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The reader--and others we’ve been in touch with--wondered how patients in a corridor impacted Life Safety Code requirements for minimum corridor width.
I think this is going to end up going much the same route as the alcohol-based hand gel dispensers, in that there's going to have to be some “come-to-Jesus” agreement about how these conditions can be managed appropriately.
The fact of the matter is, and especially now that the economy has gone in the toilet, the likelihood of there being more, bigger EDs has been significantly reduced. Since the patient population seems not to be diminishing, the issue of having to manage influxes of patients is going to remain an almost daily occurrence in healthcare.
Where the rubber meets the road would be how to we get these hallway patients out if there's a problem that would require evacuation--that's where the real risk is.
When patients come to the hospital, you have to take care of them, otherwise you run risks of running afoul of EMTALA (which is not in my area of expertise--maybe there's someone in the legal section of things who can discuss this aspect).
Bottom line? I don't think the issues behind the study are going away anytime soon, but there are certainly ways of appropriately managing that type of patient volume. It's not just life safety issues; there are also care issues that need to be considered (e.g., how do you make sure that the level of care stays where it ought to?).
In my last post, I was discussing the 30-minute threshold for when wheeled items go from being “in use” to being “in storage” in corridors.
As a quick follow-up, it appears (either by instruction or evolution) that The Joint Commission’s clinical surveyors, as they embark upon their patient tracers, are taking mental snapshots of egress corridors when they arrive on the patient care units.
Then the surveyors do a little comparison observation when they complete the tracer (which is generally 45 minutes to an hour after their arrival) to see if there are any items beyond crash carts and authorized isolation precaution carts that haven't moved or otherwise been attended during the visit.
This concern has been specifically indicated in a recent survey citation, so my advice would be to assign someone the task of making sure that the corridor landscape looks different when a tracer is completed. Try not to be too obvious about it. Ultimately, we just don't want to give away any scoring points if we don't have to.
I fielded a question not too long ago asking exactly where the Centers for Medicare & Medicaid Services (CMS) lists its provision that items in an exit corridor are considered “being stored” (as opposed to “in use”) when they are unattended by staff for longer than 30 minutes. This has become a very relevant piece of information, as it has been cited during Joint Commission surveys of late--mostly by the non-life safety members of the survey team.
So to assist in the edumacation of all (particularly those persnickety folks who want to know, “Where does it say that?”), here’s the link to the CMS document outlining (albeit in rather obfuscatory fashion) the 30-minute rule for materials in the corridor.
Interestingly enough, the reference is contained in a missive regarding corridor-mounted computer screens and the maintenance of corridor width (CMS can be almost as clarity-averse as The Joint Commission), but the practical application is very clear.
That said, I'm not necessarily surprised that it is a challenge tracking down this kind of jurisdictional Sasquatch. CMS, while making stuff available on the Web as part of its obeisance to public information availability requirements, can at times embrace the idea of “If you don't know where it is, I can't tell you where to find it” (somewhat akin to “If you have to ask how much it costs, you can't afford it”). But I suppose it’s all in the thrill of the chase.
Hi everyone, it's Scott Wallask.
I'm happy to say I've already received several e-mails from folks about our 3rd Annual Hospital Safety Center Symposium.
If you've haven't heard already, the symposium takes places take May 14-15, 2009, once again at Caesars Palace in Las Vegas.
This event is really the high point of the year for us here at HCPro, and I'm excited to announce our tentative speaker line-up:
- Dean Samet, CHSP, director of regulatory compliance for Smith Seckman Reid based in Nashville and former associate director of standards at The Joint Commission
- Joseph Cappiello, president of Simulation Education Services in Oak Brook Terrace, IL, and former vice president of accreditation field operations at The Joint Commission
- Steve MacArthur, safety consultant for The Greeley Company, and primary author of this blog
- Brad Keyes, CHSP, safety consultant for The Greeley Company and a former life safety specialist with The Joint Commission
- Marge McFarlane, MS, CHSP, Wisconsin Hospital Preparedness Program Exercise (HSEEP) coordinator and part-time safety coordinator for Sacred Heart Hospital in Eau Claire, WI
Early-bird registration is available, so please plan on joining us at the the 3rd Annual Hospital Safety Center Symposium.
When it comes to managing construction and renovation projects, Joint Commission standard EC.8.30 will soon transition to EC.02.06.05.
The key process that surveyors look for is the risk assessment. Many of you probably use the infection control risk assessment, or ICRA, form that was developed by the Centers for Disease Control and Prevention and the Association of Professionals in Infection Control and Epidemiology.
Surveyors employ a very liberal interpretation of the need for risk assessments for all projects great and small, including projects like patching and painting walls, etc.--pretty much anything that can generate dust.
That's not to say that one would have to issue permits for each instance. It is possible to establish the infection control protections as a function of the standard operating procedure for the task and go from there.
Part of the concern in this area revolves around the possibility (and in some cases likelihood) of these smaller projects growing in scope over time and creating an increased risk in the environment. Traditionally, hospitals do a pretty good job with the big projects (primarily because there is more scrutiny) but not so much with the smaller projects which, depending on where they are, can become very intrusive on the more immunocompromised patient populations.
Posted At : October 20, 2008 2:22 PM
| Posted By : Scott Wallask
Related Categories:
Life Safety Code
Hi everyone, it's Scott Wallask logging on today.
I got a kick out a story I heard from Pete Leszczak, who is a fire protection engineer for the Department of Veterans Affairs in New Haven, CT, and also has his own consulting business.
Pete--along with fire protection engineer Josh Elvove--teach our Life Safety Code Boot Camp. They just wrapped up the latest edition of the boot camp in Dallas last week, and while at the hotel, Pete and Josh noticed manufacturer-recalled sprinkler heads were in place in the conference room and the corridors (the guest room sprinklers were okay).
Pete said he and Josh actually found the manager and alerted her about the recall, and she promised to pass the word on to the appropriate folks. Now that's dedication, right? It also reminded me about the need to keep up on product recalls.
Our next Life Safety Code Boot Camp is in Orlando on November 10-12.
Let us once again cast our gaze upon the life safety specialists and how they're being scheduled for surveys, now that we've well and truly passed into the autumnal portion of the year.
Some time back, organizations started reporting that in some cases, life safety specialists were arriving solo, sometimes weeks after the regular survey team had left. When something approaching an official acknowledgement by The Joint Commission surfaced regarding scheduling problems, there was a hopeful message that things should be back on track by summer.
Well, it appears that while hope may truly spring eternal, it didn't quite spring all the way through to the current schedule. That said, it does appear that some consideration has been given to the customer service aspect of having to prepare for multiple unannounced surveys because of separate life safety tours--so, some good news.
A client organization of mine had their survey a few weeks back, but without the treat of a life safety specialist. Now earlier in the year, there appeared to be some reluctance on the part of the regular surveyors who did show up to reveal any information about when the life safety specialist could be expected beyond a general "you'll see them in the next 90 days" kind of thing (keeping us on our toes, I suppose).
However, this recent survey team that visited my client, either by design or through sheer thoughtfulness, let the hospital know which week to expect life safety surveyor (not the exact day, mind you, but still).
That said, I think there may be a bit of a sea change in how this information is handled, though if anyone out there wants to weigh in on the subject, we'd love to hear about it (and by we, I don't mean the royal we, but rather the entire healthcare world). Perhaps the survey team leaders have a little more discretionary power about revealing the dates of the pending life safety visits.
Either way, I still get the sense that The Joint Commission is struggling to maintain sufficient resources to fully staff its life safety specialist cadre.
Posted At : October 14, 2008 1:22 PM
| Posted By : Steve MacArthur
Related Categories:
The Joint Commission
If you receive a citation from The Joint Commission that you feel is unjust, one of the best defenses when it comes to the post-survey clarification process is to have failure data to support whether the risk in question is being appropriately managed.
Say, for instance, you have a recurring issue with staff parking their computers-on-wheels in front of fire extinguishers. If you can demonstrate that you've managed that risk effectively under EC.1.10, element of performance (EP) 5, by providing data that indicates a 90% or greater compliance rate, you can use that to clarify a survey finding.
Remember, for C category EPs (of which EP 5 under EC.1.10 is one):
- A score of 2 (i.e., full compliance) can be realized when your compliance rate for the applicable subject is from 90% and 100%
- A score of 1 (i.e., partial compliance) is achieved for a compliance rate of 80% to 89%
- Anything 79% and downwards garners a score of 0 (i.e., noncompliance)
It has been a very long time since I've seen a specific survey finding that was truly a “surprise.” If folks are paying attention, they should be able to identify quite succinctly the things that are likely to cause troubles during surveys--door wedges, unsecured compressed gas cylinders, whatever it may be.
A little while back a colleague mentioned to me that his hospital’s fire alarm system only announced when there was a fire on a specific unit (i.e., the alarm only sounds on the unit with the fire). He conducted his quarterly drills by going from unit-to-unit with an unannounced exercise, and asked me for my opinion on this practice.
This is potentially a very sticky wicket. Does the facility do the drills all on the same day, which might make it a challenge to convince a surveyor that any drill after the first one isn't so unannounced?
In such cases, I wonder if there is any way to announce the drill over the PA system and have multiple units respond. Perhaps you could enlist members of the safety committee or the unit managers to complete the critique forms.
Any thoughts from the blogosphere?
There are really no standards for dealing with the storage of cardboard boxes on wooden pallets. Much as it is with the storage of materials under sinks, the expectation is that each organization will conduct a risk assessment relative to the practice in question.
For instance, while there are certainly going to be containers (cardboard boxes with visible soiling, damage, etc.) that you would not want to leave in a patient care environment, there are containers (intact, from reputable suppliers, etc.) that would okay to hold briefly prior to final placement.
While I can appreciate the risks associated with some cardboard boxes (infestations and the like), I've witnessed a number of organizations that have really struggled with implementing a no-cardboard-box restriction because to take cardboard boxes out of the equation exponentially increase the difficulty on moving materials through the organization.
Toilet paper, paper towels, bedpan urinals, and even plastic bags all come in cardboard boxes. Can you imagine the logistical nightmare of removing those items from their original boxes and then trying to bring them up to stock the patient care units?
I think a judicious review of the process with an eye towards minimizing the potential risks is a much more sensible strategy than prohibitions and other more draconian approaches. I've not yet found a prohibition, including smoking bans, that effectively manages the risk without driving the risk to another level of the organization. The EC standards are all about establishing effective processes for managing risk in the environment.
This morning, I (as always) read this week's installment of our free e-newsletter, Emergency Management Alert, and found some very interesting information contained therein.
One of the entries made mention of how healthcare officials in Louisiana found that their generators weren’t powerful enough to operate air conditioning after Hurricane Gustav knocked out power in early September.
This made me think about The Joint Commission’s Sentinel Event Alert regarding emergency power. What brought these thoughts even closer to home is that my client work this week has taken me to the Gulf Coast in Mississippi, where you can still see the lingering effects of Hurricane Katrina. So I guess you might take these as words of caution.
One of the key tenets of the Sentinel Event Alert relates to conducting a gap analysis of what utility systems you have that would be compromised or even unavailable should your area experience a power outage of some duration. The Alert then advises you to share that information with organizational leadership to determine appropriate courses of action.
Now I don't live down here on the Gulf Coast, but I'm fairly certain that temperature and humidity conditions during hurricane season would be such that air conditioning would indeed--as one of the hospital leaders noted in the Emergency Management Alert article--be more necessity than luxury.
Donning my prickly surveyor hat--it's up to you to figure out if it's the hat or the surveyor that's prickly--I thought, “Should air-conditioning concerns legitimately be a surprise for any hospital leader?”
We know The Joint Commission is/has been/will be very interested in how we manage emergency power, and it did not issue this particular Sentinel Event Alert with the thought its component pieces would be considered optional pursuits. If you look at this as a best practice, as Sentinel Event Alerts would generally be, are we increasing our survey risk in not adhering to The Joint Commission’s advice, thus not quite eliminating or reducing the risk to its lowest potential?
Remember, as of 2009 EC.02.01.01 will specifically mention Sentinel Event Alerts as a source of information for identifying safety and security risks. Look carefully at past Alerts to see how they apply to the EC.
That is, after all, the goal here folks, and I suspect the potential for many, many RFIs during the coming years. To employ yet another bizarro analogy, it's like hospital facilities and safety folks are in a limbo contest. If the surveyors think you can "go one lower" and it turns out that you are sufficiently crafty and nimble to do just that, can they cite you? Yes. Will they? Stay tuned . . .
Posted At : October 3, 2008 4:36 PM
| Posted By : Steve MacArthur
Related Categories:
Emergency management
When it comes the protection of medical records and other data files, it might be useful to build the loss of some (if not all) of these documents in your next disaster drill scenario.
This might end up working best within the confines of a tabletop exercise. Hopefully this scenario will get the key stakeholders thinking about how they would manage this risk on the long and short terms.
This is yet another instance of there being no correct or incorrect response. It's what works best for the organization. At least in this instance, there is a very clear end goal: the preservation of the noted documents during emergency conditions.
Posted At : October 2, 2008 4:56 PM
| Posted By : Steve MacArthur
Related Categories:
Security
A story getting some attention up here in Massachusetts has to do with an apparition of the Virgin Mary on a window pane of an office building at Mercy Medical Center in Springfield.
Brushing aside religious discussions, to me an interesting aspect is that 500 people showed up on hospital property on Wednesday to view the image, which is on a window of an unoccupied office, according to The Republican of Springfield.
Think about the following security-related concerns that have cropped up Mercy Medical, and how they might apply to more urgent incidents:
- Police have been called in to direct traffic in the area
- Hospital security officers have worked to corral the onlookers to one end of the facility’s parking lot
- Gatherers have placed flowers and votive candles at a makeshift shrine near the entrance
As you’d expect in this type of situation, the crowd has been peaceful. But if a throng was more unruly, 500 people outside the hospital would present challenges to any security department, particularly if police couldn’t immediately assist.
Back in 2003, another Massachusetts medical facility, Milton Hospital, had to deal with 25,000 unexpected visitors over a two-week period after it, too, became home to an window apparition of Mary.
That hospital had to exert some unusual tactics, such as asking onlookers to only come between 5:30 p.m. and 8:30 p.m. each day to view the image. During “non-viewing” hours, the hospital put a tarp over the window containing the likeness. The facility also had to hire extra security officers.
How would you deal with hundreds of onlookers outside your hospital?
Posted At : October 1, 2008 10:39 AM
| Posted By : Steve MacArthur
Related Categories:
The Joint Commission
In 2009, EC.02.06.01 (currently EC.8.10) calls for organizations to maintain safe environments.
Element of performance (EP) 13 talks about the need to maintain ventilation, temperature, and humidity levels “suitable for the care, treatment, and services provided.”
The word “suitable” bothers me a bit because it encompasses a really big cross-section of stuff.
With that in mind, organizations should define for themselves what “suitable” means under EP 13, using a common mantra: How do you prove the steps you take to maintain your ventilation and temperatures are effective?
Remember, in the end, you get to decide what works in your house, and then it’s also up to you to prove your case to Joint Commission surveyors.
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