivey, CEO and founder of the Center for Personal Protection and Safety in Spokane, WA.

Statistics show that one out of four women is in a relationship in which domestic violence occurs. Since the majority of nurses are women, chances are more likely that hospitals will see some domestic violence spill over onto their grounds.

"You may have an individual who left the relationship and he doesn't know where she lives anymore, but he knows where she works," Spivey says. "Many times that's when you see extreme violence erupt in the workplace in a healthcare setting-it's a domestic relationship."

Spivey recommends that individuals who find themselves in an abusive relationship get a restraining order that includes the hospital. They should also let hospital security know about the issue, and provide a description of the person so security can intervene if necessary.

Violence can also stem from coworkers in any unit of the hospital. "What sexual harassment was in the '80s and '90s, workplace violence is becoming in this decade," Spivey says.

External violence from patients or family members is usually a more common threat given the stressful and often emotional environment of a hospital. "You're definitely dealing with a more volatile environment than we have in the past, and you're seeing violence increasing in the healthcare setting from just a few years ago," Spivey says.

Recognizing violence

Training staff members to recognize violence is the best way to avoid a situation from bubbling over into a physical altercation.

"By the time it gets to security, a lot of times it's gone too far," Spivey says. "With the right human relation skills and listening and communication techniques, you can significantly reduce the chance of violence happening."

Pontus recommends that hospitals bring nurses into training sessions with security officers so they can learn de-escalation techniques and know who to turn to if a situation gets out of hand.

There are a number of observable acts that indicate aggression on the part of a patient or family member, according to Spivey. For example, an aggressor may get very close or invade the personal space of a nurse in order to intimidate the nurse. Other nonverbal cues include a furrowed brow, tightened jaw, or clenched fists.

"If you have someone who is clearly agitated or clearly moving down that path, you do not want to isolate yourself in a room with them," Spivey says. "You want to have another person with you; whether it's a nurse or a doctor or just somebody else in there, that goes a long way toward minimizing the chances of being attacked."

Healthcare workers should always be aware of their position in the room in relation to the exit. Never allow a violent patient or visitor to position him- or herself between you and the doorway.

Hospital managers and administrators also need to educate their employees to recognize violence in the first place. Understaffing is a major contributor to violence because patients can become frustrated with their care, and nurses are often too busy to pick up on aggressive signals.

"Nurses are definitely trained with assessment skills to make a good appraisal of who they are dealing with and taking care of," Pontus says. "The problem is when they are so short-staffed they do not have the time to really recognize when there is a psych issue."

Finally, departments should incorporate warnings into their electronic medical records with the ability to red-flag patients who have a history of violence, says Adam Sachs, spokesperson for the American Nurses Association in Silver Spring, MD.

Using this method of prevention allows the nurses and physicians to know what they are dealing with before they walk into a patient's room.

Changing the culture

Changing the culture of safety in the healthcare environment has helped alter the way administrators and employees view workplace violence.

"Previously, nurses may have accepted that you can encounter violent patients and they may not have reported incidents," Sachs says. "But we want to send the message that it's not just something that's part of the job and it is something that is preventable. They need to instill a culture of safety throughout the whole facility and make it known that workplace safety is a priority."

This culture change also allows nurses to feel more comfortable bringing issues to administrators.

"Doctors and nurses are the ones that are going to see the behavior; the organization needs to have a structure in which people can report the problem to initiate interventions," Spivey says. "Whether that is a safety officer or security or HR, someone needs to be that process manager."

This communication often occurs during safety committee meetings in which nurses or nurse managers should be represented and encouraged to express concerns regarding safety measures on specific units. The key is following up with those concerns and addressing them head-on.

"The problem is people become apathetic when theyfeel nothing is going to be done," Pontus says. "That's a communication process; that's care and concern."

New national standard holds organizations accountable

In October 2011, the American Society for Industrial Security and the Society for Human Resource Management issued a new American National Standard on Workplace Violence Prevention and Intervention. This standard provides an overview for all organizations to review their policies, processes, and protocols to prevent threatening behavior and violence and address incidents that have already occurred.

Any organization, from large corporations to government agencies to healthcare facilities, should have certain prevention measures in place, says Randy Spivey, CEO and founder of the Center for Personal Protection and Safety in Spokane, WA, whose organization works with a number of Fortune 100 companies in the area. Failure to follow this standard could have a significant impact when it comes to organizational liability.

"We are seeing a huge wave of organizations responding to preventing violence now," Spivey says. "Before it was one of those nice things to do, but now it's compliance. There is huge civil liability for organizations that don't have it."

Violence by the numbers

Surveys show that violence is still a major issue in healthcare, enough that many employees rank it as a primary safety concern in the workplace. In 2011, the American Nurses Association (ANA) conducted a health and safety survey of 4,600 nurses across the country, uncovering the following statistics concerning workplace violence:

11% of nurses said they had been physically assaulted in the past 12 months. This percentage decreased since the last survey, conducted in 2001, when 17% of nurses indicated they had been physically assaulted.
34% of nurses ranked on-the-job assault as one of their top three safety concerns-an increase from 2001, when 25% of nurses ranked it as a top-three concern.

The increase in concern coupled with the decrease in incidents may indicate that there is more awareness of workplace violence in healthcare, says Adam Sachs, spokesperson for the ANA in Silver Spring, MD. Many states have also passed laws with stricter penalties for those who assault nurses, contributing to awareness throughout the country.

Unclean surgical instruments leads to outbreak

Tue, 01 May 2012 04:00:00 GMT

Unclean surgical instruments leads to outbreak

2009 Texas outbreak highlights improper sterilization

In April and May 2009, a hospital in Texas found seven surgical site infections (SSI) that occurred after arthroscopic procedures. Staff members later determined the infections were caused by Pseudomonas aeruginosa.

A follow-up study, conducted by the CDC and published in the December 2011 issue of Infection Control and Hospital Epidemiology, found that the SSIs were likely due to surgical instruments contaminated with the bacteria during instrument reprocessing. Specifically, researchers identified the source of bacteria as two specific instruments: a handheld arthroscopic shaver used to shave away bone and tissue during surgery, and an inflow/outflow cannula, which is used to suction fluid from the surgical site. Researchers inspected the tools with a tiny video camera and found human tissue and bone in the surgical instruments.

This is not the first time a study has shown such startling discoveries. Research presented to the FDA in June 2011 showed that 350 suction tips used to suction blood and fluid during surgery contained bioburden, blood, bone, and tissue. Even more troubling, nearly all the suction tips still contained the bioburden even after going through the manufacturer's recommended cleaning and disinfection process.

A growing trend

The major question regarding surgical instrument cleaning is why hospitals continue to have problems and infection outbreaks despite a number of resources and regulations. In 2008, the CDC published Guideline for Disinfection and Sterilization in Healthcare Facilities, which listed the following as factors affecting the efficacy of disinfection and sterilization:

Number and location of microorganisms
Innate resistance to microorganisms
Concentration and potency of disinfectants
Physical and chemical factors
Organic and inorganic matter
Duration of exposure
Biofilms

On July 20, 2011, in Joint Commission Online, The Joint Commission reminded healthcare facilities that National Patient Safety Goal 07.05.01 includes requirements for reducing the risk of SSIs, and IC.02.02.01, element of performance 2 focuses solely on sterilization and high-level disinfection.

As noted in the most recent study on the Texas outbreak, many instruments require specific cleaning procedures. This places added emphasis on proper cleaning procedures prior to sterilization, says Steve Gordon, MD, FACP, president of the Society for Healthcare Epidemiology of America, and chairman of the Department of Infectious Diseases at the Cleveland Clinic.

"Some instruments were not designed with cleaning in mind," Gordon says.

Improving procedures

Enhancing the efficacy of sterilization procedures requires hospitals to provide more support for their infection prevention and safety programs. Hospitals should have a centralized sterilization and disinfection department to ensure disinfection processes are streamlined and performed reliably.

Awareness is equally important, and infection control departments should be acutely aware of any spike in SSIs and have the ability to determine its root cause. "They should have ongoing surgical site infection surveillance so if there is something that appears to be unusual-either a pathogen or rate of infection-it will trigger investigation," Gordon says.

Periodic training is also important to keep staff members updated on current recommendations or procedural changes. Any out-of-date manufacturer recommendations should be updated and questions clarified through a company representative.

Briefings on Hospital Safety, May 2012

Tue, 01 May 2012 04:00:00 GMT

Training mitigates risks of norovirus outbreak

Study shows norovirus outbreaks among top risks

A norovirus outbreak may enter a hospital unnoticed, but can quickly transform into a hospital's worst nightmare, potentially forcing the shutdown of entire units to prevent the spread of infection.

According to the study, nearly 60% of the outbreaks were caused by four organisms:

Norovirus (18%)
Staphylococcus aureus (17%)
Acinetobacter (14%)
Clostridium difficile (10%)

Furthermore, 22.6% of the investigations reported unit or department closure, most often associated with norovirus.

Spreading awareness

Protecting employees

Additionally, nonessential staff, students, and volunteers should be excluded from areas that contain a norovirus outbreak.

Just-in-time training

The best way to prepare for a norovirus outbreak is to train staff members ahead of time with disaster scenariosor tabletop exercises involving a wide variety of hospital employees.

An incident command system set up for a norovirus outbreak is also important. See p. 5 for a tool that provides a guide to how a hospital command center should be structured.

She recommends bundling the tools on laminated half-sheets of paper so they are easy to hand out and quick to read during an outbreak.

Involving environmental services

Always use wet, versus dry, cleaning methods to minimize the spread of airborne particles (using vacuums may lead to further surface contamination)
Use single-use cleaning equipment and supplies whenever possible
Clean and disinfect any equipment that is not discarded
Following a vomiting incident in kitchens, buffet, or drink service areas, discard all exposed or unwrapped foods within a 25-foot radius
The following PPE is suggested for environmental services workers to protect themselves from infection:
- Tyvek® overalls
- Boot covers
- Gloves (not vinyl)
- Mask
- Eye protection
- Hair covering (optional)

Sanger recommends also including environmental and food services supervisors and managers during preplanning exercises.

"They have a lot of input," she says. "They are affected by these plans that say, 'Environmental services are going to do this,' but no one tells them that they are needed to do it."

Educating employees on why they need to take extra precautions outside of their normal job responsibilities will help them further understand their role in containing an outbreak, Rhinehart says.

Tabletop exercises

The following are a few keys to a successful tabletop exercise:

Include everyone who might be affected by the disaster. In the case of a norovirus outbreak, you should include departments such as environment and food services in addition to healthcare workers.
Bring everyone into a room, explain the disaster scenario, and provide relevant questions.
Break up into small groups (roughly five per group). The groups can be formed one of two ways:
- Have each group consist of everyone from the same department (e.g., place nurses at one table, doctors at another table, etc.)
- Mix the groups so they include one person from each department
Have the groups answer each of the questions in the scenario. Once everyone is finished, reconvene in a large group for a grand facilitated discussion.

After-action procedures

The Joint Commission has emphasized the need for after-action reports, but not all hospitals are Joint Commission-accredited.

Once the outbreak is under control, safety and infection prevention should collaborate to write a report on what was successful and what should be handled differently.

Staff reluctant to respond to radiological disaster

Healthcare worker survey highlights fears about dirty bomb incident

Fear of the unknown is a common phobia among all demographics. For healthcare workers, the unknown usually comes in the form of a disaster.

"Radiation is a very poorly understood threat, as evidenced in this particular study," Barnett says. "Gaps in knowledge and gaps in training are very much causative of this unwillingness to respond."

Training and education

There are two main reasons why healthcare workers are less inclined to report during a dirty bomb incident, according to Barnett:

Concern for safety in the workplace
Inability to do their job correctly

Building a radiological plan

For example, decontamination procedures are imperative when dealing with radiation exposures. Affected patients should go through a decontamination process outside of the facility.

Barnett notes that rural hospitals should make their own plans to provide support for surrounding urban areas if needed.

A dirty bomb incident in a major city like Washington, DC, or New York City would likely involve national agencies as well, Chao says.

"It would probably incapacitate that area and surrounding areas, so it would require a fairly large-scale response nationally or at least regionally," he says.

Establishing a culture of readiness

To increase the number of healthcare workers willing to respond to a radiological event, hospitals need to focus on their work culture and the message it sends to employees.

National planning scenario: Step-by-step response to a radiological event

Source: ASPR.

Even outside the ED, workplace violence a risk

Violent outbursts aren't restricted to one unit

Workplace violence prevention initiatives traditionally focus specifically on the ED, and with good reason: Statistically, ED staff members see the highest number of potentially violent patients.

Even though high-risk areas like the ED do need focused attention, safety officers and security directors can't neglect other hospital units where random acts of violence can occur.

Internal versus external violence

Overflow of domestic violence into the workplace is one issue that is becoming more prevalent, says Randy Spivey, CEO and founder of the Center for Personal Protection and Safety in Spokane, WA.

Violence can also stem from coworkers in any unit of the hospital. "What sexual harassment was in the '80s and '90s, workplace violence is becoming in this decade," Spivey says.

Recognizing violence

Training staff members to recognize violence is the best

Preventing drug theft in the pharmacy

Thu, 26 Apr 2012 17:48:00 GMT

The hospital pharmacy is a highly sensitive area. With large quantities of potent drugs, it’s a haven for drug addicts looking to get their fix.

Hospitals need to be particularly aware of the risks, both external and internal, that quickly erupt in a pharmacy. Strict access as well as routine audits for drug diversion will help prevent violent incidents, robberies, and internal theft by employees.

Download the PDF by clicking the link above.

Decorative fountains pose safety risk for hospitals

Sun, 01 Apr 2012 04:00:00 GMT

Decorative fountains pose safety risk for hospitals?

Fountains linked to Legionella outbreak?

Despite their aesthetic qualities, more hospitals are finding decorative fountains to be a risky addition to the healthcare setting. Some epidemiology experts have even recommended healthcare facilities eliminate the fountains altogether, given their propensity for harboring dangerous pathogens. ?

Results from a report published in the February issue of Infection Control and Hospital Epidemiology indicate that routine cleaning and maintenance of fountains does not adequately eliminate the risk of bacterial contamination. The study conducted an epidemiologic investigation of an acute outbreak among visitors in a Wisconsin hospital during February and March 2010 that infected five visitors and three outpatients. ?

?There is really no specific procedure that will, with 100% assurance, eliminate the risk of bacteria contamination from these foundations, and unfortunately these fountains are becoming more and more popular,? says Thomas Haupt, MS, an epidemiologist with the Wisconsin Division of Public Health and the study?s lead author. ?

This report is an unfortunate but very real summation of the present state of Legionella control, says Tim Keane, consultant for Legionella Risk Management, Inc., author of Guidelines for Control of Legionella in Ornamental Fountains, and a member of the ASHRAE standard committee that has developed a pending standard for Legionella control. He also authored Chapter 5 of HCPro?s Infection Control During Construction Manual: Policies, Procedures, and Strategies for Compliance, Third Edition, which covers waterborne pathogens. ?

?This was not a ?perfect storm? of unanticipated events?this was an accident waiting to happen,? says Keane. ?What?s surprising is that it took two years to happen.??

In this case, the fountain design had three sources of heat, which contributes to pathogens: submerged lighting, accent lighting, and placement next to an electric fireplace. The fountain also had a submerged pump, which added to the heat load, Keane says.?

?The research from this paper should be a strong wake-up call to the healthcare industry,? he says. ?

However, Keane notes that the study lays too much blame on the fountain itself, and doesn?t place enough emphasis on proper maintenance and testing, which is imperative when it comes to any indoor ornamental water structure. ?

Maintaining your fountain?

Many hospitals already have decorative fountains in their waiting rooms, and some have decided to take them out completely to avoid any risk of a Legionella outbreak, Haupt says. There is a significant amount of work associated with testing and cleaning these fountains on a routine basis, and some facilities can?t keep up.?

?You have to go through routine maintenance, but you also have to test specifically for Legionella,? Haupt says. ?Taking a regular culture for 48 hours does nothing. It has to be on a specific type of media for up to 10 days. It?s expensive, but that?s the only way you should be testing to make sure your fountain is free of Legionella.??

Keane disagrees. Legionella testing is the best method and can be used intermittently, but an effective treatment program should result in the fountain having little or no bacteria, he says. Accordingly, adenosine triphosphate testing, which is instantaneous, or heterotrophic plate count (HPC) testing, which takes two days, can be very effective parts of a verification process.?

Potable water systems inevitably contain bacteria; however, bacteria can easily be controlled in ornamental fountains with localized and limited piping and few components. HPC levels should be maintained at 100 colony-forming units/ml or less in decorative fountains. Since the hospital investigation, the Wisconsin Division of Public Health has developed interim guidelines that establish strict maintenance procedures, including periodic biological monitoring. ?

With the proper equipment and the right maintenance plan in place, Keane argues that fountains can still be viable in hospitals as long as a variety of risk factors are considered. According to Keane, there are five steps for ensuring the proper risk management procedures are in place to minimize Legionella contamination: ?

Step 1: Ensure the fountain?s manufacturer is aware of the risk of Legionella colonization and has designed the unit to minimize that risk. Additionally, any time a hospital undergoes new construction or renovation, it should conduct an infection control risk assessment (ICRA).?

?Hospitals, as well as all building owners, should put the onus on equipment manufacturers to supply the needed information regarding operation and maintenance of their equipment to best control Legionella colonization,? Keane says.?

Hospitals should require manufacturers to include a hazard analysis as well as a critical control points waterborne pathogen control plan that is geared specifically for their equipment. ?

Step 2: Only use biocide treatment programs that are registered with the Environmental Protection Agency (EPA). Hospitals have a legal responsibility to ensure all biocides used have proper material safety data sheets and Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) registration with EPA-approved biocide labels. Also, ensure the biocide is fed and maintained as listed.?

?In the Wisconsin case, the problem is not inherent in all fountains, but mostly from their specific design, their specific installation, and their specific operation,? Keane notes. ?These people did not follow any manufacturer recommendations for biocide treatment. The paper only listed that the circulating pump was maintained per manufacturer?s recommendations.??

Step 3: Ensure the unit is installed properly and not near any heat sources. The fountain tested in the Wisconsin study had multiple heat sources in its design and was located next to an electric fireplace, all of which raised temperatures of the water and promoted the growth of Legionella. ?
Step 4: Ensure the fountain is properly maintained and tested on a routine basis. Because fountains represent small, localized plumbing systems, keeping them free of Legionella is a feasible task.?
Step 5: Ensure the Joint Commission standard requiring a waterborne risk management plan is fully implemented and the fountain is installed per Facility Guidelines Institute (FGI) guidelines and Guidelines for Control of Legionella in Ornamental Fountains. Healthcare facilities whose construction team or designers lack experience in fountain designs frequently employ consultants like Keane to develop ICRAs and waterborne risk management plans.?

Involving infection preventionists?

The risk posed by indoor water fountains underscores the need to involve both infection control and engineering staff members during any renovation or new construction. ?The infection preventionists in Wisconsin were not even aware at the time that these fountains were being put in, and I?m quite sure they would have had some input,? Haupt says. ?

He cites the Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities as one infection prevention resource that reviews specific risk factors promoting the growth of Legionella. The guidelines also address prevention efforts that should be considered in the healthcare environment.?

The engineering and maintenance department should be involved with routine testing and decontamination of the fountain, according to the manufacturer?s instructions. Hospitals should work with the manufacturer to establish maintenance requirements tailored to the specific fountain model. Additionally, the manufacturer or designer should be required to review the Legionella colonization risk associated with the equipment. ?

Risk factors for Legionella growth?

One of the major risk factors for Legionella growth is water temperature. Warm, stagnant water is the perfect environment for bacteria growth; specifically, water that is between 77° and 113°F becomes a haven for growing Legionella, Keane says. Water should always be tested where it is warmest in order to get an accurate reading for Legionella growth.?

High-wattage submerged and overhead lighting, often found in decorative fountains, can contribute to higher temperatures. In the Wisconsin facility, there was also foam installed in the bottom of the fountain to prevent splashing, which further helped the structure serve as a breeding ground for Legionella. ?It had over a million colonies of Legionella, it was unbelievable,? Haupt says. ?So everything worked in favor of the Legionella bacteria with the warm water and the foam. They did preventative maintenance, but they were just fighting a losing battle.??

Fountains that are located near a walkway or entrance pose a high degree of risk, and fountains that include aerosol components or cause significant splashing can spread bacteria and potentially infect patients and visitors. ?They are very beautiful fountains, and their sound is very serene, but they are just a danger to the people who are immunosuppressed,? Haupt says.

Study links workplace chemical exposures to miscarriages among nurses

Sun, 01 Apr 2012 04:00:00 GMT

Study links workplace chemical exposures to miscarriages among nurses?

Data suggests that exposure to chemotherapy drugs and sterilizing agents puts nurses at risk?

It?s no surprise that highly toxic chemicals, found in chemotherapy drugs and sterilizing agents used to clean medical devices, can be harmful to those who don?t take the proper precautions. What is surprising is that exposure to these chemicals continues to be an issue.?

A study published in the American Journal of Obstetrics and Gynecology indicates that pregnant nurses who are exposed to these chemicals, as well as radiation from x-rays, have a greater risk for miscarriage. Nurse who are exposed to chemotherapy drugs are twice as likely to have a miscarriage in the first trimester, and nurses who are exposed to sterilizing chemicals are twice as likely to have a miscarriage in the second trimester. ?

Researchers surveyed nearly 7,500 nurses who had been pregnant between 1993 and 2002, asking them to recall how often they worked with particular chemicals and equipment. This created some weaknesses in the study since researchers could not accurately determine how long each woman came in contact with the hazardous chemicals, and nurses were asked to remember exposures as far back as eight years. ?

?With the chemotherapy drugs, we were not necessarily surprised to see the effect we found, but I guess the fact that we?re seeing it as late as 2001, when we submitted the questionnaire, is surprising,? says Christina Lawson, PhD, epidemiology team leader for the National Institute for Occupational Safety and Health (NIOSH) in Cincinnati and lead author of the study. ?We have been working towards promoting safety precautions when working with these drugs, especially during pregnancy, but it seems like we still have more work to do.??

Where?s the gap??

The underlying issue exposed with the publication of this study is not simply miscarriages from exposure to hazardous drugs?it?s the possible reasons those exposures occur in the first place.?

?It could be that we need to do more education or more frequent education,? Lawson says. ?It could be that people are educated but are not following the guidelines. Or it could be that the guidelines are not protective enough.??

From a training perspective, hospitals need to train nurses more diligently on appropriate protective measures, along with providing continuous reminders. Nursing shortages in healthcare mean that nurses have less time to stay up to date with current guidelines, so safety officers should maintain a dialogue with them and have an open-door policy for nurses to contact them regarding any safety concerns.?

Training programs should also focus specifically on women who are pregnant or may become pregnant, especially if they will be handling chemotherapy drugs or sterilizing agents. ?If you are a patient with cancer, the benefit of taking these very strong drugs is in your favor, you need to do it,? Lawson says. ?But if you?re working with them, and you?re working with them every day, there is no benefit to you.??

Lawson says she is currently reviewing policies in the United States and other countries to see whether safety guidelines should include alternative duty options for nurses who are pregnant. NIOSH has published guidelines for protection against hazardous chemicals, but they do not include recommendations for alternative duty. ?

?NIOSH isn?t quite there yet, but we are looking into it,? Lawson says. ?I think that women and nurses who work with these drugs, if they have concerns, they should be open to talking with their employers. And I would hope the employers are open to talking about it.??

Reinforcing radiation safety?

Employee safety training should also include frequent reminders regarding the use of x-ray equipment. In addition to complications regarding chemical exposure, the study also showed that nurses who gave patients x-rays were about 30% more likely to have a miscarriage.?

Employees should be trained and reminded to wear a leaded apron or stand completely inside the safety booth if they are in an x-ray examination room. Nurses should also be aware of the different ways they can be exposed to radiation, which the study authors list by order of intensity: ?

X-rays?
CT scans?
Floroscopies ?
Radioactive isotopes?
Radioactive implants ?

?It?s the type of hazards you don?t see or hear, so people may tend to get a little careless with their protective equipment,? Lawson notes.?

Safety isn?t just limited to the x-ray suite either. More facilities are deploying mobile x-ray units to ?use in the patients? rooms?these units are convenient, but present more potential exposure risk if employees aren?t following the personal protective guidelines. ?

NIOSH guidelines for hazardous drugs in healthcare?

The following recommendations, published by the National Institute for Occupational Safety and Health (NIOSH) in 2004, cover the prevention of occupational exposures to antineoplastic and other hazardous drugs:?

Assess the workplace, including:?
- Equipment such as personal protective equipment (PPE) and ventilated cabinets?
- The physical layout ?
- Types of drugs being handled ?
- Equipment maintenance?
- Waste handling, decontamination, and cleaning procedures?
- Spill response?
Regularly review the current inventory of hazardous drugs, with input from staff members?
Conduct regular training reviews with all potentially exposed workers where hazardous drugs are used?
Implement a program for safely handling hazardous drugs and review this program annually?
Establish procedures for handling drugs, cleaning up spills, and using PPE?
Establish work practices related to drug manipulation techniques, such as not permitting eating or drinking where drugs are handled?
Develop workplace procedures for using and maintaining all equipment that reduces exposures

Heat may replace chemicals in the fight against bedbugs

Sun, 01 Apr 2012 04:00:00 GMT

Heat may replace chemicals in the fight against bedbugs?

Traditional pesticides have shown to be toxic to humans, opening the door for safer and more effective treatments using heat?

Bedbugs are an issue that many hospitals encounter, but few want to talk about. Usually the tiny critters provoke thoughts of seedy motels or dirty mattresses, but in truth, even the cleanest environment can have an infestation?and sometimes it?s not apparent until it spirals out of control. ?

For that reason, hospitals encountering a problem with bedbugs need a quick and efficient way to detox patient rooms with minimal disruption. ?

In the past, hospitals have relied heavily on chemical treatment of bedbug infestations, but recent reports have shown that bedbugs may be building up resistance to these chemicals, and heat-based treatments may offer a more effective and safer solution.?

Now the Centers for Disease Control and Prevention (CDC) has thrown its support behind the use of heat treatments in place of chemicals. The September 23, 2011, Morbidity and Mortality Weekly Report indicated that bedbug infestations are increasing in the United States and internationally. However, the bedbugs? growing resistance to insecticides has led to a greater use of chemicals, which can have potentially harmful effects on humans.?

?Bedbug infestations often are treated with insecticides, but insecticide resistance is a problem, and excessive use of insecticides or use of insecticides contrary to label directions can raise the potential for human toxicity,? according to the report. ?

Research conducted by the CDC from 2003 to 2010 showed 111 cases of illnesses from insecticides in seven states. The most common contributing factors included:?

Excessive insecticide application?
Failure to wash or change pesticide-treated bedding?
Inadequate notification of pesticide application?

The CDC recommends more judicious use of chemicals and calls for insecticide labels that are easier to read and understand in order to prevent overuse, which can lead to illnesses associated with bedbug control. The agency also recommends increasing hospital awareness of nonchemical interventions for dealing with bedbug infestations.?

The use of heat is among the more effective nonchemical treatments that have proven useful in the healthcare environment, where chemicals present a greater degree of danger to immunosuppressed patients.?

?The CDC has been very positive about the use of heat instead of chemicals because the chemicals are injuring people,? says David Hedman, president and CEO of ThermaPureHeat in Ventura, CA. ?Needless to say it?s a sensitive area where people are bedridden or sleeping, particularly in children whose faster metabolism may increase their propensity for chemical injury.? ?

The downside to pesticides?

As the CDC notes, bedbugs can develop a resistance to chemical treatments, forcing pest control companies to use stronger chemicals or multiple treatments. ?

Pesticides usually don?t eradicate infestations in a single treatment, since they kill the adult bugs that come in contact with the chemical but do not affect the eggs; thus, another chemical treatment is required to completely eliminate the problem, says Larry Chase, vice president of ThermaPureHeat. ?

?What we are seeing is pest control operators try and solve that problem by applying more chemicals, which makes it worse from a health standpoint,? Chase says.?

More frequent use of stronger chemicals further increases bedbugs? resistance to those chemicals, prompting pest control managers to employ even stronger pesticides that pose a greater risk to human health.?

The process of heat treatment?

Heat-based treatments essentially pasteurize the entire treatment area, raising temperatures to 100º?130ºF and sometimes as high as 170º. Heating an area to pasteurization levels allows the heat to penetrate walls and cavities, completely eradicating the infestation in the area. ThermaPureHeat also uses thermal imaging to ensure all areas of the affected space reach the appropriate heating levels. ?

?If there is a cold spot, we could fail, so thermal imaging is a powerful tool for use to make sure that that entire area reaches the required temperature,? Hedman explains. ?

The treatment process typically takes from four to eight hours depending on the size and shape of the room. ?It depends on the complexity of the space, how easy it is to get the heat into the space, how many things need to be protected, how many things need to be removed, or if anything does need to be removed,? Chase notes. ?So it will vary, but a very simple space can be done quite quickly.??

Heat also has the advantage of killing all life stages of bedbugs, even eggs, which are microscopic and difficult to identify.?

Treating an outbreak quickly?

For healthcare facilities, speed is key to treating a bedbug problem. Infestations often occur in an entire unit, rather than an isolated area?and to make matters worse, indications of bedbugs, such as bites, usually don?t appear until the infestation is widespread. ?It typically isn?t until we have a major infestation that we begin getting visual sightings from staff and patients,? Hedman says.?

Adult bedbugs can lay 500 eggs over their lifetime (typically one year), meaning it only takes a few months for a full-blown outbreak to develop. ?

?One of the things we do is clearly identify the size and the spread of the infestation so you know you are treating the appropriate spaces,? Chase says. ?A lot of times what happens is someone will make a determination that a bedbug is in a certain room and they will only try and treat that room without looking to see if the infestation is spread beyond that. So part of the control measure is determining the size of the problem.? ?

In some situations, dogs are used to determine the size and scope of an affected area, Hedman says. Bedbugs give off a specific scent or pheromone; canines can be used to detect this scent and determine whether an infestation is limited to just a couple of rooms, or whether it?s manifested into a bigger problem. As soon as hospitals identify an infestation, they should isolate the area. ?

The things they carry?

A study published in May 2011 in the Centers for Disease Control and Prevention (CDC) Emerging Infectious Diseases indicates that bedbugs themselves may not be the only worrisome part of an infestation. ?

Researchers in Vancouver, British Columbia, studied bedbugs taken from three patients treated at St. Paul?s Hospital in Vancouver and found the bugs were carrying traces of MRSA and VRE. ?These insects may act as a hidden environmental reservoir for MRSA and may promote the spread of MRSA in impoverished and overcrowded communities,? study authors wrote. ?Bedbugs carrying MRSA and/or VRE may have the potential to act as vectors for transmission.??

Another study, published June 2011 in Indoor Air, the International Journal of Indoor Environment and Health, reaffirmed some of these concerns. Researchers from Natural Link Mold Lab demonstrated that bedbugs were capable of carrying microbial pathogens.?

Although neither study was able to prove that the bedbugs actually transmitted disease, it was previously thought that bedbugs didn?t carry such pathogens at all. Thus, the findings from these studies indicate that patients may be at greater risk in the event of a bedbug outbreak. ?

The studies may serve as another reason for hospitals to consider heat-based treatment over the use of chemicals. Pasteurizing rooms can kill the bedbugs along with potentially dangerous pathogens they may be carrying.

CMS releases updated requirements for machine �maintenance

Sun, 01 Apr 2012 04:00:00 GMT

CMS releases updated requirements for machine maintenance?

A clarification from CMS indicates that hospitals need to follow manufacturers? instructions for maintenance frequency and techniques?

On December 2, 2011, CMS released a statement clarifying hospital equipment maintenance requirements. Section 482.41(c)(2) of the Federal Register requires healthcare facilities to maintain and ensure an acceptable level of quality and safety, and document maintenance activities.?

The CMS memorandum, effective immediately, addressed the following two issues regarding maintenance schedules and methods:?

The manufacturer-recommended maintenance frequency is required for:?
- All equipment that is critical to patient health ?and safety?
- Any new equipment until a sufficient amount of maintenance history has been acquired?
Hospitals must continue to follow the manufacturer?s recommended techniques for maintaining equipment, even if they alter the frequency of that maintenance?

?Equipment that is critical to patient health and safety is not a candidate for an alternative, less frequent maintenance activity schedule,? the memo reads. ?Such equipment must be maintained at least as often as the manufacturer recommends.??

Noncritical equipment maintenance frequencies can be adjusted below the recommendations of the manufacturer as long as this decision is based on a documented, strategic, evidence-based assessment conducted by qualified personnel, such as clinical or biomedical technicians or engineers.?

Clashing with The Joint Commission?

The CMS memo comes 18 months after The Joint Commission indicated that CMS would align with the accreditation organization in allowing the use of alternative preventive maintenance schedules. The announcement has led The Joint Commission, the Association for the Advancement of Medical Instrumentation, and the ECRI Institute to form an informal coalition and begin accepting comments on the ruling. The coalition plans to use these comments during its discussions with CMS.?

?This change by CMS will create a major dilemma for many people in the field who do follow manufacturers? [preventive maintenance] standards,? says Alan Lipschultz, CCE, PE, CSP, president of HealthCare Technology Consulting, LLC, in Wilmington, DE. ?The Joint Commission said they convinced CMS to allow folks to put their own experience and judgment into the mix as well as the manufacturer. CMS has swung both ways on this issue.??

Under the Environment of Care standards (EC.02.04.03), The Joint Commission requires hospitals to perform and document maintenance, inspection, and safety checks of medical equipment based on their own criteria. That should include considerations from the manufacturer, but hospitals have not been handcuffed to the manufacturer?s manual in terms of preventive maintenance frequency and techniques.?

?What the Joint Commission has never done is tell any hospitals the details of how to maintain their equipment,? says Bruce Barkalow, PhD, PE, CCE, president and founder of B.H. Barkalow, PC, in Newaygo, MI. ?They never said you have to follow the manufacturer?s recommendations, for example. I can?t remember a time ever where it?s been forced on hospitals that they have to follow the manufacturer?s recommendations.??

The decision by CMS to go in the opposite direction has some people questioning the importance of manufacturers? instructions, believing the new requirement will be more onerous and costly for hospitals. Furthermore, there are instances where the manufacturer?s instructions aren?t feasible for the clinical setting, notes Lipschultz.?

?Certainly in my experience, before I became a consultant, there were times I had looked at what the manufacturer had written and said, ?This is nonsense, I can?t believe they wrote that,? ? he says. ?And I would go to the manufacturer?s field service person and ask them if they were doing a yearly inspection on this device, what would they do? And a lot of times, off the record, they would say they would do a lot less than what the procedure book says.??

Defining critical equipment?

The updated CMS rule requires healthcare facilities to follow manufacturer procedures for the maintenance of all equipment. But following the manufacturer?s instructions regarding the frequency of that maintenance applies only to new equipment and equipment critical to patient safety and health. However, defining exactly what constitutes critical equipment may be a hurdle for some hospitals, Barkalow says. ?

According to the CMS memo, critical equipment includes:?

Life support devices?
Key resuscitation devices?
Critical monitoring devices?
Equipment used for radiologic imaging?
Other devices whose failure may result in serious injury or death of patients or staff?

Examples of critical equipment include defibrillators, heart and lung machines, ventilators, and anything that has to do with life support and resuscitation, says Barkalow. ?

?But there is probably a large gray area as to what is defined as a critical device, and I think that will have to be sorted out,? he says. ?I don?t know of any agency that is willing to state what a critical device is because of different methods of use for different conditions on a range of patients, so I think CMS will be put in an uncomfortable position of trying to define it.??

Conducting a gap analysis?

Regardless of whether the new ruling is a benefit or a detriment to hospitals and clinical engineering departments, the CMS clarification has taken effect, which means inspectors will presumably expect to see hospitals adhering to manufacturer recommendations for equipment maintenance. ?

?Whether they are really going to start enforcing it, and how rapidly they are going to enforce it, is open to question, I think?but you at least need to have that conversation with your senior management, risk management, and financial folks because if you are not following manufacturers? recommendations, this is going to be a risk,? Lipschultz says. ?

He suggests performing a gap analysis that compares current preventive maintenance processes for patient care machines to the manufacturer?s instructions to see how well they coincide with one another.?

Presumably, most hospitals will have taken the manufacturer?s recommendations as a jumping-off point and developed their processes from there, Lipschultz says. ?Maybe five or 10 years ago they started doing something differently, and they may not have good documentation as to why they deviated,? he notes.?

It?s also important to contact the manufacturer to ensure you have the most current manual, Barkalow says. Some hospitals might be working off old recommendations that date back to when they purchased the equipment.?

Most importantly, hospitals need to assign someone to work out the details of how the CMS change affects hospital policies and procedures. ?

?Someone needs to be designated to this issue,? Lipschultz says. ?You need to look at your equipment management plan and see what it says. Some might say specifically that the institution is not required to follow the manufacturer?s instructions, so that language needs to be reworked.??

Build a model-specific plan ?

The gap analysis for critical care equipment needs to consider features specific to individual models, Barkalow says. As a consultant, he used to set up medical equipment programs for hospitals, and structured preventive maintenance schedules and techniques around the specific model type. ?

?There are differences, for example, between a LifePak 15® defibrillator and LifePak 500® AED,? he says. ?So everything in the programs that I dealt with, we always made it model-specific.??

After tracking failure rates of equipment every six months, Barkalow quickly found there was an 80/20 rule that applied to all equipment in general.?

?Eighty percent of all the repairs and problems came from 20% or less of the total inventory,? he says. ?That means you could focus in on that portion and find out what is going wrong and put a plan of action into place and work towards your ultimate goal of no failures.??

One concern is that manufacturers don?t have the same accountability as hospitals when it comes to producing recommendations that are feasible for the hospital and ensure the safety of the machine, Lipschultz says. ?

?There is no incentive on the part of the manufacturer to come up with something that is necessarily realistic,? he says. ?I think what a lot of manufacturers do is take what they wrote for their final quality assessment process, copy it over, and say, ?Do this every year.? It?s the path of least resistance; they don?t have to say, ?This is what we do at the factory, but this is what would be realistic in the field.? ??

However, Barkalow believes the CMS directive creates a de facto partnership between the hospitals and the manufacturers. The FDA requires manufacturers to track complaints about their equipment and then conduct corrective and preventive action investigations. Any changes can be forwarded to the hospitals to allow them to adjust their maintenance frequency accordingly.?

?I actually think it might make things better because it gives the hospitals a partner that is working towards the minimization of failures of medical devices,? says Barkalow. ?That?s what the manufacturers are dedicated to doing, and if they provide the updated guidance to the hospitals, I can?t see that as a bad thing.? ?

Legal implications of maintaining equipment?

For hospitals, the new CMS requirements may have legal implications, particularly if documented preventive maintenance procedures do not align with the manufacturer?s instructions. Hospitals are often roped into lawsuits involving adverse outcomes because they typically own the equipment and allow the device to be used on their premises. If the equipment malfunctions, and there is an indication that more could have been done regarding its maintenance, the hospital may be liable for the resulting adverse event. ?

?I would think, from a legal standpoint, if you have a problem in your hospital and there is a question about what you were doing in the way of preventative maintenance, and you haven?t been following the manufacturer?s instructions, all of a sudden the ground is starting to look a lot shakier under your feet until this issue is resolved,? says Alan Lipschultz, CCE, PE, CSP, president of HealthCare Technology Consulting, LLC, in Wilmington, DE. ?

Equipment failure is a primary cause of preventive device maintenance being brought up in a legal battle, says Bruce Barkalow, PhD, PE, CCE, president and founder of B.H. Barkalow, PC, in Newaygo, MI, who conducts forensic investigations for cases involving adverse outcomes with medical devices. ?

?I?ve seen that play a major role in a hospital?s liability and ultimate outcome of these cases,? he says.

Help! There's a celebrity in my hospital!

Sun, 01 Apr 2012 04:00:00 GMT

Help! There?s a celebrity in my hospital!?

VIP patients require planning and preparation for security and clinical staff?

In a perfect world, all patients would be treated equally, regardless of their name, income, or job title.?

But in the hospital security world, all of these factors are crucial considerations to properly protect famous or high-profile patients and comply with HIPAA laws that aim to protect the privacy of any patient. ?

The title of VIP isn?t just reserved for nightclubs. Hospitals should have a plan in place for VIPs who enter the facility either on an emergency basis or for a planned visit. ?

The most recent example of VIP care occurred in January, when two high-profile musicians, singer Beyoncé and hip-hop artist Jay-Z, were admitted to Lenox Hill Hospital in New York City for the birth of their baby girl. According to the New York Daily News, the couple paid $1.3 million to rent out the entire fourth floor of the hospital. ?

Some patients openly complained about the VIP treatment, claiming bodyguards treated the wing like ?an exclusive nightclub? and allegedly barred one new father from the sixth floor neonatal ICU. In an effort to keep images from leaking to the public, tape was placed over security cameras and employees were forced to turn off their cell phones when they arrived for their shifts, according to the Daily News. ?

VIP patients can be a source of significant revenue for the hospital, says Bernard J. Scaglione, CPP, CHPA, CHSP, director of security at New York-Presbyterian Hospital/Weill Cornell campus and a principal partner at The Security Design Group in New York City. In the case of Lenox Hill, hospital safety and security had to go above and beyond the usual patient standards to protect the privacy of not just one, but two VIP patients.?

?You have to remember that the VIP is paying for that service; it?s not like they offer it for free,? Scaglione says. ?That?s why they get that service, because they are paying for it.??

Accompanied with that revenue is the planning and preparation that goes along with caring for and managing VIP patients. Hospitals should establish a strict security plan, involving officers, doctors, and nurses, to accommodate a VIP. ?

Preparation is crucial?

By default, hospital security is a very reactive department, but handling VIP patients is one area where security directors have the opportunity to plan ahead.?

?VIP planning and what happens with a VIP falls very heavily in the proactive side as far as what security can do and should do,? says Anthony Luizzo, PhD, CFE, CST, PI, president and CEO of LC Security Consultant Group in New York City. Luizzo and Scaglione coauthored ?Aspects of Hospital Security: Protecting the VIP,? published in the Journal of Healthcare Protection Management in 2011.?

When VIPs plan a hospital visit, such as for the birth of a baby, it?s easier to accommodate these patients since their general arrival time is known in advance. Hospitals should work out the details with the VIPs and their handlers months before their scheduled arrival. ?

?Generally what happens with the VIPs is sometimes they will just take one room, sometimes they will take two, and depending on who it is, sometimes they will take more,? Scaglione says. ?It?s really an issue of planning out when they are going to get there, how they are going to get there. When it comes to a baby being born, you usually have a window of about 10 days that you can plan on.??

Emergency situations are naturally more difficult to plan for, but security departments should still have a basic plan in place for the arrival of a VIP patient. Some hospitals even keep a few VIP rooms open in case of an emergency.?

?In those situations, the patients in the hospital come first,? Scaglione says. ?If it?s an emergency, they get one room, whatever room they can get them in, and as patients are discharged or voluntarily willing to move, you can give the VIP more space.??

Can you keep a secret??

The primary concern when housing a VIP patient is privacy and confidentiality. ?

Anyone who expects to come in contact with the VIP should have some kind of involvement with planning. Clinicians, including doctors and nurses on the unit, and support staff members, such as dietary staff and environmental services, all need to be notified, with the understanding that the patient?s privacy is paramount. ?

?All the hospitals that have handled a lot of VIPs have experienced that one employee that wants to see the medical record or wants to leak out the fact that VIP is there,? Scaglione says. ?

Remind the staff that no one should know the VIP is there for any reason, whether it?s the media or even other hospital patients or visitors, Luizzo says.?

?The most important thing is that no one knows that a VIP is there,? he says. ?That?s really the best you can do. People may know that certain hospitals are always handling VIPs, but it?s really important for the staff that no one knows unless they have to.? ?

Scaglione says hospitals can gauge their success on how few people know a VIP was even there.?

?My wife loves David Letterman, and when she finds out over the news that he?s in the hospital because I haven?t told her, that?s when I know I?m successful because no one should know for any reason that there is a VIP in the hospital,? he says. ?

Handling visitors and the media?

Protecting VIPs from the media can be particularly difficult when treating celebrities who may be stalked by multiple entertainment media outlets or pestered by paparazzi. Hospitals should provide additional security to patrol the floor, stairwells, and the hospital grounds. ?

?A lot of times paparazzi will come up as a guest or visitor of another patient, so it?s really just about staying on top of it,? Scaglione says.?

Security departments should work with VIPs and their handlers to establish a visitor list that is restrictive, but also flexible in case the VIPs leave someone off the list by accident. ?

Often a VIP patient will also attract other VIP visitors, Luizzo says. This creates additional security and privacy considerations for all VIPs involved. ?

?A good example is when we had the king of Saudi Arabia in our hospital and the vice president wanted to visit him,? Scaglione says. ?It can potentially be a problem.??

Working with outside agencies?

VIPs will often have their own security, whether it?s private guards for a celebrity or the Secret Service for a government employee. Hospitals need to coordinate with these third-party teams to determine who will be at the hospital and the roles each party will play. ?

Security officers have the advantage of knowing the layout of the building and being familiar with the staff members on each floor. Officers should work in conjunction with the VIP?s private security to control visitation and privacy.?

?There?s a lot of work and synergism between the departments and agencies, but the bottom line is when you get a group of professionals sitting down and coordinating something like that, it works,? Luizzo says.

Briefings on Hospital Safety, April 2012

Sun, 01 Apr 2012 04:00:00 GMT

Decorative fountains pose safety risk for hospitals?

Fountains linked to Legionella outbreak?

?This was not a ?perfect storm? of unanticipated events?this was an accident waiting to happen,? says Keane. ?What?s surprising is that it took two years to happen.??

?The research from this paper should be a strong wake-up call to the healthcare industry,? he says. ?

Maintaining your fountain?

Step 1: Ensure the fountain?s manufacturer is aware of the risk of Legionella colonization and has designed the unit to minimize that risk. Additionally, any time a hospital undergoes new construction or renovation, it should conduct an infection control risk assessment (ICRA).?

Hospitals should require manufacturers to include a hazard analysis as well as a critical control points waterborne pathogen control plan that is geared specifically for their equipment. ?

Step 2: Only use biocide treatment programs that are registered with the Environmental Protection Agency (EPA). Hospitals have a legal responsibility to ensure all biocides used have proper material safety data sheets and Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) registration with EPA-approved biocide labels. Also, ensure the biocide is fed and maintained as listed.?

Step 3: Ensure the unit is installed properly and not near any heat sources. The fountain tested in the Wisconsin study had multiple heat sources in its design and was located next to an electric fireplace, all of which raised temperatures of the water and promoted the growth of Legionella. ?
Step 4: Ensure the fountain is properly maintained and tested on a routine basis. Because fountains represent small, localized plumbing systems, keeping them free of Legionella is a feasible task.?
Step 5: Ensure the Joint Commission standard requiring a waterborne risk management plan is fully implemented and the fountain is installed per Facility Guidelines Institute (FGI) guidelines and Guidelines for Control of Legionella in Ornamental Fountains. Healthcare facilities whose construction team or designers lack experience in fountain designs frequently employ consultants like Keane to develop ICRAs and waterborne risk management plans.?

Involving infection preventionists?

Risk factors for Legionella growth?

Study links workplace chemical exposures to miscarriages among nurses?

Data suggests that exposure to chemotherapy drugs and sterilizing agents puts nurses at risk?

Where?s the gap??

The underlying issue exposed with the publication of this study is not simply miscarriages from exposure to hazardous drugs?it?s the possible reasons those exposures occur in the first place.?

Reinforcing radiation safety?

X-rays?
CT scans?
Floroscopies ?
Radioactive isotopes?
Radioactive implants ?

?It?s the type of hazards you don?t see or hear, so people may tend to get a little careless with their protective equipment,? Lawson notes.?

NIOSH guidelines for hazardous drugs in healthcare?

Assess the workplace, including:?
- Equipment such as personal protective equipment (PPE) and ventilated cabinets?
- The physical layout ?
- Types of drugs being handled ?
- Equipment maintenance?
- Waste handling, decontamination, and cleaning procedures?
- Spill response?
Regularly review the current inventory of hazardous drugs, with input from staff members?
Conduct regular training reviews with all potentially exposed workers where hazardous drugs are used?
Implement a program for safely handling hazardous drugs and review this program annually?
Establish procedures for handling drugs, cleaning up spills, and using PPE?
Establish work practices related to drug manipulation techniques, such as not permitting eating or drinking where drugs are handled?
Develop workplace procedures for using and maintaining all equipment that reduces exposures

Heat may replace chemicals in the fight against bedbugs?

Traditional pesticides have shown to be toxic to humans, opening the door for safer and more effective treatments using heat?

For that reason, hospitals encountering a problem with bedbugs need a quick and efficient way to detox patient rooms with minimal disruption. ?

Research conducted by the CDC from 2003 to 2010 showed 111 cases of illnesses from insecticides in seven states. The most common contributing factors included:?

Excessive insecticide application?
Failure to wash or change pesticide-treated bedding?
Inadequate notification of pesticide application?

The downside to pesticides?

As the CDC notes, bedbugs can develop a resistance to chemical treatments, forcing pest control companies to use stronger chemicals or multiple treatments. ?

?What we are seeing is pest control operators try and solve that problem by applying more chemicals, which makes it worse from a health standpoint,? Chase says.?

The process of heat treatment?

?If there is a cold spot, we could fail, so thermal imaging is a powerful tool for use to make sure that that entire area reaches the required temperature,? Hedman explains. ?

Heat also has the advantage of killing all life stages of bedbugs, even eggs, which are microscopic and difficult to identify.?

Treating an outbreak quickly?

Adult bedbugs can lay 500 eggs over their lifetime (typically one year), meaning it only takes a few months for a full-blown outbreak to develop. ?

The things they carry?

CMS releases updated requirements for machine maintenance?

A clarification from CMS indicates that hospitals need to follow manufacturers? instructions for maintenance frequency and techniques?

The CMS memorandum, effective immediately, addressed the following two issues regarding maintenance schedules and methods:?

The manufacturer-recommended maintenance frequency is required for:?
- All equipment that is critical to patient health ?and safety?
- Any new equipment until a sufficient amount of maintenance history has been acquired?
Hospitals must continue to follow the manufacturer?s recommended techniques for maintaining equipment, even if they alter the frequency of that maintenance?

Clashing with The Joint Commission?

Defining critical equipment?

According to the CMS memo, critical equipment includes:?

Life support devices?
Key resuscitation devices?
Healthcare workers top injury and illnesses list

Healthcare more dangerous than mining, construction

Their jobs revolve around helping people recover from injuries and illnesses, yet healthcare workers have the highest risk for injury themselves, surpassing nearly every industry-including mining, manufacturing, and construction.

According to a report released by the U.S. Bureau of Labor and Statistics on workplace injuries and illnesses in 2010, healthcare workers experienced an injury/illness incidence rate of 5.2 out of every 100 full-time workers, a number well ahead of the private construction sector (4.0), manufacturing (4.4), and natural resources and mining (3.7).

Specifically, healthcare injuries were broken down into the following sectors-out of these, nursing homes led the way in injuries:
- Ambulatory healthcare services: 2.8
- Hospitals: 7.0
- Nursing and residential care facilities: 8.3
The reason for these elevated statistics is because in addition to some of the general musculoskeletal issues that almost every industry faces, healthcare also has to deal with unique hazards like needlesticks, says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety at Marshfield (WI) Clinic.

"We are as dangerous as any industry out there," Cunha says, "plus we have things they don't have. We have biological agents, we have bloodborne pathogens, we have radiation, and we have lasers. And then we have back injuries just like everyone else with lifting, pushing, and pulling."

Differentiating healthcare injuries

As Cunha points out, healthcare injures can be categorized into several distinct groups, including bloodborne pathogen exposures; chemical exposures; slips, trips, and falls; and back injuries. Below are some common issues safety officers face:
- Needlesticks. The Bureau of Labor and Statistics doesn't break down injuries according to type, but Cunha says injuries such as needlesticks are likely to elevate the healthcare worker injury rate above other industries. OSHA estimates there are roughly 800,000 needlestick injuries each year.
Although OSHA's Needlestick and Safety Prevention Act has helped drastically reduce the number of injuries, Cunha says operating rooms still face the biggest uphill battle. OSHA recommendations call for surgeons to use blunted suture needles, but they can only be used in certain situations, and safety scalpels don't always offer the precision of regular scalpels.

For general exposure protection measures, safety officers need to be involved with purchasing safety needles that are effective and easy to use. Employees should be trained on how to use safety needles to reduce the risk for a sharps injury.
- Back injuries. Musculoskeletal injuries are a big issue in healthcare facilities, especially among nurses and aides who frequently need to push, pull, or turn heavy patients. Cunha says many hospitals have instituted team lifting programs or purchased devices to help with lifting, but injuries still occur because employees are often too busy to employ proper methods.
Cunha says Marshfield has a high rate of knee and back injuries thanks to employees pushing heavy patients in wheelchairs. "Nobody worried about pushing 500-pound patients five or 10 years ago," Cunha says. "Now it's not unusual at all for hospitals to have patients that are over 300 pounds."
- Slips, trips, and falls. While there is always the risk that employees will be injured inside the facility by slipping on a wet surface or tripping over equipment, Cunha says most of the injuries at Marshfield Clinic occur while going to and from the parking lot. Outdoor areas are particularly precarious during the winter months in Wisconsin, which bring heavy snowfall and create icy sidewalks, entrances, and parking lots.
Hospitals in regions affected by ice and snow should have a plan for sufficiently clearing pathways during winter storms and have the appropriate equipment (salt, shovels, and plows) to prevent falls outside the building.

Make it easy

In general, healthcare workers are aware of the risks they face during their job every day. However, problems arise when competing interests take priority over safety.

To avoid the pitfalls of human nature and higher priorities, Cunha says safety officers need to incorporate safety measures seamlessly into everyday tasks. As an example of how not to do things, he points to the U.S. Postal Service, which required reeducation for injured workers on proper lifting techniques.

"A researcher came in and looked at the results of that training and found they had highly educated injured employees," Cunha says. "The retraining didn't necessarily reduce the amount of injuries."

The trick is to integrate safety measures into workers' routines so they don't need to take more time during a procedure to actively think about safety.

Putting safety on the shoulders of leadership

If there's one group to blame for the high rate of healthcare worker injuries, it's hospital leadership, says Paul O'Neill, non-executive chair of Value Capture, LLC, in Pittsburgh and former secretary of the U.S. Treasury and CEO of Alcoa.

After the statistics were released, O'Neill publicly singled out healthcare leadership, particularly at the University of Pittsburgh Medical Center (UPMC), which employs 54,000 workers.

Unfortunately, the leadership at UPMC is not unique, he says; in fact, it serves as a snapshot of most medical facilities in the country.

"For me, the reason the injury rates are so high in healthcare is because as a general matter, the people who are in charge of health and medical facilities don't really care about their people," O'Neill says. "Because if they did, they would learn from the activity of other organizations that it's possible to have an injury-free workplace, and they would make that a precondition for their work."

O'Neill says leaders need to set aggressive goals for their organization, starting with the objective that no one should get hurt on the job. Then they should back up those objectives with a systematic action plan that would improve and eliminate workplace injuries.

He points to Cincinnati Children's Hospital, which publishes its injury rates online-rates significantly lower than other hospitals. The hospital did this in part by teaming with Celanese, a chemical company with a history of excellent worker safety. Celanese was able to show the healthcare system ways to virtually eliminate injuries by adopting some of the safety principles from the chemical and manufacturing industry.

Achieving excellence

One issue O'Neill sees as a detriment to worker safety is that hospitals focus too much on small projects devoted to one particular area, rather than focusing on an overarching system of excellence.

"There has been an even more concentrated level of attention paid to certain kinds of hospital-acquired infections-for example, central line-associated bloodstream infections," he says. "That's all wonderful, but if those project efforts to concentrate on a particular activity exist in an institution that aside from those projects is not habitually excellent, then that will creep back into the project areas as soon as people stop paying attention."

The ultimate goal is to improve safety processes until they are second nature, O'Neill says. Worker safety should be an automatic focus rather than a small concentrated project.

"That's what's wrong with healthcare," he says. "[Leaders] don't really change the system. They just do projects and congratulate themselves and then revert back to where they were."

Safety initiatives have to come from the top down, O'Neill says-meaning healthcare leaders need to change the way they think about and approach safety in their institution.

"You cannot cause what needs to be done to happen from the bottom up," he says. "This needs to begin with leadership or it doesn't ever begin. If the leaders don't call out the need and facilitate the creation of systems of continuous learning and continuous improvement, then it's just a life of projects that have a shooting-star mentality; it gets results, but they don't last."