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Briefings on Hospital Safety, June 2009


June 1, 2009


Nine cost-cutting pointers for belt-tightened times

Newly published FAQs shed light on common confusions

Guard your turf during community responses on-site

OSHA info about N95s, tap water, and IT workers

Know your morgue’s limits, then prepare for an overflow

Address hazards of long shifts during disasters

Lessons learned, when the unimaginable happens



Nine cost-cutting pointers for belt-tightened times

On the surface, it would appear that trimming hospital budgets would have a negative effect on safety.

However, it doesn’t have to be that way. Briefings on Hospital Safety has drawn on the experience of its editorial advisors, soliciting their best practices for dealing with shrinking budgets. Many of the following steps can be measured to gauge success:

1. Customize your pitch for new projects by focusing on your leaders’ pet concerns. “In the minds of most decision-makers, safety and emergency management issues do not generate revenue,” says Paul Penn, MS, CHEM, CHSP, owner of EnMagine/HAZMAT for Healthcare in Diamond Springs, CA. “One of the keys is to articulate to the decision-makers that safety saves them money … It’s sad, but in these times, [safety managers] have to justify the return on investment.”

You know where the safety problems are in your hospitals, and you know the hot buttons a particular administrator might have—so push them to help raise awareness of the EC.

For example, if your chief financial officer watches for excessive workers’ compensation claims, get him or her on board with a new program (e.g., reducing employee injuries in the ED) that will reduce those claims and save money, Penn says.

2. Run an incident command center exercise to improve utilization. Zach Goldfarb, EMT-P, CHSP, CEM, president of Incident Management Solutions, Inc., in East Meadow, NY, says that one of his clients recently put its disaster training to use in a more mundane manner: The hospital wanted to track bed use throughout the hospital because the ED had been reaching capacity too often.

The most efficient way to do that was to activate the incident command center. The instant feedback and communication that resulted helped lead to a financially beneficial utilization tune-up and yielded the opportunity for disaster practice.

3. Prioritize your projects based on cost-benefit ratios. In other words, determine how much money lower injury and error rates will save, says Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant at Di Giacomo-Geffers and Associates in Trabuco Canyon, CA.

Organization pays off, says Di Giacomo-Geffers, who is a former Joint Commission (formerly JCAHO) surveyor. Identify problems, drill down to get to the root causes, and prioritize the more serious concerns. In these tough financial times, a serious problem could be defined as whatever costs hospitals the most money.

For example, if the patient fall rate in a particular area is high, investigate who’s falling and why. Lowering that rate might be as simple as installing a grab rail, says Di Giacomo-Geffers, and that would be a good return on investment for senior leaders closely watching the bottom line.

“By thinking quantitatively, some projects make more sense today than before the economic downturn,” says Barry D. Watkins, MBA, MHA, CHSP, senior EC specialist at Carolinas HealthCare System in Charlotte, NC. “For example, our department is resurrecting a project evaluation to possibly purchase an automation software system. The project was postponed prior to the economic downturn due to cost. However, senior leadership [recently] approached us asking why the particular process was performed manually.”

4. Tap into useful return-to-work activities. If an employee recovering from an injury can work but isn’t ready to go back to his or her old job, see whether you can draft that worker to help the safety department with the large volume of paperwork and rounds that otherwise take up a safety officer’s time, Penn says.

5. Use online training and virtual drills when feasible. Some tech-savvy responders are using federal grants to build virtual hospitals on Web sites such as Second Life (see the April Briefings on Hospital Safety for more details).

Earl Williams, HSP, safety specialist for BroMenn Healthcare in Bloomington, IL, is working on such a project for his staff. Williams is also using more online training courses for safety matters (e.g., properly handling hazardous materials) than he has in the past. Online modules are more cost-effective compared to hiring an instructor or sending employees to off-site seminars.

“That’s what I’m depending on at this point,” Williams says, adding that combination telephone conference and Webcasts offer much value. “In the past, most of them were very focused. We’re looking for more bang for the buck, so [educators] are now covering two or three subjects in one shot in order to get the most for our dollars,” he says.

6. Look critically at the costs of face-to-face meetings. You might find that phone and video conferencing are more affordable ways to meet. Watkins admits that multifacility organizations such as his probably spend a lot of money reimbursing employees for travel.

“While much of our travel is essential to ensure we maintain adequate presence and surveillance of our coverage areas, we are able to minimize travel by phone conferencing meetings,” Watkins says. “We also use video conferencing for our larger systemwide meetings.”

Give yourself some final icing by documenting your travel expense savings when reporting to your boss about the meetings. (See “Ideas to better organize yourself and your coworkers” below for more administrative efficiency ideas.)

7. Focus on nurse safety as a cost-saving measure. Some hospitals have a difficult time keeping nurses on staff, leading to more money spent on recruiting and training new nurses, Penn says.

Reducing nurse injury rates not only saves costs when nurses leave due to injury, but also cuts funds spent on workers’ compensation and floater nurses when the regular employees are out of work.

Developing patient lift teams or purchasing patient lifting equipment are two prominent options for decreasing nurse injuries. Such safety investments will help your facility keep the nurses it has longer and aid recruitment efforts when word spreads that your hospital cares about nurse safety.

8. Standardize EC training across facilities. If you’re in charge of safety for multiple sites, it may pay off to homogenize your staff education across the board, Watkins says. Originally, Carolinas HealthCare System looked to its EC standardization (ECS) initiative to increase the quality of the EC by making sure that everyone’s training was at the same level at each facility. But it can also be viewed as a cost-cutting measure.

“The phrase ‘work smarter, not harder’ applies more today than ever,” Watkins says.

Thanks to the ECS effort, safety managers spend less time on common items such as formatting committee meeting agendas, minutes, attendance records, subcommittee report templates, management plans, and annual review templates.

“It is a win-win proposition—enhanced EC programs and efficient use of personnel,” Watkins says.

9. Install motion sensor switches for occasionally used rooms. Although BroMenn Healthcare has already put many energy-saving measures in place, it identified one more penny-pincher: motion sensors in infrequently used rooms.

When someone forgets to turn off the lights, the motion sensor switch will dim the lights after a certain period of time, Williams says.



Newly published FAQs shed light on common confusions

The Joint Commission discusses locked soiled utility rooms, among other topics

In the spirit of its 2009 standards offering greater clarification to help hospital compliance, The Joint Commission has issued dozens of new FAQs, many of which address the EC and emergency management provisions.

Although it’s not spelled out in every FAQ, between the lines, The Joint Commission (formerly JCAHO) wants hospitals to show how their risk assessments justify not adopting recognized best practices if facilities choose alternative approaches, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

Examples of such best practices include conducting infant abduction drills and prohibiting electric fans in patient rooms.

Although these best practices are not defined in the standards, surveyors can review the content of the FAQs as though they are part of the standards—so your risk assessment data must be solid if you’re not using best practices noted throughout the FAQs, says MacArthur, who is also a contributing editor to Briefings on Hospital Safety.

“They’re giving us a laundry list of the types of things that come up during surveys [for which] there isn’t a specific requirement,” MacArthur says. “Anything that comes up on an FAQ is, for all intents, surveyable.”

To read the full slate of FAQs online, go to www. jointcommission.org/Standards/FAQs.

Locked versus unlocked utility rooms

One interesting FAQ addresses soiled utility rooms. Some hospitals lock these rooms for infection control purposes. However, The Joint Commission doesn’t require this step, nor is there anything about this measure in the 2000 Life Safety Code®.

Locking soiled utility rooms may increase staff members’ exposure to bloodborne pathogens by forcing workers to manipulate a locked door when they have an armful of waste or soiled linen to dispose of in the room, MacArthur says.

As an example of competing priorities in the risk assessment process, the FAQ states that locking soiled utility rooms may prevent exposures to patients, especially in behavioral health, geriatric, and pediatric settings, who inadvertently enter those rooms.

Although there are specific patient populations you should be attentive to in this regard, MacArthur hasn’t heard of many instances in which people have taken items from utility rooms in nonbehavioral patient care units, citing some facilities’ fears of IV drug abusers looking for needles.

“But if you think that because of the local culture you have a risk of somebody coming in and hooking a needle box, that’s something you need to take into consideration,” he says. “It’s all part of the risk assessment.”

Along the same lines, check out the FAQ dealing with ID badges, says Cameron Bruce, PE, CSP, president of Cameron Bruce Associates in Orinda, CA.

The Joint Commission requires that “the organization identifies individuals entering its facilities,” which defers to your hospital’s policy. Local provisions may require photo badges for all staff members, including physicians, Bruce says. Make sure that your policies take these rules into account.

Keeping MSDS data ready to go

Two FAQs deal with material safety data sheets (MSDS) and their implementation. One clarifies rules stating that MSDSs are needed not only for chemicals, as required by state or federal law, but also for consumer products (e.g., turpentine) when a hospital’s risk assessment determines exposure rates are greater than that of “normal consumer use.”

The second MSDS FAQ recommends hospitals keep at least one hard copy of appropriate MSDS data. The unstated message of the FAQ is that paper copies be kept in case computers go down in a power outage or other emergency, MacArthur says.

OSHA’s hazard communication standard (1910.1200) requires hospitals to ensure that staff members have access to the appropriate MSDS, should a situation immediately warrant it.

Annual tracking of disaster inventories

In the emergency management realm, an FAQ on maintaining supplies during a disaster response states: “Tracking assets and inventory for a year is recommended in order to accurately ascertain what the capabilities are for the organization.”

Does that mean your hospital must track supplies for one year—a potentially arduous, time-consuming task—or risk scrutiny with surveyors?

Once again, the answer is in the information your risk assessment yields.

“I think [surveyors] are going to be looking for evidence that you know what your supplies are,” says Bruce. Your materials management colleagues might be able to help you assess what resources you’ll need as part of your 96-hour deliberations.

“I don’t know that you have to do exactly what The Joint Commission says [in the FAQ], but you need to show them some kind of assessment or report,” says Bruce.

In the absence of compelling performance data regarding your emergency supply inventory—and until hospitals learn more about how this FAQ is being surveyed—the recommendation in the FAQ is going to be a tough one to ignore, MacArthur says.

Other areas to watch

Double-check your EC and emergency planning compliance against the following items tucked away in the FAQs:

  • When community agencies won’t participate in your emergency planning activities—The Joint Commission requires hospitals to reach out to these agencies—document your communication (e.g., letters, meeting minutes, and e-mails) to prove to surveyors that you did your part. Due diligence may include a hospital administrator communicating with a top municipal executive to explain the importance of working together.
  • “No smoking” signs are not required on doors of rooms where oxygen is being administered if you are a smoke-free campus. Strictly enforce this policy and have signs outlining the policy posted prominently at all major entrances. The FAQ cites the exception under paragraph 8-6.4.2 in the 1999 edition of NFPA 99, Healthcare Facilities.
  • Joint Commission standards don’t prohibit electric fans in patient rooms or laboratories, but many hospitals ban them for numerous reasons, including tripping dangers, fire risks, and infection control—fans blow microorganisms and dust around, the theory goes. The FAQ states that if patients use fans, it may indicate a ventilation or temperature control issue for facilities crews to examine.

That last aspect is the most interesting part of the fan FAQ, MacArthur says. If surveyors see fans in use, he says, they may look at how a hospital manages its heating and cooling systems, which may be another risk assessment to investigate.



Guard your turf during community responses on-site

San Jose incident offers lessons for hospital–fire department cooperation

February 12 started as a routine day in San Jose, CA, at the Santa Clara Valley Medical Center (SCVMC), a hospital with the region’s largest ED. But by the end of the day, 91 people had been decontaminated as the result of a chemical incident, including 37 hospital employees, 46 patients and visitors, four police officers, and four firefighters. The local fire department shut down the ED, raising questions about who should be in charge at a hospital during an emergency management response.

The events began when a teenager attempted suicide at his home using unknown chemicals. The chemicals contaminated the teenager’s residence and the hospital’s ED—all while Peggy Albert, BSN, MA, SCVMC’s emergency management coordinator, and other managers were at a retreat in another building on campus. A full-blown decontamination effort followed. (See “Chronology of a decontamination incident” below for a rundown of the events.)

Fire department sets up command center

The incident yielded interesting issues for hospitals to consider regarding what group of responders should take the lead during emergency responses involving the community.

By the time Albert received notification to report to the ED—roughly 30 minutes after emergency medical services (EMS) arrived at the hospital with the contaminated teenager—the fire department and EMS had set up a command center on the property.

“I went out to the fire truck and immediately recognized that this issue was much larger than just a simple decon because they had already locked down the emergency room,” Albert says.

She contacted the hospital administrator, activated SCVMC’s incident command center plan, and got to work. The fire department had taken the lead and called for a hazardous materials team after fire officials determined the patient and ED staff members needed decontamination.

Five hours later, after all the parties involved had been decontaminated, the ED reopened. Most of the hospital employees involved in the incident were washed with soap and water by coworkers.

The unknown chemical was eventually identified as hydrogen sulfide, which is toxic, but only in much higher exposures than anyone likely encountered that day.

Hospital debates the bounds of authority

Hospital managers believe the fire department overreacted to the incident, Albert says.

Officials from the San Jose Fire Department did not respond to several calls for comment from Briefings on Hospital Safety.

The fire department and hospital agreed to clarify procedures for responding to future incidents, Albert says. In postmortem meetings, hospital representatives indicated that they felt the incident response put other patients in the hospital and community in possible danger by shutting down the ED for hours. They also believed a much smaller group required decontamination.

“The whole event took an extensive length of time,” Albert says. “Because we were having difficulty getting information from the scene of the event, we were dealing with an unknown chemical for a very long time.”

Since the incident, relations between responding agencies and the hospital have become stronger, she adds.

Facility learns from the situation

Because the response stemmed from a scary, although relatively harmless, event, officials consider it more of a real-time drill.

Albert says many lessons were learned, including the following:

  • Medical facilities must take control of actions on their property. “Hospitals are really in charge in this event,” she says. “This event should not have been led by fire, it should have been led by the hospital. In the future, we will say to the fire department, if there’s not an active fire inside, ‘Stop, this is our territory.’ ”
  • Hospitals must seek a role in decisions. San Jose’s EMS and fire department are adding language to their response plans that will defer decision-making to SCVMC during hospital incidents.
  • Prior relations will keep everyone cool during debriefings. Because responding agencies and the hospital worked together in earlier drills and responded to other recent incidents, they were able to work together without finger-pointing to analyze what went right and what went wrong after the decontamination event.

“We have had the opportunity to get to know each other and begin to get more comfortable,” Albert says.

(Want to learn more about how to deal with the media during an emergency response? See “Review the role of public information officer before your next disaster” below.)



OSHA info about N95s, tap water, and IT workers

Editor’s note: This month, we’re sharing an OSHA-related Q&A column from our sister publication, Medical Environment Update. We hope you’ll find the following OSHA topics interesting and relevant to your hospital. Please let us know what you think of this special feature.

N95 respirators and stubble

Q. Must a worker be clean shaven to wear an N95 respirator?

A. Yes, the OSHA respiratory protection standard (1910.134) requires workers to be clean shaven when wearing a tight-fitting, facepiece-type respirator such as the N95.

A beard or even a few days’ growth of facial hair can compromise the secure face seal on which the wearer depends for protection.

In cases in which the worker is not clean shaven (e.g., because of religious preferences), a powered air purifying respirator (PAPR) is an alternative since it does not rely on a tight face seal for protection.

However, PAPRs can be more strenuous to wear for long periods of time compared to N95 respirators.

Lousy-tasting tap water

Q. The tap water in our physicians’ office is terrible. What are the OSHA requirements for an employer providing safe drinking water to its employees?

A. Tap water may not be to your liking, and although you and your office mates may prefer bottled water, your situation would probably not be an OSHA violation.

The requirements to provide water in the workplace are covered under OSHA’s sanitation standard for general industry (1910.141).

The standard states that the employer must provide potable water, which is “water that meets the standards of drinking purposes of the state or local authority having jurisdiction, or water that meets the quality standards prescribed by the U.S. Environmental Protection Agency’s National Interim Primary Drinking Water Regulations, published in 40 CFR Part 141,” according to an OSHA letter of interpretation from 1997 titled “OSHA regulation on piped potable water supply.”

To read the interpretation letter, go to www.osha.gov and search for the word “potable.”

Bloodborne pathogens training

Q. Must the information technology (IT) staff members who service computers in our laboratory be trained in bloodborne pathogens?

A. If your laboratory is designated as a restricted area, as it should be, any employees working in that area are potentially exposed to bloodborne pathogens and are covered under the standard.

The bloodborne pathogens standard (1910.1030) requires employers to identify job classifications in which all employees have occupational exposure and classifications in which some employees have occupational exposure, as is the case with your IT employees servicing computers in the lab.



Know your morgue’s limits, then prepare for an overflow

Disaster planning should include storing and securing multiple bodies

Under Joint Commission standard EM.02.02.11, there is a brief mention of managing mortuary services in the event of a disaster. Such concerns also figure into 96-hour planning under EM.02.01.01.

Many of you won’t have a hard time imagining your hospital morgue overfilling during a catastrophe. Scott Janssens, RRT, MBA, CMRP, director of materials management and safety at Heywood Hospital in Gardner, MA, recently experienced this firsthand.

In December 2008, when ice storms knocked out power for a good chunk of New Hampshire and northern Massachusetts, Heywood’s morgue began filling up. Local funeral homes couldn’t take in any more bodies because they had neither power for refrigeration nor light for embalming.

On top of that, the hospital was holding one body for the local medical examiner, who could not make it to the hospital due to road conditions.

Space is limited for corpses

Heywood’s morgue has the capacity to hold four bodies. During the storm, the morgue held three bodies as the hospital treated two patients near death and funeral homes were knocked out of commission. To put it bluntly, if anyone else died, Heywood needed a plan B.

The hospital’s emergency planning committee had been working on a fatality management plan as part of a detailed pandemic flu response, but it was still in the draft stage.

Emergency managers met with local funeral directors in the storm’s aftermath, and one director was eventually able to take a body from the morgue.

Responders then discussed an overflow plan that was in development—commandeering an ice rink—although the idea probably wouldn’t have come together quickly because security and transportation issues weren’t easily resolved, Janssens says. That left stacking bodies in the morgue as the most practical backup plan, which wasn’t a particularly savory concept with physicians and other staff members.

Luckily, the weather improved, roads were cleared, and the lights came on before a morgue surge forced the alternatives.

“We were fortunate that we never did hit overload, and the road conditions improved enough for the local funeral homes,” Janssens says. “And the medical examiner [finally made it] to Gardner.”

Exercise showcases the challenge

One facility’s countywide drill with various agencies and neighboring hospitals yielded a wealth of tips for others who are working to develop their fatality management plans.

Bob Connor, project manager for safety and emergency management at Parrish Medical Center in Titusville, FL, says the event they chose was a shooting incident at a local college involving 28 mock victims brought to his facility from several campuses.

“We have a pretty detailed emergency operations plan and a fairly detailed incident command setup that includes start-to-finish triage, so we think we’re relatively prepared for that kind of occurrence,” Connor says.

Parrish Medical’s morgue has a capacity for three bodies; however, a temporary morgue can expand to hold 15 victims while awaiting a refrigerated truck to take the cadavers away.

How to set up temporary morgues

Connor offers the following advice for planning for an influx of casualties, based on his facility’s plan and the experience from the drill, which occurred in March:

  • Designate a zone—in Parrish Medical’s case, it’s a black zone that goes with green, red, and yellow zones for patients of different acuities—where casualties will go during incidents once the morgue fills up. Parrish Medical’s temporary morgue is a storage room that gets cleared out and is connected to a loading dock for refrigerated trucks.
  • Make sure that any temporary morgue has means of refrigeration or air-conditioning that can be turned all the way up and verify that there is adequate ventilation.
  • Provide security for temporary morgues by locking them down and stationing security officers around the clock.
  • Have materials management representatives draft memorandums of understanding with refrigerated truck companies to transport bodies if needed. You may need more than one truck if there is a large mass casualty event.
  • Develop a plan for handling unidentified victims (e.g., where to hold them until they can be identified and how to connect with responders and families for identification).
  • Scale up your hypothetical scenarios, figure out the point at which you can’t accept any more bodies, and meet with public health agencies and other authorities to draft a plan for those cases.

“I don’t think you can plan enough,” Connor says. “I think you plan all you can effectively plan ... and what you did this year, you rethink next year. It’s a never-ending game.” (Connor shares his thoughts about news coverage in “Limited media access to morgue operations is personal for one safety pro” below.)

What Heywood learned from its near-miss morgue situation was that fatality response plans may be needed in more scenarios than a pandemic flu response, which had been the case before a real-world situation changed the facility’s thinking.

“In our case, it was an ice storm, but it could have been due to a tornado, blizzard, hurricane, or earthquake,” Janssens says, adding that Heywood is filling out more fatality management details in its response plan in the wake of the ice storm experience.

Looking at a temporary morgue as a tool reflects more of an all-hazards approach. “We have done a significant amount of planning for pandemic [flu],” Janssens says. “Hopefully, we will never have to use those plans, but … when the situation occurs, we can take that plan out with the knowledge that some thought and planning has already gone into solving the challenges.”



Tip of the month

Address hazards of long shifts during disasters

Hospitals hit by 2009’s winter and spring weather events—ice storms, flooding, and other emergencies—likely had to employ creative staffing models to pull through the days when regular employees couldn’t make it into work because they were stranded at home or dealing with family logistics.

Technically, there is no specific OSHA standard governing shift length in these circumstances. However, the agency offers guidance for such situations in an FAQ document titled “Extended/Unusual Work Shifts.”

According to OSHA, the following are some dangers of extended shifts:

  • Most of our bodies are tuned to work eight-hour shifts during the day. Unusual shifts for workers accustomed to day shifts lead to increased fatigue, stress, and concentration, all of which raise the odds of injuries and accidents.
  • Unusual shifts typically result in less than full recovery during off-shift hours. It can take up to 10 days for an employee to adju


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