RSSAll Entries in the "CDC/infection control" Category

Reusables vs. single-use: The next round in the World Series of Risk Assessments?

As summer starts its (hopefully) gradual fade into the record books and the marathon of the baseball season starts its kick to the finish line, it seems that we are (yet again) faced with some guidance from the federales that I think will be best served by having a risk assessment in your back pocket.

Over the past few years (truly, more than a few, but we can focus on the most recent past), there has been a lot of scrutiny regarding the management of endoscopes, including how much of a role clinical engineering might play in managing the scopes as devices, how to ensure effective processing of the scopes once they have been used, etc. And just the other day, I encountered an article discussing the FDA’s recommendation to begin transitioning to scopes with disposable parts, nominally to ensure the efficacy of the post-use processing process (don’t you just love a processing process!). You can find the meat and potatoes of the FDA’s recommendation here. I’d encourage you to read this very carefully as there is mention of process elements, such as the use of adenosine triphosphate (ATP) test strips to assess scope cleaning—a use that is not currently sanctioned by FDA—to the point that the FDA is asking facilities not to rely on the ATP test strips to assess scope cleaning. There’s some other stuff that is worth consideration, so (again), please check it out.

The recommendation does indicate (and, to a certain extent, provides for) a period of transition to the disposable scopes, but now that the proverbial horse is out of the barn, I think it is only a matter of time before our friends in the various accreditation organizations start digging into the transition process as a function of patient safety (I don’t think there’s any among us that would dispute this as a patient safety concern), particularly as to how we are keeping folks safe during the transition period. And how do we typically provide evidence of the process for mitigating risks? Why, it’s our old(er) friend the risk assessment process. I think it is crystal clear that this serves as yet another example of the collaborative process between infection control, clinical engineering, perioperative services—and I encourage you to make good use of the risk assessment process. Even more so, if you are scheduled for an accreditation survey any time in the next 12-18 months (until the use of single-use scope technology is more pervasive), I would get this on your to-do schedule as soon as possible. As with so many things, you may have lots of data to support that your existing procedures, etc., are not putting anyone at risk, but (as these things tend to devolve) we’ve already seen how a really (and I mean really, really) small incidence rate (that of risk de ligature) drive a veritable cornucopia of significantly painful survey findings. And there’s every reason to include this in the list of contenders for the next heavy duty survey focus area.

Like water for opportunistic organisms: Protecting patients through utility systems

As a wise individual once noted, “water always wins” (at risk of betraying my nerd status, you can find the entire quote here), and it seems like water in its numerous forms is giving facilities professionals a run for their money this year. From mold in an OR in the Northwest to the constant battle (or so it seems) with Legionella prevention, this is as challenging a time as I can recall for facilities. And that doesn’t even take into account the ongoing impact of minor intrusions—leaks, condensation, overflowing toilets—it is an almost endless list of troubles.

My intent was to provide the above as information, with my usual encouragement to leverage point-of-care/point-of-service staff in the early identification of trouble spots, but I’m also thinking that perhaps someone out there in the field has been able to develop an effective plan for the proactive management of water woes. Certainly, I know of folks with fairly predictable “rainy seasons” and then there are those locations in which rain is a constant threat, not to mention the intrusion of humidity by various (and sometimes nefarious) means. So, what do you do that works (recognizing that this is not a one size fits all proposition)? Do you have any useful/effective strategies you can share with the blogosphere? I generally only hear about stuff that doesn’t work, so it would be a treat indeed to tout someone’s intuitive brilliance.

As a final note for this week, those of your laboring under the yoke of TJC accreditation might do well to give the August issue of Perspectives a look (it’s become less of a regularly useful read for me, but every once in a while). In the Consistent Interpretation column/article, there’s a lot of discussion (under the guise of the Infection Control standards) of PPE use/availability/education, etc. Again, the findings are falling under the IC standards from a past survey result standpoint, but I don’t think it’s a stretch for some (or almost any) of these to be applied as Hazardous Materials & Wastes Management findings. Again, not everything applies, but I think if we’ve learned nothing else over the years, it’s the funky application of survey concepts from one are of scrutiny to another. Stranger things have happened…

Try to keep things cool over the second half of the summer!

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

There’s no such thing as someone else’s code: Infection control and the environment (again…)

Periodically, I field questions from folks that require a little bit (well, perhaps sometimes more than a little) of conjecture. Recently, I received a question regarding the requirements in ASHRAE 170-2008 regarding appropriate pressure relationships in emergency department and radiology waiting rooms (ASHRAE 170-2008 says those areas would be under negative pressure, with the caveat that the requirement applies only to “waiting rooms programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease”).

Right now, that particular question is kind of the elephant in the room from a regulatory perspective; there is every indication that The Joint Commission/CMS are working their way through ASHRAE 170-2008 and have yet to make landfall on this particular requirement—as far as I know—feel free to disabuse me of that notion. The intent of the requirement (as I interpret it) is to have some fundamental protections in place to ensure that an isolated respiratory contagion does not have the capacity of becoming a legitimate outbreak because of inadequate ventilation. Now, you could certainly use the annual infection control program risk assessment to identify whether your waiting rooms are “programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease” based on the respiratory disease data from the local community (and you might be able to obtain data from a larger geographic area, which one might consider a “buffer zone”).

Best case scenario results in you being able to take this completely off the table from a risk standpoint, next best would be that you introduce protocols for respiratory patients that remove them from the general waiting rooms (depending on the potential numbers, you may not have the space for it), worst case being that you have to modify the current environment to provide appropriate levels of protection. The notation for this requirement does provide some relief for folks with a recirculating air system in these areas, which allows for HEPA filters to be used instead of exhausting the air from these spaces to the outdoors, providing the return air passes through the HEPA filters before it introduced into any other spaces.

Knowing what I do about some of the ventilation challenges folks have, I suspect that it may make more sense to pursue the HEPA filtration setup than it would be to try to bring each of the spaces under negative pressure, but (going out on a limb here) that might be a question best answered by a group of knowledgeable folks (including an individual of the mechanical engineering persuasion) as a function of the (wait for it…) risk assessment process.

Ultimately, it comes down to what the Authority Having Jurisdiction chooses to enforce; that said, it might be worth having someone work through your state channels or by putting the question to the Standards Interpretation Group at Joint Commission (I suspect that their response would not be not particularly instructive beyond the usual “do a risk assessment” strategy, but there is a new person running the Engineering group at TJC, so perhaps something a little more helpful might be forthcoming). At any rate, as noted above, I’ve not heard of this being cited, but I also know that if there’s an outbreak tied to inadequate ventilation somewhere, this could become a hot topic pretty quickly (probably not as hot as ligature risks at the moment, but you never know…).

When the tough get going: Emergency Management and other considerations

First off (and apologies for the short lead time on this), but next week (February 13), CDC is hosting a webinar on the importance of assessing for environmental exposures during emergencies (and in general). While this is likely to be some useful information as a going concern, you can also earn CEUs for tuning in. A summary of the program as well as registration information, etc., can be found here. Overall, I think hospitals had a pretty good track record of emergency response in 2017, but somehow these things never seem to get easier over time…

Another issue that I see starting to gain a little traction in the survey world is dealing with concerns relating to medical gas and vacuum systems; for the most part (I’m sure there are some exceptions, but I can’t say that I’ve run into them), folks in hospitals tend to rely on contracted vendors to do the formal inspection, testing, and maintenance of medical gas and vacuum systems, which tends to keep an in-depth knowledge of the dirty details at (more or less) arm’s length. A couple of weeks ago, I received some information from Jason Di Marco of Compliant Healthcare Technologies (many thanks to Jason!) that I thought would be worth sharing with you folks. Of primary interest is a downloadable guide to medical gas systems (available here in exchange for your email address) that really gives a good overview of the nuts and bolts (as it were) of your med gas system. Jason also publishes a blog on the critical aspects of medical gas and vacuum system inspection, testing, maintenance, compliance, etc., where I found a fair amount of useful information. Again, I can see the regulatory compliance laser focus starting to turn in the direction of all the systems covered under NFPA 99 and I can also see some of those prickly surveyor types trying to pick at the knowledge base of the folks managing these processes. So, in the interest of never having too much information, I would suggest getting a little more intimate with your medical gas and vacuum systems.

These are a few of my favorite things: Safety Risk Assessments!

A somewhat mixed bag of news items for you this week: a cornucopia of compelling content, if you will…

The Center for Health Design has published a pretty cool safety risk assessment tool that is available free on its website, although you do have to register (also free). The web page offers an introductory video describing the risk assessment, so you can check it out before you register.

In other news, Maine became the first state to ban flame retardants in upholstered furniture. As I travel the highways and byways of these United States, I see a fair amount of holiday decorations that have been treated with flame retardant sprays of various manufacture as folks try to provide a cheery environment for patients and not run afoul of the safety Grinches (and I use that term with all due respect and affection, having been a Grinch myself once or twice in the past). I don’t know if we’ll be able to say “as Maine goes, so goes the nation,” but this might have some interesting impact on the field-treating of combustible decorations.

As our final note this week, data from the U.S. Nurses’ Health Study II suggests that there is an increased risk of Chronic Obstructive Pulmonary Disease (COPD) among nurses with frequent exposure (at least once a week) to disinfectants in certain tasks (cleaning of surfaces, etc.): https://www.ersnet.org/the-society/news/nurses-regular-use-of-disinfectants-is-associated-with-developing-copd . The study indicates some of the “culprits” as glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds. The article on the link also indicates that a recent European study of folks working as cleaners also showed an increased risk for COPD (somehow, not a surprising revelation to me). I think the bottom line on this (and perhaps our charge moving forward) is (and the article doesn’t really mention this) ensuring that folks are using appropriate PPE when they are using those types (or any type) of disinfectant products. PPE is always a tough thing to “sell” to folks, and while I think folks do understand that there are risks involved (just as there are risks associated with all sorts of behaviors—smoking springs to mind), there does seem to be a reluctance to take proper precautions every time one engages in these types of activities. I know this stuff isn’t particularly “sexy” when it comes to the topics of the day, but reinforcing basic protective measures can’t be a completely lost cause, can it?

 

 

We hold these truths…

In the wake of the high-rise fire in London a few weeks ago, those of you with high-rise facilities are probably going to experience some intensified attentions from your local fire folks (it’s already started in Houston). Any time there is a catastrophic fire with loss of life, it tends to result in an escalation in the interests of the various AHJ’s overseeing fire safety. While I suspect that your facilities are not at risk to the extent the conditions at the Grenfell Tower appear to have been, it is very likely that your locals are going to want to come out and kick the tires a little more swiftly/demonstrably than they have in the past. And, since we are responsible for a fair number of folks who are not (or at least less than) capable of getting themselves out in a fire, I think there is a very strong possibility that scrutiny will extend to non-high-rise facilities as well. I think we can say for pretty much certain that the regulatory folks probably didn’t miss this as a news story, and it’s not a very big leap to want to apply any lessons learned to how their areas of responsibility would fare under intensified scrutiny.

As a related aside, one of the challenges that I periodically face in my consulting engagements is the pushback of “it’s always been like this and we’ve never been cited” or something similar. My experience has been that a lot of times, the difference between a good survey and a not-so-good survey can be the surveyor taking a left turn instead of a right, etc. We have certainly covered the subject of imperfect buildings and how to find them (they are, after all, everywhere you look), so I won’t belabor the point, but this probably means that the focus on the physical environment is going to continue apace, if not (and I shudder at the thought) more so. We’ve got a lot of work ahead of us, folks—let’s get those sleeves rolled up!

Finally, as a head’s up, there’s going to be a webinar in August hosted by HC Info on strategies for meeting the CMS guidance (almost makes it sound helpful, doesn’t it) relative to the management of legionella risk that we covered a few weeks back. (Apparently space is limited, so you might want to get right on this: http://hcinfo.com/legionella-compliance.)

Something (nothing official, just an intense feeling) tells me that this is likely going to be a significant survey focus over the next little while, so I’m in favor of gathering as much expert information, etc. as possible. Again, while I have no reason to think that most folks are not appropriately managing these types of risks, I also know that the survey expectation bar appears to have been raised to an almost impossible-to-attain level. To echo the motto of the Boy Scouts—Be Prepared!

Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

  • Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:

 

  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

I have nothing to say and I’m saying it!

A somewhat funky news item for this week’s bloggy goodness: In the March edition of the American Journal of Infection Control (house organ of APIC), there was a news release sharing the results of a study that indicates that hospital room floors may be an overlooked source of infection . The study also got a mention in Physicians Weekly, which means that in all likelihood it’s been noticed by any of the regulatory folks—and you know what that’s likely to mean…

At any rate, once I got past the “no, duh” thought (somehow this comes as no surprise to me), I got to thinking about the complexities of cleaning, particularly as a function of the omnipresent application of dwell times for disinfectant products and the whole concept of keeping things wet long enough to kill the bugs. I think we’ve focused a lot on getting folks who use disinfectants to be able to articulate how long something has to stay wet (good thing), but not as much on watching to make sure that we are applying that knowledge along with the application of the disinfectant. For example, it’s 3 p.m. on a Monday afternoon and the ED is jammed with patients waiting for inpatient beds. The EVS staff is scrambling to get the rooms ready for occupancy and somebody, somewhere is tapping their foot (and perhaps grousing about “how long is this gonna take?”). The question I keep coming back to is this: when there’s a rush on anything, have we well and truly built enough time into the process for surfaces to be properly disinfected? The study mentions surfaces in some hospital rooms in the Cleveland area, but there’s not a lot of discussion in the press release about cleaning methodologies, so I’m not sure what might be in play. The press release also talks about high-contact objects (personal items, medical devices, nurse call buttons) coming into contact with floors and subsequent transmission to other surfaces (including hands!). To me, this sounds like occupied rooms and I suspect that the likelihood of the floor in an occupied room staying wet long enough to properly disinfect is fairly remote. Wet floors are slippery floors and slippery falls increase the potential for falls. I mean think about it: how many times have you seen somebody waving a wet floor sign over a wet floor to get it to dry more quickly? In my experience, the last piece of any process is frequently the one that gets jammed the most time-wise. Think about construction projects that ended up having issues with improperly installed flooring. When you think about it (or when I think about it), it makes perfect sense: the flooring install is usually the last thing to happen and those folks are almost always under the gun to get things finished (so the project is on time, so the project is not quite so late, so the project gets done early) and floor prep (particularly preparation of the surface upon which the flooring is installed) becomes the sprint to the finish line at the end of the marathon. I am absolutely convinced that we are not going to “solve” this problem until everyone agrees to a reasonable amount of time for these tasks to be completed. Is it physically (and that includes making sure that surfaces are wet enough, long enough) possible to properly do a terminal disinfection of the room of a discharged patient in 20 minutes? 30 minutes? 45 minutes? And that’s not even considering the cleaning of the room of a discharged isolation patient. Maybe there are (or will be) quicker ways to disinfect surfaces; UV disinfection technology is growing, but it’s still pretty expensive technology and I think the jury is still out on how absolutely effective it is on all surfaces.

There’s little question that there are improvements to be made in the area of cleaning and, most times, the EVS folks seem to end up with the fingers pointed in their direction. But in the absence of some clearly established parameters that allow for proper administration of the disinfection process (parameters that are resistant to the tap-tap-tapping of feet…are you done yet?), I don’t know that it’s going to happen any time soon.