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Briefings on Hospital Safety May 2009

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May 1, 2009

Battle-tested hospitals offer 12 pointers to beef up EOPs

Safety managers in New England and Kentucky were among the most recent to learn how well their hospitals’ emergency operations plans (EOP) operated over the long haul.

Ice storms in those regions in December 2008 and January 2009 knocked out power to a grand total of nearly 2 million homes and businesses, many for 72 hours or more, and put EOPs to the test.

Martin Wheatley, director of engineering and safety committee manager at Muhlenberg Community Hospital in Greenville, KY, and Troy Walker, director of the hospital’s ambulance service, coordinated response efforts while the hospital went 76 hours on backup power.

Meanwhile, Scott Janssens, RRT, MBA, CMRP, director of materials management and safety at Heywood Hospital in Gardner, MA, saw his facility stay on generators for 48 hours. However, because the rest of the small city and surrounding area remained without power for much longer, Heywood Hospital extended its emergency operations to 105 hours total.

“We learned a great deal about how the hospital functions on emergency generators long term,” Janssens says. “The hospital was not really designed to be on generators 24 hours and beyond. We’re very good at the short-term things, but the long-term? It requires additional thought.”

Communication breakdown

The notion of having backup plans for your backup plans comes into play when a massive power outage wipes out everybody’s Internet connections, cell phones, and land lines. Even worse, downed lines and branches made it difficult to get around in Massachusetts and Kentucky, which added up to a situation in which hospital employees couldn’t get to work or even tell their supervisors about their absences.

Janssens, one of Heywood Hospital’s incident commanders, was stranded at home and assumed that his e-mails to his colleagues about staffing and overtime were getting through his BlackBerry for the first half-day of the outage. It turned out his e-mail didn’t get any further than his computer at the hospital. Once the roads were cleared, Janssens managed to make it to the hospital six miles away, where he found out his coworkers hadn’t heard from him—in fact, they were actually searching for him.

At Muhlenberg Community Hospital, the ice storm had similarly wiped out communications, so employees found innovative ways to get word to their departments about when they could come in, mainly through word of mouth via people who could get onto the roads, says Wheatley.

“We had sections of the county we could not get to by ambulance or any other means,” Walker says.

EOP contingencies to pursue

Based on the experiences at Muhlenberg Community and Heywood hospitals, review the following 12 tips with your emergency planners:

  1. Run a full incident command center as part of your next emergency drill. Officials at Muhlenberg Community Hospital realized that when the power outage hit, their prior drills had not envisioned a large enough area for an incident command center. Their first location—administrative offices—wasn’t adequate, and their alternate location worked better, but not perfectly. Fully evaluate your primary location and its backup, which is on Muhlenberg’s to-do list for sharpening its response plan.
  2. Cozy up to local ham radio operators. At Heywood Hospital, amateur ham radio was the fallback communication system for a period when the hospital’s phones went down and cell phones weren’t working.
  3. Understand which electrical outlets your emergency power system covers. At Heywood Hospital, it was ironic to note that some ICU areas had no power to bathrooms, copiers, or vending machines, yet the Christmas lights remained on. Officials there will review emergency power availability to avoid this situation in the future.
  4. Designate staff members to pick up employees who want to come in but encounter obstacles. Muhlenberg Community Hospital established a shuttle service to fetch workers stranded in their homes for one reason or another.
  5. Plan for pharmacy customers to show up at your door. Until every local drugstore and retail chain pharmacy gets its power back or community responders set up temporary pharmacies elsewhere, hospitals must prepare to fill prescriptions from folks who need their medications. (For more on this aspect, see “Hospitals will wear even more hats during a community disaster” on p. 3.)
  6. Plan for gas stations to be without power. How will your employees get to work if they can’t gas up their vehicles? In Kentucky, county responders helped one station set up emergency power, commandeered the fuel for emergency services, which included hospital employees, and rationed fuel until other stations came back online. Fuel for employee vehicles is an important resource easy for hospitals to overlook in emergency planning, says Wheatley.
  7. Plan for your cafeteria to do booming business. Wheatley and Janssens say their cafeteria was one of the few working restaurants in town—at times, it was the only one. Your EOP should anticipate serving additional employee meals if workers have been called in and meals for community residents who can’t get food anywhere else if grocery stores are without power.
  8. If you store supplies in a warehouse, ensure that it has backup power. Warehouses need light, access to computerized inventory systems, and possibly power for overhead doors if they’re too heavy to open manually.
  9. Keep patient registration and billing computer systems on generator power. Billing is the financial lifeblood of a hospital. If you lose the ability to bill, you face trouble in terms of a longer recovery from a disaster.
  10. Anticipate the bathing needs of employees. If local water pumping stations lose electricity or homeowners can’t power their private wells, it may be impossible to use the shower at home. Hospitals may need to designate showers in which workers can bathe, Janssens says. The same concern applies to washing personal laundry.
  11. Pick temporary shelters that have backup power systems. Doing so will allow the hospital to avoid performing routine care (e.g., providing electricity for home medical equipment) during a time of urgent need. Janssens says that shelters should retain some medical staff members who can take care of minor concerns that would otherwise precipitate a hospital visit and who can deal with less acute patients who have been discharged to a shelter. It’s also important to verify that shelters are handicapped accessible, say Walker and Wheatley.
  12. Develop mutual aid agreements with distant ambulance services. Choose ambulance companies in areas remote enough that bad weather in your community won’t affect them. Muhlenberg Community Hospital assembled a strike team of 10 ambulances from facilities unaffected by the ice storm. The assisting ambulances helped speed up a 12-patient evacuation and provided transportation for patients.

Hospitals will wear even more hats during a community disaster

When ice storms knocked out power in the communities served by Heywood Hospital in Gardner, MA, and Muhlenberg Community Hospital in Greenville, KY, utility companies were at first unable to pinpoint when they could restore service to the general public.

In such situations, hospitals generally receive priority assistance to get power back up, which leads to medical centers becoming sought-after sites for those in the general public who need electricity or services provided by electricity.

For example, when power loss shuts down local pharmacies, a hospital not only has to continue patient treatment, but also must act as the corner drugstore. Healthcare facilities may also be called upon to help people on oxygen therapy whose equipment doesn’t work at home without electricity.

The surprising part for Heywood and Muhlenberg Community hospitals was how they ended up assisting the public in nonmedical ways, safety managers at both sites say. For example, the facilities accommodated cold citizens who came to warm up in buildings that had heat. Muhlenberg Community Hospital also provided temporary housing for staff members who had no means of getting home or who elected to put in as much overtime as needed.

“A lot of people [either] stayed or couldn’t leave,” says Martin Wheatley, director of engineering and safety committee manager at Muhlenberg. “We put them up in extra rooms we weren’t using.”

These scenarios may be interesting to debate at your hospital, either with a full-blown drill or as an agenda point on the next safety committee meeting.


Preview of the Hospital Safety Center Symposium

Simple steps may help avoid life safety compliance woes

Although it might sound like obvious advice, plenty of safety officers have nonetheless slipped on this thought: If you want to stay on top of Joint Commission life safety compliance, you first need to carefully look over the life safety and EC standards.

As a firsthand observer of life safety compliance concerns, Brad Keyes, CHSP, said he is stunned at how many managers haven’t actually read the standards in the first place.

Keyes, who is a consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, spoke during HCPro’s free January 29 audio conference, “Hospital Safety in 2009: A Sneak Preview of the 3rd Annual Hospital Safety Center Symposium.” He will also be a featured presenter at the 3rd Annual Hospital Safety Center Symposium, which takes place May 14–15 in Las Vegas (go to www.hospitalsafetycenter.com for more details).

Keyes offered the following suggestions for hospitals to polish their life safety compliance efforts:

  • Understand which codes apply to you beyond the Joint Commission standards. Find out which National Fire Protection Association standards, local and state fire codes, and other applicable regulations apply to your locale—and read them.
  • Verify that you’ve documented the results of your inspections. This seems like simple advice, but Joint Commission surveyors are continually citing facilities for slipups with fire protection inspection and documentation requirements under EC.02.03.05. That standard’s predecessor, EC.5.40, was among the top 10 most-cited standards in hospitals in the first half of 2008, according to the most recent Joint Commission statistics. Don’t forget to have paperwork handy that details how you corrected any deficiencies found during inspections.
  • Take advantage of renovations and construction. If crews are popping a room’s ceiling tiles or gutting walls, or new construction is showing the bones of a structure, grab your flashlight and conduct an inspection on the spot for improperly sealed smoke barrier penetrations from pipes, computer wiring, or other objects.
  • Track down undocumented room changes. Life safety deficiencies sometimes crop up from projects that safety managers or facilities directors were unaware of involving repurposing of rooms. For example, find out whether patient rooms have been taken out of service and turned into storage. Such changes may trigger additional Life Safety Code® requirements under new construction for items such as sprinklers and rated doors.
  • Keep administrators informed about plans for improvement (PFI) in your Statement of Conditions. Remember that when you open a PFI, it enters your hospital into a contract of sorts with The Joint Commission (formerly JCAHO) to address the deficiency. The PFI includes a completion date that figures into accreditation decisions under LS.01.01.01 if the deadline isn’t met or formally extended. Keep administrators apprised of your actions at every turn in the process so they don’t try to pull funding for a PFI, which won’t meet Joint Commission muster, Keyes said.
  • Continue to use a building maintenance program (BMP). Although a BMP no longer gives hospitals a scoring break come survey time, conducting a BMP still gives you a structured, regular method of assessing your life safety compliance.


New federal funds coming

Keep new technology leashed until you learn its behavior

Given the Obama administration’s goal of improving healthcare information technology (IT) systems, many hospitals are taking a hard look at how medical equipment interacts with such networks.

The way these items coexist—in harmony, one hopes—is defined as “convergence.” It’s a new term because up until a few years ago, most patient monitoring systems and other devices plugged into the wall and worked on their own. Now, many of these machines send information directly into the hospital’s main network and interact with software such as electronic recordkeeping programs.

Unfortunately, when devices and networks don’t converge as planned, errors can occur, especially when:

  • Caregivers ignore safety alerts and alarms from devices
  • Patient privacy rules are violated as machines automatically pass protected health information into unprotected, accessible areas of a network
  • Staff members enter wrong drug names into pharmacology systems

Devices closely interact with technology

“Medical devices are becoming more and more computer-based,” says James Keller Jr., vice president of health technology evaluation and safety at the ECRI Institute, a health research firm in Plymouth Meeting, PA. “Much of the data that is being stored and used within medical devices is being transmitted across hospital networks.”

In fact, it can be difficult to tell the difference between a computer and a medical device.

Safety managers, even if they’re not convergence troubleshooters, play an important role in sniffing out problems and marshaling the resources to fix them. According to a Joint Commission Sentinel Event Alert issued in December 2008, safety officers also need to get more vocally involved in equipment purchases.

“This is a really big issue,” says Frank Painter, MS, CCE, hospital technology consultant at Technology Management Solutions in Trumbull, CT. “It’s a change in the way information is going to be obtained and passed around the healthcare organization ... It’s going to affect not only the quality and reliability, but the integrity of care and their confidence in the system.”

Stay grounded as funds become available

Hospitals will likely buy more hardware and software this year compared to years past if Congress passes President Obama’s healthcare reform bill as written at presstime in mid-March. The bill calls for $19.2 billion to be disbursed to hospitals for upgrading their IT infrastructure.

Keller and Painter say that hospitals, especially those that receive grant money, should heed warnings about hasty spending decisions and take time to evaluate new technology and how it will integrate into a facility’s particular environment.

Given the money available, Keller warns of hospitals being sold on technologies that aren’t ready for the medical setting. Rushing a purchasing decision can lead to costly mistakes.

Painter recommends that hospitals avoid buying cutting-edge equipment unless the facilities have sophisticated biomedical departments that can handle such projects. Instead, hospitals should consider systems and equipment upgrades that already have proven track records in the industry, he says. (See “Answer these questions about your next technology purchase” on p. 7 for more assistance in determining how new technology fits in with your existing systems.)

Get involved in piloting new technology

The Sentinel Event Alert, titled “Safely Implementing Health Information and Converging Technologies,” warns that technologies designed to cut down on medical errors can, in some cases, actually create more of them.

Although The Joint Commission (formerly JCAHO) references specific information management and leadership standards in the alert, it stated in an accompanying press release, “Since technology is so common in healthcare, from admitting patients to the operating room to ordering and administering medication, any Joint Commission accreditation standard can be tied to technology.”

The Joint Commission and the ECRI Institute, which participated in announcing the alert, recommend hospitals create multidisciplinary teams that review current technology and evaluate new gear ahead of purchasing to make sure it fits in with the hospital’s existing systems and the way staff members work. Safety managers need to be part of that evaluation, along with physicians, nurses, IT staff members, and others in the facility involved in buying or using technology.

Multidisciplinary analysis of new technology is critical in seeing through marketing and sales smoke, which is often based on optimistic laboratory tests that can sound good to your IT department, but may not reflect actual performance in your hospital, Painter says.

Strategies to consider

The Joint Commission recommends hospitals take 13 specific steps to combat technology convergence problems. The steps are somewhat similar to those set forth in a guidance document published in the ECRI Institute’s October 2008 Health Devices. They include the following:

  • Get safety managers involved in risk assessments before new technology is introduced
  • Encourage IT buyers to visit other facilities using a prospective technology to see how it works in the real world before signing a purchase order
  • Monitor staff members to make sure technology work-arounds aren’t causing or obscuring errors
  • Develop a system of safety alerts and a protocol for dealing with them
  • Monitor skipped alerts and investigate how and why they happen
  • Establish training programs for each department that will interact with a new technology

The multidisciplinary team that safety officers should be a part of should develop what the ECRI Institute calls a strategic vision, defined in a mission statement for implementing new technology that aligns the business and safety values of the facility.

“It’s important for safety managers to participate on a collaborative team to help establish a vision and provide their unique perspectives on patient safety and general safety in the hospital,” Keller says.

Editor’s note: To read the full Sentinel Event Alert, go to www.jointcommission.org and click the Sentinel Event tab near the top of the page.

Answer these questions about your next technology purchase

If you can answer yes to the following list of questions when considering the safety implications of a new piece of equipment or software at your hospital or evaluating existing equipment in a routine review or after a problem arises, you’re well on your way to avoiding error-prone technology:

  • Do we have a strategic safety vision that defines our approach to integrating new equipment and technology?
  • Does this piece of equipment or software fit into that vision?
  • Have we done a risk assessment of this technology?
  • Have we concluded that the pros outweigh the cons for this technology?
  • Does this technology’s ease of integration with our hospital’s servers and operating systems compare favorably to its competitors?
  • Does this technology meet our standards and fit into our best practices for that category of device or software?
  • Have we critically analyzed our staff’s work flow, including that of physicians and nurses, and determined that this product will help the work flow, not hinder it?
  • Has this technology’s performance in pilot projects and test runs satisfied us?
  • Did we consult with caregivers, nonclinical staff members, and patients in choosing the best device or software for the job?
  • Have we addressed all the issues that caregivers, nonclinical staff members, and patients have raised related to this technology?
  • If this technology involves medication, have we consulted with pharmacists?
  • Can this technology’s safety alarms be forwarded or passed over? If so, do we have staff members who are trained and able to monitor alarms so that they don’t get forwarded to a dead end?
  • If this technology eliminates any safety checks we currently conduct, can we replace the lost checks with equally effective ones?
  • Does the vendor understand our clinical area, and is this technology recommendation based on that understanding?
  • Do we have a schedule for maintenance and upgrading equipment and its various components?
  • Have we limited potential distractions in the environment for users of this technology?
  • Has the hospital planned for any unique or additional maintenance activities that this product will require?
  • If a device works on its own proprietary network, is it worth the purchase as opposed to a device that integrates into the hospital’s servers and operating systems?
  • Does this technology protect private patient information when applicable?
  • Has the hospital’s wireless device point person determined that this product will not interfere with other devices?
  • Will our Wi-Fi signal reach this technology, if applicable?
  • Has our hospital’s medical error reporting system been updated to reflect the new product going into service?

Additional comments and observations:

Sources: Based on material from The Joint Commission, the ECRI Institute in Plymouth Meeting, PA, and Frank Painter, MS, CCE, hospital technology consultant at Technology Management Solutions in Trumbull, CT.


Survey monitor

Hospital proves its 96-hour mettle in emergency plans

Hurricane Ike displaced a lot of people and changed a lot of plans, including Huntsville (TX) Memorial Hospital’s Joint Commission survey. The survey was originally scheduled to take place in the second week of September 2008, but as Ike’s path became clear and disaster preparation escalated in earnest, the accreditor decided to reschedule.

“If [surveyors] wanted to know my disaster plan, they should have showed up then,” says Charlene Gordon, RN, the ER clinical coordinator and emergency preparedness manager at Huntsville Memorial. “I’d have given them a vest and put them to work!”

The survey took place January 12–16, and the hospital had all the right answers for surveyors in terms of emergency management planning, Gordon says.

Reflecting on a past response

The 75-bed hospital lies about 90 miles north of Houston, an area “run over by Ike,” as Gordon puts it.

The facility went without power for about 96 hours during the storm, and the emergency operations plan and backup power systems held firm throughout. Although there was no major wind damage to the building, a downed power line near the hospital’s oxygen system did initially complicate Huntsville’s response efforts.

Hospital staff members made it through with help from a county emergency operations center, which sent a utility crew to remove the power line after verifying that it wasn’t live. The county set up remote facilities to take care of patients who needed help with minor concerns and sought supplemental generators to aid the hospital in bringing up more systems had Ike hit even harder than it did.

‘We did our 96 hours for real’

Gordon and her colleagues got to share the whole episode with The Joint Commission (formerly JCAHO), which chose Huntsville Memorial as one of the first to be surveyed under the 2009 standards, including the 96-hour provision under EM.02.01.01.

“We did our 96 hours for real,” Gordon says. The hospital’s binder on the experiences of Hurricanes Ike and Gustav are 4 inches thick and full of information detailing the county’s response plans, problems, and solutions.

“That’s the kind of thing [surveyors were] looking for,” she says.

Planning with community is key

The emergency management tracer the surveyors conducted involved a chlorine leak. They closely examined the plans Huntsville Memorial had made with other community agencies and staff members’ knowledge of those plans.

Surveyors asked many questions regarding how the hospital would notify the public of its role in the disaster response, as well as how it would coordinate response efforts with county and city police, the fire department, emergency medical services, and public health officials.

They also drilled deep into communication protocols, including those called for under EM.02.02.01. Gordon and her colleagues were ready, having weathered Ike and recently tapped into a new reverse-911 system through which the county can broadcast messages via mass phone calls. Gordon also laid out recent drills the hospital conducted, including local television and radio stations, which tested notification and broadcast procedures.

“As soon as things start to go bad, wherever it is, we start to come together immediately,” she says, explaining that information gets disseminated through the hospital’s and county’s public information officers.

“We function as one team, and I was able to prove this to the surveyors,” Gordon says. “I was able to show them the brochure and the agreement and all the things that we are able to do to communicate to the community instantly.”

Adjusting to new standards and scoring

The life safety specialist came separately—and stayed in a different town and hotel—from the physician and nurse surveyors, but the visits overlapped, Gordon says, adding that the regular surveyors didn’t talk much with the life safety specialist until they met at the end of the survey.

The specialist checked fire doors and smoke penetrations, as is customary. He also followed the forwarding of fire alarms and asked for detail on what happens on overnight shifts when staff members take breaks, says Gordon.

Because of the new scoring and reporting system, the hospital did not receive an immediate full report of its survey results, but instead was given a tentative preliminary report.

“They don’t give you everything right away. They make you wait weeks to get all your information, [so] we weren’t really sure how we did,” Gordon says. She notes that the surveyors were fair and knowledgeable, especially considering that everyone was working under a reorganized set of standards.

Immediate record of the proceedings

Gordon says Huntswood Memorial, at least initially, learned more about its survey results through employees assigned to follow surveyors and write down what they overheard. The hospital not only had scribes, but also runners, who would take off to notify the person in charge of a particular area when surveyors uncovered a compliance issue.

Gordon recommends other safety officers and survey prep coordinators follow suit if they want to get a jump on fixing compliance issues in the weeks-long gap between a survey and The Joint Commission’s report notifying the hospital of its results.

“Make sure they have someone by [surveyors’] sides at all times and they have a nice little notebook and a sharp pen,” she says.

When surveyors pointed out defects, the scribes would record the observations, which allowed the hospital to fix many small problems immediately.

If you choose to use scribes, remember to plan ahead for these people to be designated and available when surveyors arrive unannounced.

Life safety violations top most-cited standards list

In what is bad news for safety officers and facility directors, the former EC.5.20 was the most cited Joint Commission standard in surveyed hospitals in the first half of 2008.

According to The Joint Commission, during that period, 46% of hospitals received citations under EC.5.20, which required compliance with the Life Safety Code® and the Statement of Conditions.

EC.5.20’s provisions expanded into the new life safety chapter, which debuted in January. With a total of 10 standards and more than 100 elements of performance in the new chapter, the potential for citations has increased.

EC.5.40 (inspection, testing, and maintenance of fire protection equipment) was cited in 28% of hospitals in the first half of 2008, making it the sixth most cited standard. EC.5.40 has become EC.02.03.05 in the 2009 standards.

Survey at a glance

  • Emergency management highlights: Surveyors examined past documentation relating to Huntsville (TX) Memorial Hospital’s
  • response to Hurricanes Ike and Gustav. Surveyors also asked questions about the facility’s 96-hour provisions and communication strategies during an emergency.
  • Life safety highlights: Surveyors reviewed how staff members monitored and handled fire alarm signals when they were forwarded.
  • Standards focused on: EM.02.01.01 (emergency operations plan), EM.02.02.01 (communication during an emergency), and LS.02.01.34 (fire alarm systems).


Nurses’ union pact aids emergency preparedness efforts

New Minnesota agreement also satisfies Joint Commission requirements

The Minnesota Nurses Association and Allina Hospitals & Clinics came to terms on an interesting agreement in early February that hardwired staffing strategies into the system’s emergency management plans.

The pact satisfies the following issues that many hospitals face:

  • It works out in advance how Allina hospitals will honor staffing rules set forth in labor agreements (e.g., no mandatory overtime) during

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