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Hospital Safety Center, August 2009


August 1, 2009


Report urges you to prep for more HSEEP influence

Cut your energy bills with these award-winning ideas

New fire watch rule hinges on planned disruptions

The EPA again extends the deadline on its oil spill rule

HVA and other disaster preparations receive scrutiny

Laundry inspection standards offer you best practices

Tune up EtO safety with new OSHA guide

Surviving security budget cuts in a recession

How should infant security differ from pediatrics?

Emergency management

Report urges you to prep for more HSEEP influence

It may pay to stay familiar with developments in the Homeland Security Exercise and Evaluation Program (HSEEP), as increased use of this federal endeavor is a likely next phase in hospital emergency planning.

This notion is based on findings in a new report, Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and Priorities Going Forward, published by the University of Pittsburgh Medical Center’s (UPMC) Center for Biosecurity.

After 9/11, the first wave of preparedness saw hospitals develop better response plans and establish relations with other agencies within their communities. The next wave will likely be the continued phase-in of HSEEP (pronounced H-seep) standards for hospital exercises, says Eric Toner, MD, the UPMC study’s lead author and principal investigator. “Over the course of the last seven or eight years, hospitals are demonstrably better prepared than they were prior to that time,” Toner says. “The No. 1 conclusion we came to is that the direction everyone’s moving in is toward greater and greater collaboration and development of emergency preparedness coalitions on a regional basis.”

Advice for healthcare facilities

The poor economy has forced hospitals to cut back in many areas, including emergency preparation, Toner says. Conversely, real emergency responses are on the horizon: Toner notes that the H1N1 swine flu pandemic will likely continue into the fall flu season.

“Hospitals will be busy, as they always are in pandemic flu years,” he says, noting, however, that he doesn’t see H1N1 as a catastrophic threat.

For overburdened hospital emergency management coordinators who might not be locked into freely flowing grant monies, Toner offers the following pointers for moving forward on emergency plans and reaching out to the community, as The Joint Commission (formerly JCAHO) sets forth in its standards:

  • If you haven’t already, meet with the “alpha dog” agency in your area to share your hospital’s preparation needs as part of a discussion on what sides can do together.
  • Get together with other hospitals in the region and share your preparation plans. Although your site’s plan will have to be customized to your facility, you can still share information with other medical centers, which may save duplicate efforts and consolidate research.

“That’s the way to leverage limited resources and limited time,” Toner says, adding that a multihospital, multi-agency community exercise is a jackpot when it comes to sharing work.

“Let everyone create it, evaluate it, and write it up,” he says. “There’s no need for everybody to do all that work individually.”

The UPMC report clearly states that HSEEP “can improve hospital exercises.” HSEEP also gives hospitals a structure to evaluate what went right and wrong during a drill, Toner says.

Many hospitals are already using HSEEP methods to conduct their drills, and Toner believes it will become the standard in the near future, especially among hospitals receiving federal preparedness grants. But even if your facility doesn’t use HSEEP, Toner recommends reviewing the program’s tools.

“Doing a good [postexercise] analysis takes time, and it’s hard,” he says. “HSEEP is cumbersome because it’s rigorous. You can quibble with HSEEP, but it’s out there being used by emergency management agencies, fire, police, and EMS. Healthcare really needs to move in that direction, so they might as well get ready.”

After researching how different localities ran their drills, the report’s team found that the most effective HSEEP implementations started with someone in a public health department who was well versed in HSEEP. That person disseminated guidance to the various entities that participated in a drill.

Heavy hitters in the mix

The UPMC report was commissioned by the U.S. Office of the Assistant Secretary for Preparedness and Response—better known by the acronym ASPR—which is the agency that sponsors emergency planning grants for your hospital. The study also received input from The Joint Commission, as its standards are referenced heavily in the report. The commission latched on to the report, linking to it from its Web site. (See p. 3 for more about the report.)

“Joint Commission was involved in some of our working groups,” Toner says. “We had talked to them along the way to get their perspective on what had happened in hospital preparedness over the years.”

Toner’s team interviewed more than 130 hospital emergency management coordinators and experts to compile the report.

Editor’s note: Download the free report at www.upmc- biosecurity.org.

Cut your energy bills with these award-winning ideas

What does going full tilt on environmentally green efforts get you, really, in this economy?

A lot, say the two winners of this year’s Practice Greenhealth Environmental Leadership Circle Award.

Lower energy, water, and waste bills have all come thanks to aggressive recycling programs, not to mention goodwill built among patients and the community, says Dawn LeBaron, vice president of hospital services at Fletcher Allen Health Care of Burlington, VT, one of the facilities that received the award.

The only way to convince administrators to jump on the bandwagon is to save money with your environmental initiatives. That can be a tough sell because the stigma of green construction and other waste-reducing schemes is that they cost more to do the right thing. But that hasn’t proven to be necessarily true.

“For the most part, all of our environmental efforts have saved us money,” says John Ebers, sustainable business officer at Metro Health Hospital of Wyoming, MI, the other award winner. “Some of [our efforts] take a longer-term view … but I think that speaks volumes about our organization.”

The Environmental Leadership Circle Award, Practice Greenhealth’s highest honor, goes to hospitals setting the highest standards for environmental practices. Practice Greenhealth is a national association that promotes environmentally beneficial efforts in healthcare.

Increased recycling and lower light use

Greening your facility and changing habits don’t happen quickly, but there are some higher-reward items to go after first, LeBaron and Ebers say—namely, more efficient energy use and recycling more material instead of throwing it in the trash barrel.

Fletcher Allen had a recycling program in its business and physician office for some time, but LeBaron and her colleagues recently pushed it further, obtaining recycling bins for newspapers and medical supplies in patient rooms. They also chase down and recycle IV bags and blue wrap in which sterile supplies come packaged.

The key to making any recycling program work is education through departmental meetings, which is then reinforced with small reminders (e.g., e-mails). Ebers says Metro Health staff members showed a desire to get into the green efforts but weren’t sure what to do. Once they were shown the way, compliance came pretty quickly.

“You’ve also got to make it easy for them to do it,” LeBaron says. “That’s what our environmental services [team] is working on doing.”

A big money-waster is excessive use of lights. Ebers says the following two measures will show results quickly:

  • Changing light fixtures from T12 to T8 wherever possible. T12 and T8 refer to light tube diameters, with the smaller T8s being more energy efficient.
  • Swapping out incandescent lights for LED lights on exit signs because LEDs last longer.

Also, if your facility has one, changing lighting in the parking garage can be a big money-saver.

LeBaron says that going after the biggest light-wasters—business offices and restrooms—with motion detectors that switch off lights when no one’s around helped Fletcher Allen lower consumption. In total, the facility decreased electrical demand by 8% from 2007 to 2008.

However, getting staff members to shut off lights and computers when they’re not in a room can be a more difficult task.

A big ball of mercury

Some of Fletcher Allen’s efforts didn’t save money but were the responsible things to do—such as reducing mercury on the premises, which provided a safety benefit by reducing potential employee exposure to the toxic element, LeBaron says.

The hospital accomplished that by cleaning out drain catches of a certain age. About 10 years ago, hospitals phased out mercury thermometers. Drain traps older than that were loaded with mercury, which is heavier than water and thus doesn’t wash out.

Fletcher Allen eradicated mercury everywhere else it found it on campus, including a 40-lb. ball of mercury used in an ancient boiler (the hospital upgraded the boiler’s hardware to function without the mercury). The facility also specified mercury-free medical gear for future purchase.

Planting a funky roof

Ebers, too, says that some of the measures he helped put in place might not be practical for every facility, such as a 48,500-square-foot vegetative roof for one building at Metro Health, which involves soil and 100,000 plants instead of shingles and asphalt. The vegetative roof will pay for itself—over a 20-year span—by helping with water runoff and providing a thermal barrier over the building. Also, it will last longer than a traditional roof.

But more common steps, including water reduction programs, are within the reach of many hospitals. Metro Health cut down on irrigation, having planted hardy, native vegetation on its grounds. These plants needed irrigation the first year to establish themselves but will look good without it in future seasons. This year, Metro Health is shutting off the irrigation on 20,000 square ft. of landscaping.

Pros and cons of vendor involvement

Once you start pricing out new gear, supplies, and construction ideas with an eye toward conservation, you’ll notice the “greenwashing” phenomenon: Vendors tout the environmental benefits of their products, regardless of whether they’re truly beneficial.

Ebers, whose desk gets bombarded with marketing materials on a daily basis, has a simple way of cutting to the chase: The more a vendor has to tell you its product is green, the less environmentally friendly it probably is, he says.

Some HVAC or power supply vendors might be willing to conduct an energy assessment of your facility, offering to find where you’re wasting energy. Understand what the vendor wants from you in exchange—perhaps a minimum purchase of equipment or services, LeBaron says.

In some cases, you might be better off paying for an independent consultant to perform the same assessment; however, Fletcher Allen ended up buying heating and cooling equipment from a long-standing vendor that conducted such an energy audit.

“You commit to doing a portion of what they identify,” LeBaron says. “But when you get down to it, [the vendor] spent a lot of time in this facility working with our own engineering team to identify opportunities, and that was a good thing.”

Joint Commission notebook

New fire watch rule hinges on planned disruptions

The Joint Commission has made a significant shift in policy when it comes to fire watches required under the Life Safety Code® (LSC) and standard LS.01.02.01.

The LSC requires facilities to institute fire watches when a fire alarm or sprinkler system is out of service for more than four hours in a 24-hour period. LS.01.02.01, element of performance (EP) 1 mirrors that requirement.

However, the June Joint Commission Perspectives qualifies that requirement, stating that there is a difference between scheduled and unscheduled disruptions to alarm and sprinkler systems.

Generally, a scheduled disruption (e.g., servicing a system) would not mandate a fire watch, whereas an unplanned system loss (e.g., a component failure) would require a fire watch.

“If you take one smoke detector out of an area … you haven’t compromised the system,” said George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission (formerly JCAHO). “You may have compromised a single device,” but that isn’t enough to justify a fire watch.

Also, if a hospital has planned disruptions lasting two hours in the morning and three hours in the afternoon, those two outages don’t trip the four-hour threshold in the LSC because they count as separate occurrences, said Mills, who spoke during a Joint Commission Resources audio conference in June.

Mills pushed the idea that all evaluations about fire watches should also include a discussion about whether interim life safety measures are warranted.

Look for more analysis in the August issue of our sister newsletter, Healthcare Life Safety Compliance.

Emergency management tracer is gone

Starting immediately, hospitals undergoing a survey will notice a difference in how surveyors review emergency management efforts. Although surveyors will continue to review your hazard vulnerability analysis and emergency operations plan in the incident command center—and possibly conduct tabletop drills—there will no longer be a designated emergency management tracer on the unit floors, Mills said.

However, survey teams have been encouraged to look at emergency management concerns as part of other tracer activity, which will result in more staff members participating in disaster preparation discussions with surveyors, he added.

Scoring changes involve EC standards

As of July 1, The Joint Commission has amended the scoring of various EC and life safety standards. The changes, which were published in the June Perspectives, center on The Joint Commission’s criticality scoring levels and scoring categories.

Eight EPs within the EC and life safety standards have been upgraded from indirect to the more serious direct impact requirements. “Occasionally, we felt things were a greater risk, so we changed [them] to direct impact,” Mills said.

For example, standard EC.02.03.05, EP 11 requires hospitals to test their fire pumps every 12 months and will be a new direct impact requirement. Joint Commission officials felt this was an “extremely important test” that warranted a higher criticality ranking, Mills said.

In fact, fire pump failures are often noted by Joint Commission officials as situations that would trigger criticality level 1, so the connection to proper pump testing is clear.

The EPA again extends the deadline on its oil spill rule

The long and winding road to enacting the latest version of the federal spill prevention, control, and countermeasure (SPCC) rule has taken yet another twist.

The Environmental Protection Agency (EPA) has again extended the date by which SPCC-regulated facilities must amend their plans to reflect updated provisions to November 10, 2010. The prior deadline had been July 1, 2009.

The amendments to the final rule add many clarifications, including new information on what exactly defines a facility’s boundaries.

“This extension will allow the regulated community approximately 16 months beyond the previous compliance date of July 1, 2009, to make changes to their facilities and to their SPCC plans necessary to comply with the revised SPCC requirements,” according to the EPA.

One caution: The amended final rule does not affect the overall regulation, as the EPA still requires that facilities in operation before August 16, 2002, maintain an oil spill plan in accordance with the SPCC regulations.

Oil is commonplace in healthcare

Hospitals often store oil—anything from heating oil to cooking oil—in large amounts, both above and below the ground. Larger facilities may have tens of thousands of gallons on the property.

The purpose of the SPCC regulations is to prevent oil spills from occurring. However, if a spill does occur, the rule outlines what actions sites can take to minimize an incident’s effects.

The SPCC rule applies to facilities that store and use a certain amount of oil that could potentially discharge into navigable U.S. inland waters and streams. A key to oil spill prevention is the need to provide for adequate secondary containment of spills, such as berms or dikes around storage tanks.

The latest delays to the SPCC amendments came about after the Obama administration issued a January memo to federal agencies urging the extension of compliance deadlines for regulations that had been published in the Federal Register but had not yet taken effect. The extensions were recommended to give agencies a chance to review them and offer comments before they went into effect.

EPA representatives tell Briefings on Hospital Safety that the most up-to-date information on the SPCC deadlines is posted at www.epa.gov/emergencies/content/spcc.

Survey monitor

HVA and other disaster preparations receive scrutiny

The Joint Commission’s 2009 life safety and emergency management chapters have proven to be focus areas for surveyors, at least based on a visit to Oregon State Hospital’s (OSH) Portland and Salem behavioral health campuses February 23–27.

The hospital retained its accreditation, with four direct impact findings spread across the 635-bed facility and 51 others under elements of performance (EP) with lesser criticality levels. Under The Joint Commission’s new scoring system, a facility the size of OSH could have up to 13 direct impact findings before citations affected accreditation.

Many of the indirect impact findings were related to EC and life safety standards. That isn’t a surprise, says Ted Ficken, quality improvement director at OSH, as the facility is fairly long in the tooth, with one of its buildings dating back to 1883.

Follow-up survey expected

At the time Briefings on Hospital Safety interviewed Ficken in June, the hospital was still within its 45-day period to rectify the indirect impact findings through the evidence of standards compliance process. Once that process is complete, the surveyors will come back to the facility.

“We were told we’d maintain full accreditation, but they intend to make another visit just to look at life safety and environment of care issues,” Ficken says. “My response to them was, ‘If we have full accreditation, then we don’t want to pay for a return visit,’ but they said it would be free.”

The combination of three sentinel events in the past year (after five years without any), new construction under way, and the age of the existing facilities probably influenced The Joint Commission’s decision to revisit OSH, says Ficken.

Emergency response plan reviewed

Ficken says he sent word out through the facility’s communications center that The Joint Commission (formerly JCAHO) was on its way after getting 30 minutes’ advance notice on the facility’s extranet site. Surveyors reviewed OSH’s emergency plan and found its hazard vulnerability analysis (HVA) “not completed to their satisfaction,” Ficken says.

This observation is in line with a warning given by George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, during a May Joint Commission Resources audio conference. HVA problems have been challenges for surveyed hospitals in 2009, Mills said.

At OSH, surveyors also required the facility to perform more testing on emergency generators that power a well on one of the properties. The well provides backup water if municipal supplies go down.

There was no tabletop exercise to test the facility’s 96-hour plan, which surveyors often conduct at acute care hospitals. However, with a new facility under construction—due to open at the end of 2011—surveyors wanted to know how the old facilities would deal with a surge of behavioral patients in a disaster.

The answer? “We wouldn’t take in new patients” until the completion of the new facility, Ficken says. Surveyors noted in the final report that they wanted that point written down in the emergency operations plan.

Issues noted by life safety specialist

The life safety specialist found several items that other hospitals preparing for upcoming Joint Commission visits might want to double-check:

  • Stairwell signs (LS.02.01.20, EP 29). Surveyors required more detailed wording for multistory buildings indicating what floor someone in the stairwell is on and the direction and story of exit discharge. OSH added more signs.
  • Vendor paperwork (various potential standards, such as EC.02.03.05). A contractor had conducted fire safety checks on behalf of the hospital but hadn’t filled out reports completely because dates or signatures were missing. OSH went back to the contractor and got the reports completed properly.
  • Electrical requirements (various potential standards, such as LS.02.01.70). Surveyors found inadequately labeled circuit breaker boxes, so OSH amended its signs at the breaker boxes.
  • Monthly portable fire extinguisher checks (EC.02.03.05, EP 15). Out of more than 500 fire extinguishers, three had not been checked in the month prior to the survey.
  • Water temperature (EC.02.01.01, EP 1). Eyewash stations with hot and cold taps weren’t regulated properly, which leaves open the potential to deliver water that could burn someone’s eyes. This is an interesting example of an item a life safety specialist noted that has little to do with fire protection requirements, a pattern that occasionally shows up during surveys.

Regarding the eyewash stations, Ficken says the facility disconnected the hot water tap, so it only runs cold.

Hospitals should be wary of this move, however, as eyewash provisions from the American National Standards Institute generally promote the use of tepid water. OSH also offers portable eyewash bottles that are always at room temperature.

Waiting out the old

Most of the issues uncovered in the survey won’t be concerns in the new, more modern facility OSH recently began building, Ficken says. Until it’s open, the facility can address all of its survey problems through fixes or small upgrades.

However, in some cases (e.g., exposed pipes under sinks acting as suicide risks), workers will need to address the danger through more frequent surveillance rounds.

“We’ve eliminated as much of [the risks] as we could—and could afford,” Ficken says. “For now, to keep patients and staff safe, we’ve got continuous rounds.”

Finally, Ficken offered this pair of pointers for EC folks:

  • Keep your periodic performance review detailed and up to date—by doing so, there won’t be many surprises come survey time.
  • Go over the 2009 standards, focusing on the life safety EPs. “[Surveyors] really paid attention to that,” Ficken says.

Laundry inspection standards offer you best practices

Soiled hospital laundry poses an exposure threat to employees, patients, and families.

The Healthcare Laundry Accreditation Council (HLAC), an organization formed in 2005, aims to help hospital laundries and industry contractors maintain standards of cleanliness and infection control through its triennial independent inspections.

Moreover, the standards delve deep into matters of employee safety, including protective equipment and training, zeroing in on best practices for complying with OSHA’s bloodborne pathogens standard (1910.1030).

So far, only independent laundries have signed up for accreditation—no hospitals yet—but HLAC is working to get in-house laundries accredited at healthcare facilities, says executive director Kathy Tinker.

“We’re not trying to compete with Joint Commission, but HLAC recognizes that The Joint Commission probably isn’t walking into the laundry itself,” Tinker says.

Ubiquitous problems pose a need

HLAC’s standards incorporate OSHA requirements, federal health guidelines, and recommendations from several national organizations (see “Laundry accreditation standards focus on cleanliness and professionalism” on p. 11 for more details).

Ed McCauley, president and CEO of Indianapolis laundry co-op United Hospital Services, points out that many hospital laundries must make do with less space than their off-site contractors. That dilemma can lead to infection control problems.

In addition, in-house hospital laundries don’t necessarily have as up-to-date equipment as third-party contractors, which could be another reason to have an independent group weigh in on the site’s performance, McCauley says.

Pitfalls that you can anticipate

Hospitals that are considering HLAC accreditation and want to begin the process—or that simply want to survey their procedures with an eye toward improving safety and guaranteeing textile hygiene—should look at the following potential trouble spots:

  • Training. Make sure laundry employees know what personal protective equipment to wear when handling soiled laundry. Hospitals should ensure that these workers follow hand washing protocols, avoid dangling jewelry, refrain from eating and drinking in the laundry area, and know how to enter the soil-sort area.
  • Clean laundry storage. A big part of HLAC’s standards covers how to store clean laundry so it stays clean, in terms of handling or airflow.
  • Linen flow. Because of lack of space, there often aren’t clearly defined aisles in small hospital laundries. Make sure work flow helps prevent mixing of clean and soiled textiles and doesn’t create an infection control risk.
  • Airflow. It’s a simple notion, but not necessarily an obvious one: Is air from the soiled side of the laundry going over to the clean side? Is the air vented properly?
  • Management. Make sure the person running your laundry is well trained in OSHA matters.

Tip of the month

Tune up EtO safety with new OSHA guide

Do you know what the action level for ethylene oxide (EtO) exposure is in the hospital? Would your EtO emergency plan pass OSHA muster? What about your employee training and exposure monitoring methods?

For example, when taking 15-minute samples, which 15 minutes of the day should you choose?

OSHA answers all of these questions and more in a new, 87-page document, OSHA’s Small Business Guide for Ethylene Oxide. The guidance, available at www.osha.gov/Publications/ethylene-oxide.pdf, explains the vagaries of OSHA rules surrounding the use of EtO.

Even though some hospitals wouldn’t be considered small businesses (i.e., those with 250 or fewer employees), the publication still serves as a good primer for newcomers to the healthcare safety field, as well as a refresher course for veterans.

Not only does OSHA describe all the jargon involved with EtO testing (e.g., excursion limits versus exposure limits), but it distinguishes which results call for an employer to limit exposures.

Clarifying EtO provisions

The guide discusses the following points:

  • Taking steps to reduce exposure levels with engineering controls
  • Providing information and training
  • Developing and putting into action a written compliance program for reducing EtO exposure and establishing a schedule for periodic leak detection
  • Providing respirators
  • Establishing a regulated area, along with necessary signs
  • Ensuring that caution labels are fixed to containers
  • Providing medical surveillance
  • Establishing periodic air monitoring

Recordkeeping notes

OSHA also reiterates certain agency rules, such as the mandatory maintenance of EtO air sampling records for 30 years and the right of employees as well as their representatives to observe the hospital’s EtO monitoring process.

Another note for the recordkeeping department: When an employee gets a written opinion from a physician that states whether the worker would be at increased risk from further exposure to EtO, the hospital must keep that document on file for 30 years after the employee’s last day on the job.

For more about EtO, see “Ethylene oxide sterilizer rule goes into effect” on p. 7.

Surviving security budget cuts in a recession

How to thrive under pressure to cut

As hospitals across the country are suffering from the recession, budget cuts have become widespread in many hospital departments, and security departments are no exception. Security is important, but it doesn’t generate revenue, making


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