Briefings on Hospital Safety, August 2015
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August 1, 2015
OSHA offers respiratory toolkit for hospitals
Latest guidelines address respirator use and maintenance and hazard assessments
In a move largely seen as the latest effort from OSHA to crack down on some of the most dangerous hazards facing healthcare workers, OSHA has released a toolkit designed to help healthcare workers and safety professionals understand their protections during infectious disease outbreaks.
The guidance manual, entitled Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators, was released in May and is a collaboration with the CDC and NIOSH that covers topics including why hospitals need a respiratory protection program, the types of respirators and protection available, and how to develop a protection program in a facility.
"Appropriate respiratory protection is a vital line of defense against airborne hazards hospital workers might face on the job," said NIOSH director John Howard, MD, in a written statement. "This toolkit is an important resource to help healthcare employers ensure their workers are out of harm's way when it comes to respiratory hazards."
The toolkit is the latest of several that OSHA has released in the last year and is likely an attempt to address statistics that show that healthcare workers suffer some of the highest number of workplace injuries and illnesses in U.S. workplaces.
Last year, OSHA dedicated a portion of its website to preventing slips, trips, and falls in hospitals, by far the largest cause of injuries in healthcare. Then, earlier this year, an update was issued to its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, known to many in the healthcare safety field as OSHA Rule 3148, and was a response to a higher incidence of active shooters and other violent events in healthcare facilities.
"In my opinion, OSHA has been tough on healthcare since the early 1990s when they enacted the Bloodborne Pathogens standard, followed by the safer sharps regulations," says Ken Weinberg, BA, MSc, PhD, consultant in environmental health, safety, and toxicology for Safdoc Systems, LLC in Stoughton, Massachusetts, and a former director of safety for 12 years at Massachusetts General Hospital in Boston, who looks at the new guidelines as a positive step. "Healthcare has been one of the most regulated industry sectors since then, and it continues. Healthcare employees and the public in general think of healthcare as the good guys, and seldom consider the potential for harmful exposures in that workplace. Vigilance is needed to keep this fact in the spotlight."
The issuance of the respiratory toolkit appears to be geared toward helping hospitals protect their workers in the wake of last year's Ebola outbreak in U.S. facilities, as well as MERS and other infectious diseases. Violations of OSHA's Respiratory Protection standard, which requires healthcare employers to establish and maintain a respiratory protection program in workplaces where workers may be exposed to respiratory hazards, are on the list of the most-cited of citations that OSHA hands out to healthcare facilities each year.
"Hospitals are one of the most hazardous places to work," says assistant secretary of labor for occupational safety and health David Michaels, PhD, MPH, in a statement released by OSHA. "One of the ways that we can protect workers in a healthcare setting is by providing employers with the resources needed to ensure a safe workplace. This toolkit will help protect those workers who dedicate their lives to caring for others."
Tools to protect your employees
Respirators are used to protect against exposures to airborne transmissible infectious diseases as well as chemicals and certain drugs that may be used in healthcare settings. OSHA's new toolkit covers respirator use, existing public health guidance on respirator use during exposure to infectious diseases, hazard assessment, the development of a hospital respiratory protection program, and additional resources and references on hospital respiratory protection programs. See the graphic on p. 4 for an example of the tools and checklists available in the new guide.
Some of the best features of the new respiratory toolkit include a user-friendly description of the types of respirators?such as N95 and negative pressure respirators?and the proper way to conduct a fit test on users. A technical, yet easy-to-understand explanation of the hazards present in hospitals is illustrated by photos that demonstrate, for example, the droplets that remain suspended in the air after someone sneezes.
Informative graphics describe when users should wear certain types of respirators, and photos demonstrate what a proper fit should look like.
Another section covers developing a respiratory protection plan in the workplace?something all safety professionals should be thinking about?and starts with how to conduct a hazard assessment of how likely you are to have someone with an aerosol-transmitted disease (ATD). For instance, factors that should be considered include:
- Who is exposed to suspected or confirmed cases of ATDs?
- Who will greet and triage patients?
- Who will provide care for ATD patients?
- Who will be performing aerosol-generating procedures on patients with ATDs, on cadavers,or in laboratories?
- Who will be cleaning the ATD patient rooms?
- Do you have contractors (e.g., those who service ventilation systems), or temporary workers in your facility who are reasonably anticipated to be exposed to patients or equipment that may be a source of ATD pathogens?
- Who will be designated as a first receiver of victims exposed to unknown radiological, biological, or chemical agents?
To access the entire OSHA document, check out the link at www.osha.gov/Publications/OSHA3767.pdf.
Is OSHA watching you?
While the release of the respiratory toolkit is largely looked at as a positive step in the right direction of making the healthcare field safer, some in the industry are looking at the string of updated guidelines as a warning from OSHA that the agency is about to get tough on healthcare facilities.
"The bottom line is that OSHA is coming. Accordingly, employers in the healthcare industry should act now to ensure that their employees are working in the safest possible conditions and that, when OSHA appears at their door, they can demonstrate their commitment to employee health and safety," wrote Valerie Butera, a healthcare law attorney from Epstein, Becker and Green, in an online blog on the National Law Review. "Notably, both of those guidance documents include a preface reminding employers that the Occupational Safety and Health Act ("Act") requires employers to comply with safety and health standards and regulations promulgated by OSHA and that, in addition, the Act's General Duty Clause requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. Employers should not take these statements lightly."
The fact The Joint Commission is also issuing alerts and posting OSHA's recommendations on its website is also looked at as a warning to hospitals to take the guidelines seriously.
As a supplement to the OSHA toolkit, The Joint Commission developed an educational monograph, Implementing Hospital Respiratory Protection Programs: Strategies From the Field, to assist hospitals in implementing respiratory protection programs. According to an OSHA statement, the monograph identifies common implementation challenges, provides specific examples of innovative strategies from healthcare organizations, and examines the role of leadership, quality improvement, fit testing, and training challenges and program evaluation.
"Respiratory protection programs enhance safety for both workers and patients, but there are many common challenges associated with their implementation," says Ana McKee, MD, executive vice president and chief medical officer for The Joint Commission, in the statement. "We hope that by showcasing the innovative and effective strategies used by healthcare organizations across the country to overcome some of these challenges, hospitals can learn from one another as they implement and improve their own respiratory protection programs."
Is this a warning to hospitals that they should prepare for OSHA and The Joint Commission to get tough on them for violations of the Respiratory Protection standard?
Perhaps. But you aren't likely to see an uptick in inspections because of it. OSHA still says it doesn't have enough inspectors to cover all U.S. workplaces, and the construction industry still surpasses healthcare in the number of workplace injuries in the country. OSHA still tries to handle most situations in a way that allows employers to fix hazardous situations themselves, and as long as there aren't any major injuries or employee complaints, many employers don't look at an inspection as a major threat.
"In my system if there has even been a complaint to OSHA, it has been followed up by a letter rather than a visit," says Dan Scungio, MT(ASCP), SLS, laboratory safety officer for Sentara Healthcare, a multihospital system in the Tidewater region of Virginia. "All responses were mailed in. That said, I will remain compliant as I am able."
Respirator Cleaning Procedures
RPP Appendix F: Respirator Cleaning Procedures
Appendix B-2. to Sec. 1910.134: Respirator Cleaning Procedures (Mandatory)
These procedures are provided for employer use when cleaning respirators. They are general in nature, and the employer as an alternative may use the cleaning recommendations provided by the manufacturer of the respirators used by their employees, provided such procedures are as effective as those listed here in Appendix B-2. Equivalent effectiveness simply means that the procedures used must accomplish the objectives set forth in Appendix B-2, i.e., must ensure that the respirator is properly cleaned and disinfected in a manner that prevents damage to the respirator and does not cause harm to the user.
I. Procedures for Cleaning Respirators.
A.Remove filters, cartridges, or canisters. Disassemble facepieces by removing speaking diaphragms, demand and pressure-demand valve assemblies, hoses, or any components recommended by the manufacturer. Discard or repair any defective parts.
B.Wash components in warm (43 deg. C [110 deg. F] maximum) water with a mild detergent or with a cleaner recommended by the manufacturer. A stiff bristle (not wire) brush may be used to facilitate the removal of dirt.
C.Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. Drain.
D.When the cleaner used does not contain a disinfecting agent, respirator components should be immersed for two minutes in one of the following:
1.Hypochlorite solution (50 ppm of chlorine) made by adding approximately one milliliter of laundry bleach to one liter of water at 43 deg. C (110 deg. F); or,
2.Aqueous solution of iodine (50 ppm iodine) made by adding approximately 0.8 milliliters of tincture of iodine (6-8 grams ammonium and/or potassium iodide/100 cc of 45% alcohol) to one liter of water at 43 deg. C (110 deg. F); or,
3.Other commercially available cleansers of equivalent disinfectant quality when used as directed, if their use is recommended or approved by the respirator manufacturer.
E.Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. Drain. The importance of thorough rinsing cannot be overemphasized. Detergents or disinfectants that dry on facepieces may result in dermatitis. In addition, some disinfectants may cause deterioration of rubber or corrosion of metal parts if not completely removed.
F.Components should be hand-dried with a clean lint-free cloth or air-dried.
G.Reassemble facepiece, replacing filters, cartridges, and canisters where necessary.
H.Test the respirator to ensure that all components work properly.
Conducting and evaluating the emergency drill
Your exercise has been planned out and it's ready to go. How to do it right and get valuable data you need
Editor's Note: This story is part two of a series exploring how to plan, conduct, and measure results of an emergency exercise at your facility. Next month, learn how to take information gathered, learn from your mistakes, and apply it to future emergency planning.
One of the most stressful, yet crucial and educational, roles you will play in your job as a hospital safety professional is making sure your staff is prepared to be ready when an emergency occurs.
It could be that your facility is a busy trauma center that sees its share of real-world emergencies that allow your staff to practice their skills and activate your emergency plans, or maybe you work in a small community hospital in the suburbs that doesn't see a lot of action. Either way, The Joint Commission and CMS want the same thing from you?for you to be ready to respond to any emergency situation, large or small?and the best way to do that is to conduct regular emergency drills.
Your emergency planning and drilling need will vary, depending on the facility's size and hazards inherent in your community (You have done a hazard vulnerability assessment, right?).
Assuming you have already planned an emergency drill?tabletop or operational?that will stress your facility's staff and resources, as well as introduce a surge of patients that your staff will have to deal with, the question now is how to conduct it safely and efficiently, without severely interrupting your regular operations and keeping everyone involved safe. Afterwards, how do you quickly assess the drill, get feedback from participants while the information is fresh in their heads, and gather information that can be used as a learning tool?
"Exercises are really equal to practicing before the big game," says Christopher Sonne, CHEC, assistant director of emergency management solutions for HSS Inc., Denver, a company that provides emergency management training, facilitation, and subject matter expertise for hospitals and healthcare providers throughout the United States. "The exercise is a fantastic way to find where our areas of opportunity are in controlled environments where lives and safety are not at risk."
Sonne and his colleague, Tracy Buchman, DHA, CHPA, CHSP, national director of emergency management for HSS, teamed together to coordinate an informative April 28 HCPro live program, "Emergency Planning: Conducting an Effective Preparedness Exercise."
Their advice provided input on how hospitals can benefit from properly conducting and evaluating emergency exercises.
Do you even need to conduct an exercise? This is a loaded question, and no emergency preparedness expert will tell you "no." But the reality is that some hospitals are so busy, and get hit with emergency traumas and other incidents that their emergency plans and preparation are constantly being tested. In that case, that real-world experience might be enough to satisfy regulatory requirements.
To be sure, Buchman says that any combination of real-world events or planned exercises must be able to show (and document) that your facility practiced six critical functions of emergency planning, specifically:
- Resources and assets
- Safety and security
- Staff responsibilities
- Patient clinical and support activities
"Now if you have a real-world event where you only evaluated a handful of those, then you may need to build a smaller exercise to get the evaluation of the other six critical areas that you might have not gotten," she says. "But as long as you have an influx of patients, exercise and a second one that might be real world, then that is compliant."
Let the government write your script. Many facilities have a hard time deciding what kind of drill should be practiced (scenarios are available), and then they don't know how to put together the logistics of how the drill will be run.
The good news is that the government has put together a series of scripts that can be used during a drill, especially during tabletop exercises that outline the roles that would be expected during an emergency. Available at www.emsa.ca.gov, these forms not only give you a road map, but also a way of documenting participation in drills.
- Job Action Forms. Under the Hospital Incident Command System (HICS) formed after 9/11, these 76 forms outline exactly what physicians and other people involved should do. "Often training by section sheets is easier than doing it all in one room and it gives you more detailed information by physician," says Buchman. "The Job Action Sheets are also there to help the individual document the actions that they took and record the decision and action time. You can also use these documentations after the fact to put together an after-action report and improvement."
- Operation Section Sheet. This is a handy tool, especially if you are in a tabletop exercise, practicing roles that different people would assume during an emergency over varying time frames. For instance, during a drill simulating a hurricane response, you might want to simulate what happens during the first two hours of the event, and then jump ahead to when the action kicks in four hours later, when say, the storm surge arrives or the power goes out.
- Incident Planning Guides and Response Guides. These are your scenarios, and there are several to choose from, including active shooter, utility failures, chemical exposure response, mass casualty incidents, and bomb threats. "These guides are formatted by mitigation preparedness response and recovery, and they're used to facilitate building your facility's hazard-specific plans," Sonne says. "So if you don't have a plan for one of those particular scenarios, this will give you the steps of questions that you can answer and then populate a policy and procedure which then you can test once you've done your education piece." See p. 8 for an example of an Incident Planning Guide.
Play safe. Emergency preparation experts say that if you are going to do a drill, make it as realistic as possible. But you need to also be careful. You need to remember that the everyday activities of your hospital will still be going on, and not everyone may know it's a drill. So you need to make sure to use signs and code words so everyone involved knows what is a drill and what's for real.
Some facilities choose to get local resources, such as police or the fire department, involved, including real people calling 911, using real radios, and responding to the scene of a mock accident. Again, if these aren't communicated, confusion could quickly set in.
"I might start to send out little bits of pieces of information in regards to a simulated weather event and in the subject line at the beginning of my email and at the end of my email, I always put in 'This is an exercise.'," says Sonne. "Especially if you're calling your community partners, dispatchers, 911, always make sure you utilize this as a best practice and when you make those communications, it will save a lot of headache and quite possibly your job at the end of the day."
Another thing to consider is the safety of those involved in your drill. People have been known to get hurt during a simulation, and unless there is a way to stop the action if needed, other people may not take it seriously if someone mentions that they are hurt. It's always a good idea to make sure that there is a predetermined code word or phrase in place, and make sure it's understood that if anyone uses this code, the drill is over and it's back to the real world to make sure everyone is safe.
"You have to make contingencies for if those real-world events occur, especially during active shooter training," Sonne says. He calls these things "player controllers."
"If you are injured or if one of your actors or volunteer victims are injured during that event, how are they going to let you know that 'Yes, I truly am hurt'?" This can be simply done by having them announce 'real world' in response to and after any statement that they make. So yes, real world because my arm is bent in a direction it shouldn't be in and I have broken my arm. You need to reinforce that real world piece a couple of times. That should be clearly delineated to help people stay safe."
Take a bath. Well, not really. But the most effective exercises have what is called a "hot wash" at the end, after the scenario has ended. It's a way for all participants to get into a room while their memories are still fresh, before they've gone back to their regular duties, and have a chance to reflect on the day's activities.
"When you do a hot wash, I kind of have a rule of thumb in terms of timing, and it's called a pizza rule," says Sonne. "You get enough pizza for everyone to have one or two slices. You should have at least your initial hot wash go no longer than an hour; otherwise, you tend to get too far into the weeds."
Emergency workers and hospital staff love free food, so if you can get them into a room in a relaxed environment, they are likely to be honest about things.
If someone feels like they could have done a better job bandaging the leg of the triage victim, or if someone noticed the random people walking through the doors of the ER when it should have been locked down, this is the time to get it out in the open.
It should not be a time for finger-pointing, but a time to debrief and gather information that can be used for improvement later.
Gather more information. There are always going to be people who either did not want to publicly make criticisms during the hot wash, or those who get ideas after the hour-long session is over.
For that reason, there should always be a way of making sure that feedback can be gathered afterward. Done correctly, it's a great way to create a documentation paper trail.
"Participant feedback forms are a great resource of candid insights into what the players, observers, participants, or controllers found as part of the exercise," Sonne says. "Commonly, I would actually scan these and actually include them as an appendix or an additional section as part of my after-action report. "
Incident Planning Guide: Active Shooter
This Incident Planning Guide is intended to address an incident involving an active shooter, defined as an individual actively engaged in killing or attempting to kill people in a confined and populated area. Hospitals may customize this Incident Planning Guide for their specific requirements.
A 40-year-old man enters your hospital's main lobby, pulls a shotgun from under his jacket, and shoots the lobby security officer. He then shoots a visitor who attempts to close the interior doors to the facility. As this occurs, a hospital volunteer in the main lobby calls 911. An employee hears the noise and walks toward the main lobby to investigate. The shooter fires at the approaching employee, but the employee dives for cover and the shooter misses. The shooter continues into the building, while the employee calls the hospital's main switchboard operator and reports that a man has entered the building shooting at staff and visitors. The operator activates the Active Shooter Plan, notifying facility leadership and security, while making an overhead announcement to notify all staff of the incident in the main lobby area. The shooter proceeds through the hospital into patient care areas, shooting at people indiscriminately. Within 10 minutes, law enforcement officers arrive and begin their tactical response. A patrol supervisor has set up their command post outside the hospital, where one of your security officers is acting as a liaison to the hospital's Incident Commander. Law enforcement tactical team finds the shooter dead in a patient care area, with a single gunshot wound to the head, then conducts a building-wide sweep to clear any other potential threats. Several wounded people are known to be within your hospital and at least three others are dead. The emergency department is on diversion and at least one patient care area (where the shooter expired) has been evacuated, is designated as a crime scene, and will not be released to return to normal patient care operations for several hours. Law enforcement remains on scene coordinating interviews and collecting evidence. Fire department and emergency medical services are also on scene. The Hospital Command Center (HCC) turns its attention to recovery: reopening the emergency department, rescheduling appointments and procedures, assessing the impact of canceled deliveries, and providing behavioral support to patients, families, and staff. A media briefing is scheduled in one hour.
Did Olympus know? What you should know
As scope maker gets investigated by the feds, experts offer advice for what to do next
Olympus Corp., manufacturer of about 85% of duodenoscopes and other diagnostic gastrointestinal (GI) scopes in U.S. hospitals, reportedly set aside $450 million in May to help pay for legal settlements related to infected scopes that led to patient deaths.
Featured in a May 27 story in the Los Angeles Times, the settlement money seems to be the closest thing yet to an admission of guilt from the Japanese company, which has come under scrutiny in past months for apparently failing to quickly warn American hospitals that one of its medical duodenoscopes is extremely difficult to clean, and maybe impossible to properly disinfect.
"This is pretty much no surprise," says Libby Chinnes, RN, BSN, CIC, infection prevention and control consultant, IC Solutions, LLC in Charleston, South Carolina. "Inspection is not enough. You can't really see inside the scope, and all of them are different. We don't ever really know that they are clean. Many [healthcare facilities] are still cleaning manually and there is a lot of room for error."
Olympus has become the target of lawsuits stemming from outbreaks of antibiotic-resistant bacterial infections in patients after undergoing endoscopic retrograde cholangiopancreatography (ECRP) procedures performed with the company's TJF-Q180V model of duodenoscope.
Virginia Mason Medical Center in Seattle joined a lawsuit against the company in May, claiming patients were put at risk because the company failed to disclose design flaws in their endoscopy scopes that led to superbug infections and death. The lawsuit claims that between 2012 and 2014, 39 people at the hospital became sick with E.coli bacteria, and 11 of those patients died, after being infected through contaminated duodenoscopes made by Olympus.
That followed a lawsuit filed February 23 by patient Aaron Young, who became sick after undergoing procedures at The University of California's Ronald Reagan Medical Center in Los Angeles. Young claims he was one of nearly 180 people exposed to an outbreak of carbapenem-resistant Enterobacteriaceae, which is highly resistant to antibiotics and reportedly can kill up to 50% of infected patients. Two patients died in that outbreak. In March, officials at Cedars-Sinai Medical Center in Los Angeles discovered that four patients were infected with CRE and 67 other people may have been exposed.
According to a report in Bloomberg Business, the lawsuit claims that the company redesigned the scope in 2014, but provided hospitals and doctors with a safety cleaning protocol for an older endoscope that had a significantly different design. Because of this, the older cleaning process wasn't effective in removing all residual body fluids and organic debris, the lawsuit claims.
A rush to judgment
It's tough to know who is guilty, because it's still unclear who knew what and when.
Immediately following the outbreaks earlier this year, the FDA and the CDC got involved, issuing a warning to hospitals that tiny elevator channels and grooves in the scope's new design may make it impossible to properly remove biofilm and other infectious residue from the scope.
Meanwhile, Olympus responded with a 13-page letter to customers in March, issuing new cleaning procedures along with special brushes designed for cleaning the microscopic channels.
Later reports surfaced that Olympus sent at least two letters to hos
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