Hospital Safety Center, January 2010

Inside:

Resolve to improve your life safety programs in 2010

GIS mapping technology strengthens emergency prep

Actions you can take to stave off bedbug infestations

ASHE winner discusses the future of green construction

Union and hospital system cooperate on pandemic pact

Briefings on Hospital Safety 2009 story index

Use OSHA bulletin to reinforce accelerator safety

Threat assessment team helps protect employees

Best practices for healthcare security

Resolve to improve your life safety programs in 2010

With no major new Joint Commission deadlines passing on January 1, 2010, the changing of the calendar offers an opportunity to take stock of your life safety management plans.

The Joint Commission released statistics in November that showed four fire safety–related violations among the top 10 cited standards in surveys for the first half of 2009. Three of them used to fall under the old EC.5.20, which was 2008’s No. 1 trouble spot for hospital surveys.

The latest round of top citations includes the following standards:

• LS.02.01.20 (No. 1 cited standard during the first half of 2009, with 45% of hospitals receiving findings), which requires hospitals to maintain their means of egress
• LS.02.01.10 (second most cited at 43%), which requires hospitals to design and maintain building features to minimize the effects of smoke and fire
• EC.02.03.05 (tied for fourth most cited at 38%), which requires hospitals to inspect, test, and maintain fire protection equipment
• LS.02.01.30 (sixth most cited at 36%), which requires hospitals to maintain building features to protect people from smoke and fire

These issues are prevalent at every facility, and their monitoring programs can almost always be reevaluated, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and contributing editor for Briefings on Hospital Safety.

“I have no reason to think that these [standards] won’t stay up near the top, because everybody has to deal with these. Everyone has doors that don’t close and latch or [has] unsealed penetrations or missed testing,” MacArthur says. “We do not live in a perfect world, so there are no perfect programs, and thus one can find deficiencies anywhere at any time—it’s the reality of the situation.”

Stay tight on ILSM oversight

One area to review is your plans for improvement (PFI) and interim life safety measures (ILSM) that go with those PFIs, says Dean Samet, CHSP, director of regulatory compliance services at Smith Seckman Reid, Inc., in Nashville.

Don’t let PFIs that haven’t been completed yet slide by, as doing so could put your facility on thin ice. Failure to make sufficient progress toward the corrective actions described in a previously accepted PFI (see LS.01.01.01) or failure to carry out applicable ILSMs (see LS.01.02.01) can result in citations and even conditional accreditation.

Scrutiny of ILSMs has been “ratcheting up for the last several years,” Samet says. “All people have to do is follow the rules and stick to the schedules, and they should be okay.”

Hospitals have had plenty of opportunities to shore up ILSM compliance, Samet says. “Now it’s time for The Joint Commission to get tough, in my opinion,” he says. “It’s all in the name of providing a safe environment for the patients and punishing the slackers.”

Be careful with initial safety training

The new hospital accreditor on the block, Det Norske Veritas’ (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO), surveys its accredited hospitals once per year.

The Centers for Medicare & Medicaid Services (CMS), however, validates an initial DNV survey for reimbursement purposes and those occurring every three years thereafter.

That timeline means DNV-accredited hospitals need to be in compliance with life safety issues from the get-go with CMS, says Randy Snelling, CPEO, chief physical environment officer at DNV Healthcare.

CMS granted DNV “deeming authority” in September 2008, which means a hospital that receives NIAHO accreditation also meets CMS’ Conditions of Participation for Medicare funding.

DNV’s top-cited physical environment concerns, based on Snelling’s interactions with hospitals working on NIAHO accreditation, include unprotected penetrations in barriers and door latching problems.

Another item that crops up is initial employee safety training, Snelling says. OSHA requires training for new employees on hazard communication, personal protective equipment, needlestick prevention, and possibly fire extinguisher use.

Many hospitals fall short of these requirements, letting inadequately trained employees start working before they’re ready.

“We’re finding that training isn’t always necessarily happening before an employee’s initial assignment,” Snelling says. “If you’re handing out little packets and telling people to read them on their own and you’ll get back with them in three or four weeks, you’ve made a statement about where that safety orientation is on the priority list.”

Hospital applications abound

GIS mapping technology strengthens emergency prep

Many people have computer navigation devices in their vehicles. These work with GPS satellites and use the same geographic information system (GIS) mapping technology that is helping hospitals enhance their disaster preparedness, safety, and security programs.

Another everyday application of GIS is obtaining driving directions online from sites such as Google^™ Maps or MapQuest^®.

The best part? A lot of this technology is free or cheaply available to hospitals if emergency planning leaders twist the correct arms of fellow responders in the community and tap into government resources from the U.S. Department of Homeland Security and other agencies.

Such networking can count toward Joint Commission compliance, too, as the accreditor emphasizes community outreach during the course of emergency planning under emergency management standard EM.01.01.01.

“GIS doesn’t just produce pretty maps with pretty colors,” says Ric Skinner, GISP, owner of Stoneybrook Group, LLC, a health geographics consulting firm in Sturbridge, MA. “It’s … technology that enables people and functions and organizations to come together that might not have considered it before.”

Sort of like baking a cake

Dalton Sawyer, MS, CHEP, director of emergency preparedness and continuity planning at University of North Carolina (UNC) Health Care in Chapel Hill, explains GIS like this: Imagine a custom map as a cake, with different data being layered on.

For example, during the interview for this story, Sawyer and his peers were preparing for a weekend college football game and the crowd and traffic problems that go with it. The Google Map they drew included a base layer with roads, towns, buildings, and predicted traffic patterns. Sawyer distributed the custom map to emergency medical services (EMS) and police and fire departments for help in routing patients to UNC Health Care.

“It’s absolutely essential to preplanning for disasters,” Sawyer says. “You can’t really do a good all-hazards preplan for a facility unless you use GIS.”

Imagine the potential for mapping technology when developing a hospital emergency response plan for a flood. Not only would seeing the U.S. Geological Service’s floodplain maps reveal where a flood would most likely occur, but overlaying it with a highway map would reveal which normal routes for ambulances, suppliers, and employees would be shut down and which would be the best alternatives.

Looking at these visual resources makes it straightforward to develop strategies for routes affected in 10-, 100-, and 500-year floods. Ditto for tornadoes, industrial accidents, or any other disaster ranking high on your hazard vulnerability analysis. In the days and hours leading up to a hurricane’s landfall, GIS would aid in planning how to keep patients moving to and from the hospital when evacuation routes are gridlocked as residents flee the area.

Visual data is one of the main benefits of GIS. It’s a picture that makes decision-making faster, more obvious, and intuitive, says Skinner, who is the editor of the upcoming book GIS in Hospital & Healthcare Emergency Management.

“In hospitals, we feel helpless because we have no idea what’s going on in the outside world and we have to rely on information people have told us,” Sawyer says. “Most people are visually oriented. You can tell me that this street and that street are blocked, but if you show me, it gives me a better situational awareness of what’s going on.”

An essential first step with GIS is to plot evacuation routes from the hospital, Sawyer says. Next, figure out which streets to close if the hospital goes into lockdown. Both tasks can be accomplished with a free Google Maps account. (To learn more about common applications of mapping technology, see “Lots of ways for hospitals to use GIS” below.)

Reaching out to your neighbors

Although your hospital might not be willing to invest funds in GIS software, it’s likely that multiple emergency response organizations in your area have already done so, Sawyer says. These groups might be willing to create maps on your behalf or give you time on their system to do it yourself, as Sawyer does.

He and Skinner recommend contacting the following sources first:

• Public safety forces. Ask your local police department to map out crime statistics. To get a more detailed picture, consult with the fire department as well and plot call locations over the past five years in a database and map.
• EMS. Ambulance companies probably have the most robust situational awareness GIS installation in your area—routing ambulances, helicopters, and the rest of the rescue fleet requires it. These programs often show bed availability at local hospitals, where police and fire units are deployed, and minute details such as traffic camera feeds.
• Military. Maybe there’s an Army installation or National Guard base near your facility. These trained GIS pros can demonstrate their use of the mapping technology and give you pointers for finding maps on government Web sites relevant to your planning.
• State agencies. Your state’s health department and emergency management agency likely use GIS in one form or another, Skinner says. Explore the area maps they possess and see whether the information furthers your preparedness knowledge.
• Local and regional emergency management organizations. Is there a regional emergency response cooperative of which your hospital is a member? Find out how it uses GIS and schedule a meeting to get up to speed. These groups—and the military folks mentioned above—also can offer intelligence about mapping terrorism targets.
• Internal data. Plotting addresses of sick patients and staff members, obtained from the hospital’s accounting and medical records departments, can help predict potential outbreaks by yielding localized data for annual hazard vulnerability analyses.

Finding training that’s affordable

Keep in mind that many state and community colleges offer courses on using GIS technology, and federal, state, and private grants may be available to help defray your formal training costs. Sawyer’s GIS training came as part of his bachelor’s and master’s degree classes.

“You don’t need to be at that technician level if you’re in emergency management,” Sawyer says. “You just need to know how to use it.”

And although many tools (e.g., Google Maps) and resources (e.g., government data) are free, investing in commercial mapping software can greatly enhance and automate your preparedness efforts. Getting on board with GIS now will help get you ready for the near future as this technology evolves and becomes more pervasive in our daily lives.

“GIS is growing so rapidly in a lot of different areas,” Skinner says. “[Soon] you’re not even going to think you’re using GIS. It’s going to be like opening up [Microsoft^®] Word to type a letter. You’re going to open up an application and create a map. It’s going to be that simple.”

Lots of ways for hospitals to use GIS

Hospitals can use the following applications of geographic information system (GIS) mapping technology:

• Evacuating patients. During the 2007 wildfires in San Diego County, GIS-trained epidemiologists helped 15 healthcare facilities track rapidly evolving fire paths and smoke-affected areas to assist with patient inflow and evacuations, says Ric Skinner, GISP, owner of The Stoneybrook Group, LLC, a health geographics consulting firm in Sturbridge, MA. The end result was efficiency: Most patients were only moved once, accompanied with three days’ worth of medications, staff members from the sending facility, and medical records.
• Life safety management. GIS also offers applications for internal hospital emergencies, such as mapping access points for patient relocations during a fire, Skinner says.
• Infectious disease surveillance. GIS can map disease outbreaks such as H1N1 swine flu. Plotting which particular patients and staff members become infected can help hospitals and public health departments determine what areas in a community are hardest hit, and it may even predict who is next.
• Family reunification. “Experience with past disasters has shown that family members become extremely frustrated when they have to search from hospital to hospital for their loved ones,” Skinner says. “No common format or system for patient tracking is available.” A local hospital coalition could split the cost of a software event-tracking system that can greatly aid in mapping patient whereabouts and give family members real-time location data in the aftermath of a disaster, he says.
• Patient location. GIS can track patients and residents who wander from behavioral or long-term care units, or keep tabs on newborns.
• Security planning. Hospitals can assess security risks by analyzing neighborhood crime data plotted on maps.
• Home care services. GIS can make home care delivery routes more efficient, Skinner says. Home care routes can change on an almost daily basis, or even as a workday unfolds. Analyzing traffic patterns, accident data, and other points (e.g., where the driver is coming from) may enable drivers to serve more patients in less time.

Mapping all of the above can help paint a detailed picture of the types of disasters that can happen, especially when combined with weather data covering the major events likely to occur in your region.

“The first year is going to take more work to build those databases,” Skinner says. “In subsequent years, it’s just a matter of updating the analysis based on new data coming in. A lot of the natural events aren’t going to change from year to year, in terms of probabilities and impact.”

Actions you can take to stave off bedbug infestations

“Don’t let the bedbugs bite” is a funny saying many parents tell their kids at nighttime, but it’s not as charming when the critters actually invade your hospital.

The problem has grown enough that the American Society for Healthcare Environmental Services (ASHES) partnered with pest control company Orkin, Inc., of Atlanta to present a white paper about avoiding bedbugs at ASHES’ annual conference in Reno, NV, in September.

“The timing of this report and our annual meeting made it an opportune time to present this to our members and the hospital field,” says ASHES Executive Director Patti Costello. “[It] provides insight to help our members better understand the practical issues and solutions surrounding these pests.”

The white paper, titled Pulling Back the Sheets on the Bed Bug Controversy: Research, Prevention and Management in Hospital & Long-Term Care Facilities, is available for free at www.ashes.org.

Bedbugs aren’t a disease risk

According to the white paper, bedbugs are one of the few parasites that feed almost exclusively on human blood. Scientists believe these tiny insects thrive in mattresses and baseboards because they prefer to live in 60°–70°F temperatures, so they bite people and then return to cooler areas.

Although most people don’t have reactions to bedbug bites, and the insects don’t transmit communicable diseases to humans, an increasing number of hard-to-squelch bedbug infestations have affected hospitals.

Places where patients bring in more possessions and stay for longer periods (e.g., behavioral health floors) are the most vulnerable, as patients bring the bugs in with them on their personal effects, says Ron Harrison, PhD, BCE, corporate technical director at Orkin.

“It has become a huge problem in the last two or three years,” Harrison says.

How to avoid infestations

The Orkin/ASHES white paper offers the following best practices to detect infestations:

• Inspect mattresses and bedding as they are brought in
• Encase mattresses and box springs with inexpensive synthetic coverings, which prevent the insects from getting in and traps and starves those already inside
• Check incoming furniture, which can harbor bedbugs
• Utilize pricey monitoring technology offered by pest management professionals that can check for bedbugs; cheaper monitors that are more affordable to hospitals will likely be available within two years

Combating entrenched bedbugs

When you already have an infestation, there are many ways to attack the issue. If the facility has an integrated pest management program that uses environmentally conscious methods first, go after bedbugs as follows:

• Dispose of infested furniture
• If possible, wash affected items in hot water with detergent and run them in a dryer
• Inquire with pest management professionals about special equipment to heat an affected room and its belongings to the necessary temperature to wipe out bedbugs
• Freeze items if feasible; this seems as effective as heat

Meanwhile, less environmentally friendly chemical deterrents include:

• Fumigation
• Alcohol-based, nonresidual chemical treatments
• Residual chemical treatments for carpet edges, baseboards, furniture, headboards, etc.

ASHE winner discusses the future of green construction

Recently recognized by the American Society for Healthcare Engineering (ASHE) as a leader in facilities management, Donald E. Wojtkowski, FASHE, PE, executive director of design and construction at SSM Health Care in St. Louis, promotes patient viewpoints as the cornerstone of medical center design.

Wojtkowski won the inaugural ASHE Excellence in Facilities Management Award for “outstanding commitment to improving the healthcare physical environment.”

He shepherded the construction of the St. Clare Health Center, a new 154-bed hospital that opened March 30 in Fenton, MO. In the following Q&A, Briefings on Hospital Safety caught up with Wojtkowski to discuss how facility design affects patient care and why his project went forward without seeking formal Leadership in Energy and Environmental Design (LEED) designation. LEED is a green building certification system developed by the U.S. Green Building Council (www.usgbc.org).

Q. Congratulations on the award. Ecological concerns during the planning of St. Clare’s, you’ve said, was a priority but not the driving force behind its design. Why?

A. The thing that we did really differently at St. Clare was we started off trying to identify what the optimum patient experience should be. Rather than have the patient experience be an outcome of the design process, we wanted it to drive the design process.

It caused us to look at things differently, [as we established] a bunch of patient experience teams we formed early in the process that followed patients through our existing facilities, brainstormed on what we would think the optimum experience would be, and brought in patient focus groups to help us understand their point of view.

Q. What were the top outcomes of that process?

A. [We put] our diagnostic and clinical platform on one level for the entire facility to avoid the need for vertical transportation for patients on stretchers. We made five or six different portals of entry to the facility to keep surface parking close to the hospital so our patients don’t have to walk a quarter of a mile.

The patient room that we designed, I think, wound up being an optimum patient room. We went with same-handed configuration rather than mirror image. We integrated dispensing of medication at the bedside, including controlled substances, which we believe is having a remarkable impact on reducing medication errors.

We integrated every energy-efficient system into the hospital that we could, and we avoided the temptation to value-engineer out items for the sake of meeting a budget. We were budget compliant, but when you’re in the middle of a project and you’re looking for ways to save money, it’s very easy to start compromising on your energy systems, and we refused to do that.

Q. The facility isn’t LEED-certified, yet ecological concerns were a top priority, right?

A. Designing green was very important to us, but we made a very important decision early when we identified the cost for pursuing LEED certification—not for accomplishing the LEED initiatives, but the administrative costs of the commissioning to get the credential. Rather than invest in a credential, we decided to invest those funds [about $250,000 at the time] in tangible, green initiatives.

We tracked all of our LEED points … We believe we earned more than 26 [minimum points to gain the credential], and if we went for certification, we would have achieved it, but certification wasn’t our goal.

Q. Do you believe that ecologically minded building construction is a passing fad or something that will be permanently hardwired into the process moving forward?

A. I think what we’re seeing is that designing green is going to become an element of prudent engineering practice. That’s how we approached it. Certainly when it comes to engineering, there’s cheap and expensive ways to design systems, and [the latter] are usually the most costly, but when you start looking at life-cycle costs, rather than first costs, it’s always well justified. I don’t know how long the LEED credentialing system will be sustained. There are many other ways of approaching it, other processes you can go through to recognize a green building initiative. I’ve always had a problem with LEED certification mainly because there’s no recertification requirement associated with it. From a facilities management standpoint … the systems are extremely complex. If they had a recertification process, it would help the facilities managers because it would be an incentive. They’d be provided the resources and manpower and competency required to protect and preserve that credential.

Q. What detail of the new hospital’s design are you most proud of?

A. I’m most proud of the application of built technology in the building systems. We took some risks ... in our choice of engineering applications and nontraditional approaches to steam generation and air handling.

Super Carol: An animated safety superhero helps teach hospital workers

The communications department at SSM Health Care in St. Louis has come up with an innovation: an animated safety champion named Super Carol who appears in employee- focused print and online media, offering information on hot-button issues such as hand washing protocols, patient lifting, and needlestick prevention.

Check out Super Carol for yourself at www.ssmhc.com.

The character was hatched in late 2008 and stars in cartoons that come out each quarter, so there aren’t any real metrics available to measure her effectiveness, say Lorraine Kee, SSM’s corporate Web manager, and Alan Wesley, corporate publications manager.

However, Kee and Wesley have received kudos from coworkers they meet in the hallway, and Super Carol is attracting more hits to SSM’s Web site. That means the character is helping to familiarize employees and others with safety-oriented content, especially when she’s getting Twitter mentions. SSM’s communications office also produces Super Carol posters, which are distributed to hospitals in the system to further reinforce her message.

“We were looking for a fun, short, quick way to deal with safety topics,” Wesley says. “We thought a superhero would be a fun way to do things. It gives the cartoon a lot of energy and movement.”

So the health system set about creating the overzealous, bespectacled Super Carol, who flies around the hospital dressed in scrubs and is a bit obsessive with safety details. Instead of singling out noncompliant employees and harping at them, she does battle with fictional enemies Count Von Shortcut and Bad Habitus, whose center of operations is the Castle of Carelessness.

Watching Super Carol chase after these villains, say Kee and Wesley, gives staff members a break from the same old safety handouts everyone has to deal with.

Union and hospital system cooperate on pandemic pact

In a development that might be attractive to other hospitals and bargaining units, the California Nurses Association (CNA) has worked pandemic flu preparation into its next labor agreement with Catholic Healthcare West (CHW), a 41-hospital system spanning California, Nevada, and Arizona.

Although the agreement doesn’t delve into vaccinations—mandatory or otherwise—it covers personal protective equipment (PPE) and promotes communication between union rank-and-file members and hospital management via a joint task force charged with limiting the spread of seasonal and H1N1 swine flu.

The top three issues the pact aims to solve are probably endemic to many hospitals’ response plans. Sacramento nurse Richard Sandness, RN, one of the CNA members who sat at the bargaining table, points to the following pain points the union and health system will be working together to eliminate:

• N95 respirator inventories. When a patient with confirmed or suspected H1N1 presents to the hospital, caregivers should have N95s available per October’s recommendations from the Centers for Disease Control and Prevention. The pact between the CNA and CHW addresses how staff members who need N95s can get them right away.
• Exposure notification. Nurses need to know whether they’re potentially facing H1N1 exposures.
• Patient screening and tracking. Patients coming down with or getting over H1N1 may show up at the hospital for treatment of other medical issues. Uncovering these cases and tracking them through the hospital is key to controlling the flu’s spread.

Not just for H1N1 response

The upside of making a union-friendly plan—which can cover other diseases beyond the flu—is that it gets staff members more deeply involved in emergency preparation and response. Although management can put together a plan, the union has the ability to poll the nurses to make sure they understand and can execute it. “It’s management’s responsibility to provide the proper safety equipment, but on the other end, are we getting it when it runs out in the department? Does everyone know where the proper safety equipment is?” Sandness says. “We’re working on it on both sides.”

The agreement codifies guidelines CHW had been following, says Jill Dryer, a spokesperson for the health system.

“The agreement covers measures that CHW already has in place, including information and training for direct caregivers as well as the provision of personal protective equipment, including N95 respirator masks and clothing,” Dryer says. “We are pleased to now have the CNA’s full collaboration in furthering our efforts.”

N95 availability prominently featured

Union members working at CHW hospitals sometimes had trouble procuring N95s when their hospitals were in possession of them, Sandness says. The H1N1 component of the contract also seeks to minimize differences in the interpretation of flu prevention guidelines from facility to facility, such as the use of surgical masks versus N95s.

“We wanted clarity, so we were working under one guideline for the greatest protection,” Sandness says, adding that doing so will also improve utilization. One of the first tasks the agreement will tackle involves streamlining protocols and processes to get nurses—some recovered from H1N1, others displaying H1N1-like allergy symptoms—back to work more quickly after symptoms subside.

The pact also covers communication protocols. In one case, a pediatric patient made it through emergency appendectomy surgery at a CHW facility without anyone involved knowing she also had active H1N1, so none of the caregivers wore PPE.

The union pact calls for setting up notification protocols to let nurses know when they’ve been exposed to H1N1. It will follow the protocols currently in place for notifying nurses who have been exposed to lice, Sandness says.

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