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Hospital Safety Center June 2010


June 1, 2010


Joint Commission backs off of emergency prep tracers

Reviewing new ambulatory EC standards reveals MRI and diagnostic imaging best practices for hospitals

Healthcare reform items for safety committees to review

It’s okay if facilities don’t have perfect EC processes

FDA approves new Steris System 1 alternative

EC risk assessment important part of suicide prevention

Don’t put your lab at risk; check on proper PPE use

Include water fountains on your Legionella hit list

Annual security assessments become California law

Hurricane season brings security challenges


Joint Commission backs off of emergency prep tracers

Several developments have come to light regarding 2010 emergency management sessions that Joint Commission surveyors conduct during accreditation visits.

The biggest switch is that the formal emergency management tracer, which was part of some 2009 surveys, has been de-emphasized, said George Mills, MBA, FASHE, CEM, CHFM, CHSP, senior engineer at The Joint Commission. Mills spoke during a Joint Commission Resources, Inc., Webcast April 7.

The change in the tracer occurred as of January 2010, said Kenneth Powers, spokesperson for The Joint Commission. Although the revision appears in the accreditor’s 2010 Survey Activity Guide for Healthcare Organizations, it has not been overly publicized.

If, during the session, a surveyor finds an emergency management concern worthy of a tracer, it can be rolled into other tracers conducted by fellow surveyors. “Instead of conducting a special session on the emergency management tracer, surveyors assess the organization during regular tracers that are conducted throughout the survey,” Powers said.

Session tilts toward conversation

The emergency management session remains scheduled for 90 minutes, but you can expect more dialog between surveyors and hospital representatives regarding disaster preparation efforts and the performance of emergency exercises, Mills said.

“This interview process evaluates the organization’s preparedness to cope with emergencies identified in their hazard vulnerability assessment,” said Powers.

According to the Survey Activity Guide, the following items could be discussed during the session:

  • The hospital’s involvement with the community and other healthcare facilities (EM.01.01.01)
  • The inventory of assets that would be needed during an emergency response (EM.01.01.01)
  • The hospital’s capabilities when it can’t be supported by the local community for at least 96 hours (EM.02.01.01)
  • Planning for the six critical functions of communication; resources and assets; safety and security; staff responsibilities; utilities; and patient support activities (EM.02.02.01 through EM.02.02.11)
  • The hospital’s processes for disaster privileging of licensed independent practitioners and verification of other practitioners who are required to have a license or registration (EM.02.02.13 and EM.02.02.15)
  • Improvements to the emergency operations plan or lessons learned from emergency drills (EM.03.01.03)

The preceding list aims to explore whether the emergency management efforts are appropriate and realistic for a hospital. “The emphasis is on how prepared the organization is to cope with emergencies,” said Powers.

Utility planning remains a focus

You may want to double-check your utility contingency plans, which Mills continues to note as a subject of high importance to him.

Although memorandums of understanding are great ways to prepare for utility disruptions, they are weakened if several facilities or community organizations have agreements to get the same piece of standby equipment, such as a 25,000-gal. water bladder, Mills said.

Hospital emergency management coordinators should talk to their counterparts in the community about this concern, and if, in fact, several parties lay claim to a limited resource, it is time to conduct a drill and see what happens, he said.

Surveyors have been educated to ask hospitals about memorandums of understanding, how to evaluate these agreements against the emergency management standards, and aspects of testing these agreements.

Memorandums are excellent pieces of an escalating emergency drill, as called for under EM.03.01.03, element of performance 13.

Other standards to review in regards to utility contingencies include:

  • EM.02.02.09 (managing utilities during an emergency response)
  • EC.02.05.01 (managing utility risks)

In particular, think about the provisions under those standards in terms of the hospital’s capabilities to survive without assistance from the community for up to 96 hours.


Future changes in acute care?

Reviewing new ambulatory EC standards reveals MRI and diagnostic imaging best practices for hospitals

Although new elements of performance (EP) for advanced diagnostic imaging only appear in the EC chapter for ambulatory providers, these requirements may still be worth hospitals’ attention.

For starters, the disparity now between the ambulatory and hospital EC chapters when it comes to MRI and radiology safety results in a more strenuous approach for ambulatory settings, says Tobias Gilk, M.Arch, president and MRI safety director at Mednovus SAFESCAN®, based in Leucadia, CA. SAFESCAN develops ferromagnetic detection products for MRI suites. 

“The Joint Commission hates disparities when they don’t need to be there between the hospital and ambulatory accreditation programs,” Gilk says.

The Joint Commission acted quickly to amend its ambulatory diagnostic imaging requirements after the Centers for Medicare & Medicaid Services (CMS) mandated that outpatient imaging providers become accredited by a federally designated organization by January 1, 2012.

“The Joint Commission has been going at a breakneck pace since December” to align with CMS’ rules, Gilk says.

CMS has designated the following organizations to provide advanced diagnostic imaging accreditation: The Joint Commission, American College of Radiology, and Intersocietal Accreditation Commission.

CMS’ 2012 deadline will affect more than 7,000 sites that utilize advanced diagnostic imaging, according to The Joint Commission. The rules apply to the technical component of MRI, PET, and CT services, but not to x-ray, ultrasound, mammography, or other imaging.

Passing over hospitals, for now

In some sense, The Joint Commission’s effort to revise its ambulatory accreditation standards has led to the organization bypassing similar hospital provisions. Yet inpatient facilities can take useful information from their outpatient brethren in terms of best practice and  also perhaps preparing for future changes in the hospital standards for advanced diagnostic imaging.

“[The Joint Commission is] going to be doing work on the hospital side,” Gilk says. “I’d bet my paycheck on it.”

The CMS ambulatory diagnostic imaging provisions don’t apply to hospitals that provide such services—at least not yet—because hospitals bill for this under different payment systems than ambulatory surgical centers. 

Changes within the EC standards

Let’s look at the specific imaging provisions that The Joint Commission added to the ambulatory standards.

Under EC.02.02.01 (managing safety and security risks, similar to the hospital version of the standard), new EP 14 requires ambulatory organizations that provide advanced diagnostic imaging services to manage MRI risks associated with the following situations:

  • Patients who experience claustrophobia, anxiety, or emotional distress in an MRI scanner
  • Patients who may require emergency care while in the scanner room
  • Metallic implants and devices entering the MRI suite
  • Ferromagnetic objects entering the MRI suite

Briefings on Hospital Safety has previously detailed the risk prevention steps surrounding the latter two bulleted items, but it may not be as clear how the first two items apply to the EC.

Regarding patients who need emergency care while in an MRI scanner room, Gilk believes this provision of EP 14 ensures that there is physical space to properly handle a patient who goes into a code blue (e.g., availability of a crash cart and medical gas hookups). You don’t want a code team running into an MRI room without properly screening them for metallic objects, a precaution that, on the flip side, might delay urgent care to the distressed patient, Gilk says. Therefore, ambulatory centers should keep a space outside of the immediate MRI scanner room equipped for resuscitation efforts.

As for the first bullet about claustrophobic patients, Gilk is surprised to see it on the list, because he can’t find a compelling connection in EC.02.01.01 between patient comfort and the physical environment.

Setting frequencies for image upkeep

Meanwhile, ambulatory standards EC.02.04.01 and EC.02.04.03 address medical equipment management and testing, again similar to the hospital EC chapter.

Under EC.02.04.01, new EP 7 mandates that the ambulatory organization identify activities and frequencies for maintaining the technical quality of diagnostic images. Also, EP 15 of EC.02.04.03 wants ambulatory sites to maintain the clarity and accuracy of images. Both EPs leave much in the hands of ambulatory centers to determine exactly how the provisions are carried out.

This approach differs from the stricter provisions of the American College of Radiology, which requires sites to use a “phantom”—an object filled with gel and a low-contrast test pattern—to test the parameters of an MRI scanner, Gilk says. He will be working with The Joint Commission to provide basic MRI education to its ambulatory surveyor roster.

The inequality of diagnostic image provisions between ambulatory and hospital settings may pressure The Joint Commission to introduce similar standards for acute care facilities. It’s not difficult to foresee affected ambulatory surgical centers decrying a double standard that hospitals need not meet, especially given that hospitals provide MRI services to patients who are more critically ill, Gilk says.

A good source of prevention steps for MRI accidents is the February 2008 Joint Commission Sentinel Event Alert (see the related story below).

Consider zoned approaches to keep people safe in MRI areas

In its Sentinel Event Alert about MRI safety, The Joint Commission quotes the American College of Radiology’s Guidance Document for Safe MR Practices.

A prominent piece of the guidelines discusses a zoned system of access restrictions into an MRI area:

  • Zone I: General public
  • Zone II: Unscreened MRI patients
  • Zone III: Screened MRI patients and personnel
  • Zone IV: Screened MRI patients under constant direct supervision of trained personnel

You can read the full guidelines at http://tinyurl.com/2m95qa.

You can also check out the Sentinel Event Alert at http://tinyurl.com/2htx47.


Healthcare reform items for safety committees to review

As the initial waves of the newly passed healthcare reform law begin to ripple out, safety committee members should consider how the changes could affect EC and occupational health concerns.

“To the extent you believe the healthcare reform law will increase the demand for services, it could certainly have the effect in the near term of straining the resources of hospitals … [and] that would affect [managers] who are overseeing the safety and health of employees,” says Bradford Hammock, partner at Jackson Lewis, LLP, a law firm in Reston, VA, where he heads the workplace safety compliance practice group.

The law will provide coverage to about 32 million uninsured people and offer tax credits to about 4 million small businesses to help cover the cost of insurance for their employees.

According to experts and industry observers we  talked to, the following three reform-related areas may be worth adding to your next safety committee meeting agenda:

Monitoring more patients and visitors. When it comes to the physical security of hospital buildings and the well-being of workers, healthcare reform may bring increased traffic into the nation’s EDs.

EDs are among the top locations in medical centers for violence between patients and staff, generally because EDs act as funnels into the rest of the facility. “You have overcrowded emergency rooms right now,” says James Blair, FACHE, president and CEO at the Center for Healthcare Emergency Readiness in Nashville. “You’re going to make 30 million people eligible [for insurance]. They won’t be coming hat in hand.”

In other words, someone who is accepting charity medical care is likely to have patience while waiting in an ER. 

But when people believe they have a right to medical care—“and that’s what the rhetoric has led everyone to believe, that everyone in America is covered,” Blair says—some individuals may be difficult to physically control when they find out at the ER that they have to wait until certain provisions for covering the uninsured kick in over the next four years.

That dilemma puts ER nurses, physicians, and security officers on the battleground of dealing with potentially upset, confused, or even violent patients who don’t fully understand the healthcare reform laws passed in March.

Hospital security expert Fredrick Roll, MA, CHPA-F, CPP, agrees.

“I think a greater number of folks will show up and push for their ‘entitlements,’ ” which will up the ante for workplace violence in medical centers, says Roll, president and principal consultant at Healthcare Security Consultants, Inc., in Frederick, CO.

However, others aren’t so sure about a long-term increase in ED visits.

Although there may be a spike in traffic in the near future, the long-term situation may see fewer traumatized people arrive at the ED, says Randall Snelling, CPEO, chief physical environment officer at DNV Healthcare, Inc., a hospital accrediting group based in Cincinnati.

Expanding on his point, Snelling says healthcare reform will hopefully prompt more ill people to initially seek treatment from primary care physicians instead of the ED. 

“Once everyone gets their arms around it … folks won’t be coming to the ER with stomachaches,” he says.

Stemming from that, EDs may also host fewer folks who are stressed out because they can’t afford healthcare, which will lower the potential for confrontations.

Stretching your limited supplies even further. Fears of patient surge issues in the ED because of healthcare reform mirror concerns about an influx of patients from a community emergency.

Although not a potential disaster in the traditional sense, healthcare reform, by potentially bringing more people into hospitals, will challenge facilities by depleting them of supplies more quickly, Blair says. 

It’s already tricky enough determining just-in-time inventories of surgical masks, latex gloves, food, and other provisions. 

Hospital planners and emergency managers will soon need to get a firmer grasp on how healthcare reform could tax the supply chain.

“It’s a matter of numbers,” Blair says.

Whenever a major regulatory change occurs that affects an industry directly, implementing the changes takes away resources from other areas, such as safety and occupational health, Hammock says.

“The reality is you have X number of people to do things,” he says. “When something major comes along, you’ll pull resources from other areas.”

An interesting note: A provision in the healthcare reform bill establishes a National Healthcare Workforce Commission, which will include among its roster healthcare workers and employers, writes John Howard, MD, director of the National Institute for Occupational Safety and Health (NIOSH), in his NIOSH Science Blog (www.cdc.gov/niosh/blog).

The workforce commission is expected to submit recommendations to federal lawmakers and agencies to improve the safety and worker protection for healthcare employees, Howard writes.

Hoping a more efficient healthcare system frees up funds. Safety, security, and facilities departments may stand to improve their budgets in the long haul if healthcare reform does indeed save money, Snelling says.

These increased funds could better help medical centers pay for needed repairs and upgrades or staff education about safety topics.


It’s okay if facilities don’t have perfect EC processes

A risk-free physical environment is a nearly impossible goal to attain, said Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

“But that’s okay—and it’s okay if we do not have perfect processes,” MacArthur wrote recently on his blog, Mac’s Safety Space (http://blogs.hcpro.com/hospitalsafety).

“The management of the environment of care, as it is with most risk management undertakings, is one of continuous tweaking (in the industry this is known as process improvement),” he wrote. 

“It’s all about getting better—which has a strange commonality with the purpose of healthcare, no?” he added.

MacArthur noted that The Joint Commission’s physical environment standards are full of provisions for hospitals to identify how they do things, but the standards never say activities must be done perfectly.

“It’s all about identifying improvement opportunities and then identifying strategies to make those improvements ‘real,’ ” he wrote. 

“Even then, there are strategies that will fall by the wayside because they weren’t the right move or at the right time. This, ladies and gentlemen, becomes what is known as experience.”

Check out Mac’s Safety Space frequently for the latest advice and commentary about hospital safety concerns. By subscribing to the blog, you can receive updates by e-mail about new postings.


Hospital safety notebook

FDA approves new Steris System 1 alternative

The FDA has approved a new alternative system to the Steris System 1 (SS1) processor—which came under federal fire because of alleged infection control risks with the device—but not without some confusion.

The Steris System 1E (SS1E) is a liquid chemical sterilant processing system that is used to process reusable heat-sensitive devices (e.g., endoscopes and their accessories) that cannot be processed using steam. The FDA cleared the SS1E March 16 and publicly posted an announcement April 5. 

“This is good news for our [SS1] customers, and we look forward to working with them as they continue their transition to acceptable alternative technologies,” Walt Rosebrough, president and CEO of Steris Corp. in Mentor, OH, said in a statement.

The original SS1 is a popular sterilizing device used by thousands of hospitals and clinics in the United States. The FDA said Steris modified the SS1 and the agency hasn’t approved the modifications yet.

Steris has been critical of the FDA’s stance, saying there has been no documented case of infection caused by the SS1 when the equipment is used properly.

The FDA has asked hospitals to transition away from the SS1 to alternative reprocessing systems by August 2011.

“The SS1E may be considered as an alternative to the SS1 for processing compatible heat-sensitive devices, as healthcare facilities transition away from the SS1,” the FDA said.

Items reprocessed in the new SS1E are not considered sterile and should be used immediately, the agency said. This has confused some in the healthcare industry who had expected an SS1 alternative to sterilize items. We’ll update you as further information becomes available on this aspect.

Steris is hopeful the SS1E will fill the gap created by the SS1 controversy. “Steris continues dialogue with the agency to close out the remaining System 1 issues and expects to announce a transition plan in the near future,” it said.

To read the full FDA approval, go to www.fda.gov and search for K090036.

California says low humidity raised the risk of surgical fires, leading to a $100,000 fine

California health officials this week punished a hospital that allegedly raised the risk of fires in a labor and delivery operating room (OR).

According to records reviewed by the California Department of Public Health, three scheduled Caesarean sections were performed at Southwest Healthcare System in Murrieta October 26 and 28, 2009, despite low humidity levels noted earlier on those days in the surgical suites. Low humidity in an OR increases the risk of fire from sparking surgical instruments, much like dry days can raise the potential for brush fires.

The state said the alleged lapse constituted an immediate jeopardy to patient safety and issued a $100,000 penalty against Southwest Healthcare.

The hospital planned to dispute the findings.

Minnesota hospital fined $7,000 for fatal fall

A hospital and a window washing company were both fined by Minnesota’s OSHA agency stemming from the death of a window washer who fell from scaffolding at the facility in September 2009.

Park Nicollet Methodist Hospital in St. Louis Park, MN, was fined $7,000 by the state, and CID Services, LLC, of Minnesota was fined $28,750, according to records available from federal OSHA.

Minnesota OSHA cited the hospital under the state’s suspension scaffolds standard, which requires scaffolds to be installed with proper support and workers to be provided with safety belts. CID Services was also cited under the scaffold standard, as well as under a state statute requiring employers provide personnel with hazard-free workplaces.

Both the hospital and CID Services were contesting the citations, according to WCCO-TV in Minneapolis.


EC risk assessment important part of suicide prevention

Patient suicides remain one of the top sentinel events reported to The Joint Commission, so safety officers should consider how EC issues might contribute to suicide risks.

The Centers for Medicare & Medicaid Services (CMS) could also have a say in your suicide prevention efforts should its inspectors visit your hospital.

The EC will likely be a focus in 2010 for surveyors when it comes to patient suicide risks, Sharon Chaput, RN, C, CSHA, director of regulatory and quality management at the Brattleboro (VT) Retreat, said during HCPro’s recent audio conference, “Suicide Risk Assessment: Comply with The Joint Commission’s National Patient Safety Goal and Keep Your Patients Safe.”

EC.02.01.01 sets the stage

At the very least, suicide hazards should be part of an annual EC risk assessment. EC.02.01.01, which requires hospitals to manage safety and security risks, is often cited by surveyors, sometimes for suicide-related concerns, Chaput said. Specifically, surveyors cite element of performance (EP) 1, which requires hospitals to identify safety and security risks associated with the EC through internal sources such as ongoing monitoring and root cause analysis, as well as credible external sources, including Joint Commission Sentinel Event Alerts.

Also, watch out for EP 3, which requires hospitals to take action to eliminate or minimize any identified safety and security risks in the physical environment. 

“There is no specific requirement from The Joint Commission at this time for how often to complete this risk assessment, but the key wording is ‘ongoing monitoring of the environment,’ ” said Chaput. “One easy way to accomplish this is to use an environment of care suicide risk assessment tool.” The tool can be used during hazard surveillance rounds.

Debate swirls about risk-free environs

There has al


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