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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.

Domo arigato (for nothing), Mr. Roboto!

In the never-ending pursuit of the effective management of risks associated with healthcare-acquired infections (HAI) comes a new study that begs the question: How clean is your robot? Back in October of last year (don’t know how I missed this one in the news feed…), the Society for Healthcare Epidemiology of America (SHEA) released the results of a study indicating that the (at least at the moment) complete sanitation of robotic instruments is virtually impossible when compared to “ordinary” instruments. I don’t know that I had given the subject a great deal of consideration, but, at least on the face of it, I can see where there are probably whole lot more nooks and crannies, etc., that could potentially become contaminated during a procedure. The article speaks of greater protein residue and lower cleaning efficacy (a reported 97.6% efficacy rate for the ‘bots, as opposed to the 99.1% for ordinary instruments). It would seem that researchers suggest that it might be necessary to establish new cleaning standards that use repeated measurements of residual protein instead of just taking one measurement after cleaning. The article doesn’t talk about what cleaning methods were observed, so I’m presuming that the typical methodologies were employed, though I’m also thinking that some of the larger portions of the bots end up staying in the procedure rooms, and I’m thinking that when the stuff starts flying, that’s a tough thing to clean. Maybe there’s an application for the use of UV radiation in these types of situations. At any rate, I guess we can file this one under the “you never know what’s going to catch your eye” category, but it may be enough of a subject to prompt a survey question or two about the efficacy of the process.

On the FAQ front, the folks in Chicago have uploaded one that addresses patient-use refrigerators. Not wanting to be a spoiler (or “spoilah” as it is sometimes uttered in Bawston), but if you wanted to guess that there might be an element of risk assessment in the mix, I, for one, would make no move to disabuse you of that notion. I guess the more things get updated, the greater the likelihood that certain themes will manifest themselves over, and over, and over, and over…

In other news, guess we need to think about being a little more careful about what we purchase during those bake sales… I don’t know if you saw the piece last week about a couple of folks at a hospital in NC falling prey to some cannabis-containing baked goods. As events unfolded, the police ended up getting involved, etc., though no charges are to be filed (no drugs in the baker’s possession—I guess everything went into the batter), but I guess it does point out that we’re never too far away from Woodstock. I guess it’s time to update the “don’t take the brown acid” to “don’t take the brownies without a pedigree.” I wonder how this would play on the OSHA 300 log next year?

And now, batting cleanup…

Or, oh me of little faith…

Another somewhat hodgepodge-ish coverage of sundry and assorted niceties this week. For some reason, this week has resulted in a lot of ideas flying around in my noggin (I suspect you might have weeks like that too, from time to time), but I think there’s a sufficiently common theme for these to hang together. Hopefully some level of cogent thought will hold sway…

First up, a discussion about topics relating to cleaning, and by extension, cleanliness. Health Facilities Management recently published an article regarding a three-year study aimed at identifying ways of improving patient room cleaning (my philosophy on that is that we need to consider more than just the cleaning of patient rooms, but more on that in a bit). The article covers some of the process breakdowns observed during the study, and speaks to the inclusion of housekeeping staff in unit meetings, etc., to enhance the sense of the importance of their roles in the process of providing care to the patient by making sure the environment is clean. I think you folks know that my primary background is in the EVS (from the EVS world?) and I have never needed to be “sold” on the importance of the frontline housekeeping staff in supporting the care environment. I know from experience that it’s a tough job and I can tell you with absolute certainty that there is way more stuff in the typical patient room to clean than their used to be. (I only had to periodically dust off the abacus, etc.) The article provides some interesting data on the cleaning of various surfaces in the room, but I’ll let you see those for yourself. In looking at the data, it does make me ponder how much of a leap of faith it is to leave a restroom without having a paper towel (or some such) in hand to twist the ol’ door knob. I just can’t bring myself to stride right out without a thought in the world—but I see folks do that all the time and only about half of them wash their hands…

One of the things I’ve been seeing in survey country is a focus on what I will call the concept of the patient-ready room; this goes beyond the regimen of daily cleaning of surfaces, etc., and gets to the land of discharge cleaning, etc. I think one of the key conversations you can have in your organization is to figure out what a “patient-ready room” means and to start educating folks. Some things to consider:  making sure the waste containers are empty; making sure that everything in the room works (just as you would yip if you had a hotel room where stuff wasn’t working properly—or at least I hope you would yip); making sure there are no stained ceiling tiles, etc. Again, this room is going to be somebody’s home—it may only be for a day or so—but think about someone flat on their back and only having the TV and that stain on the ceiling to look at. And they’re probably not going to say anything while they’re staying with you (I suspect that most folks are just to amped up about being there to speak up much), but they may very well remember that ceiling tile if they get a satisfaction survey. And don’t get me started about schmutz on the floor or on the bed rails; I see it happen far too often and I don’t know if too many organizations that can’t do a little better with that.

As a final thought in this realm, I know a lot of folks have secured the areas under sinks to prevent storage, etc. If your organization prohibits under-sink storage, it’s probably the simplest solution to keeping them (whoever “them” might) out. But I ask you this: how often are you opening up those areas to see what’s going on? It seems like lately I’ve been running into a fair number of conditions bordering on Roquefort—or perhaps a Gorgonzola or Stilton. Just because you can’t see it, doesn’t mean there isn’t something growing under those pesky sinks—and if the water intrusion isn’t enough to leak down below, you may have no reason to look. But I’m thinking you might want to think about thinking about setting that up as a process. Just sayin’…

Breathe deep the gathering gloom…

As part of our (seemingly) never-ending quest to find topics of interest for you folks, we turn to the fascinating world of utility systems management, in particular, the management of aerosolizing water systems. As a safety generalist, I am always on the lookout for resources that will help increase my understanding of certain subjects and I try to pass on to you those that I find most useful (particularly over time). That said, I feel I have been somewhat remiss in not alerting you to a resource that I have been following for a fairly long time (it might even extend back to my days as a hospital safety manager—so we’re talking well into the safety Mesozoic era—love those birdsongs!). While the focus is Legionella prevention and education, there’s a lot of information regarding the management of risks associated with the aforementioned aerosolizing water systems—possibly the most risky (in terms of potential impact on patients, staff, and visitors) of the various high-risk utility systems.

The resource of which I am speaking is HCInfo; one of the highlights (at least for me) is that you can sign up for periodic e-mail updates; I find the updates, at the very least, to be thought provoking. The most recent blog posting on the site covers the potential impact on litigation relative to cases of Legionnaire’s disease in the wake of CDC’s release of its guidance for developing a water management program to reduce Legionella in buildings (you can find that august offering here). As noted in the blog entry, the CDC has come up with some very specific recommendations that could very well be the next bludgeon used by our regulatory friends. While the focus of the blog is on the litigious nature of things, there are a couple of take-home messages:

 

  1. “You should develop a water management program to reduce Legionella growth and spread that is specific to your building” (page ii of the CDC toolkit);
  2. “Legionella water management programs are now an industry standard for large buildings in the United States (ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta).”
  3. “This toolkit will help you develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” (page ii of the CDC toolkit)
  4. “Environmental testing for Legionella is useful to validate the effectiveness of control measures.” (page 21 of the CDC toolkit)

 

So, while not quite “marching orders,” there is enough certainty lurking within the pages of the toolkit to push for having some sort of plan in place for the management of your aerosolizing water systems (TJC has had a long-standing requirement to minimize pathogenic biological agents in aerosolizing water systems, the CDC toolkit may increase specific focus on this area). The one area that would seem to represent something of a sea change is the “useful”-ness of environmental testing for Legionella. Back in 2003, when CDC published its Guidelines for Environmental Infection Control in Health Care Facilities, there was just enough wiggle room to more or less dismiss the need to do environmental testing for Legionella (to test or not to test, that is the question—and it appears to hinge on what one might consider due diligence). I think partially due to the amount of bureaucratic language in the recommendations section, the sense was that the regular testing was not only just optional, but not really recommended (again, lots of room for interpretation). The current toolkit language definitely makes the case for testing as a means of validating the effectiveness of your control measures. But (as always appears to be the case), it is up to the individual facility to determine frequency, etc. But there is a way to get to that:

 

One of the key components of the CDC toolkit is (wait for it…) a risk assessment of your facility to help determine the applicable risks in your facility. The question then becomes: how long before our regulatory fiends (oops, friends!) start asking pointed questions about what we’ve been doing in this regard. As always, I provide this as information, but as the survey process continues to evolve (mutate?) in how infection prevention concerns are covered, this one really feels like something we need to button down as soon as possible. No doubt there are those of you who have already embarked upon this journey, so if you have any useful war stories that you could share, I’m sure everyone would benefit from your insight. I think this stands a good shot at being next in the line of hot button survey topics—and it’s an important one. My prediction is that everyone will be in reasonably good stead relative to the recommendations in the toolkit (this could be a very timely—and useful—performance improvement initiative for the EOC Committee), but I would encourage you to take whatever steps are required to be certain that you are in good shape.

The answer, my friends, is blowing in your facility

As I think everyone is aware, there has been a lot (okay, perhaps quite a lot) of focus during our pas de deux with the regulatory survey groups running around our hospitals on the various and sundry environmental conditions (temperature, humidity, air pressure relationships) for which there are various and sundry requirements (we’ve discussed those general considerations in the past, but if you need a refresher, feel free to dig through the archives at Hospital Safety Center). But a recent issuance from the CDC really starts to point to some of the ways in which the whole air pressure thing can actually influence the effectiveness of the management of immunocompromised patients as a function of air pressure relationships. There’s also an interesting study done by the folks at Johns Hopkins that speaks to the amount of time the doors to surgical procedural rooms are open during cases. I think we can all agree that keeping the doors shut during cases should probably be on the list of good ideas, but I suppose there can be a lot of coming and going—enough to de-pressurize the room. I’ve always felt that it is important to have some sense of how long it takes to de-pressurize and re-pressurize some of these critical areas; you want to make sure that folks are checking the pressure relationships when you have your greatest chance of success, recognizing that these rooms all “breathe” to one extent or another (and some of them come very close to wheezing…).

At any rate, information like this will likely only increase the attention paid to these areas during our survey encounters, with the added dynamic of this information being representative of the time-honored “smoking gun.” So, certainly acting on the CDC’s recommendation that immunocompromised patients not be placed in negative-pressure environments is something we can implement right away, but you’re probably going to want to come up with some sort of methodology for identifying those patients that rule in for that demographic (I’m thinking that our patients would tend more towards the immunocompromised side of the coin than not). We certainly don’t want to inadvertently put patients at elevated risk for infection, etc., by placing them in an inappropriate environment, so I think my immediate advice would be to look really closely at the information from the University of Pittsburgh Medical Center cases. If the end result looks an awful lot like a risk assessment, then I think you’re in the right place—and your patients will be, too!

 

This American Hospital: HAIs resulting from exposure to lead

As I think I’ve mentioned in the past, I listen to a fair amount of public radio when I’m in the car, and this past Saturday, I stumbled (I’ve found that my errands don’t always coincide with the start and end of programs—thank the gods of radio for podcasts and other forms of re-broadcast) into the middle of a story that I found quite compelling. The program itself is called This American Life and emanates from WBEZ in Chicago; the nominal purpose of the program is to provide a forum for the airing of stories about (natch!) This American Life, which allows it to cover a lot of ground. I always find the stories pretty interesting/compelling, etc., but this past weekend’s episode really got me thinking about the ongoing struggles faced by hospitals as they try to balance security, workplace violence management, the management of behavioral health patients, education of staff in being able to effectively manage crisis situations, etc. Basically, the whole gamut of issues relating to the continuing disenfranchisement of the behavioral health patient community. There are some places that do pretty well with this, but I think the opportunities to do better far outweigh the improvements made so far (that’s as close to editorializing as I’m going to do for the moment).

As I think about it, while Joint Commission compliance is probably THE hot button item when it comes to the management of risks and conditions in the physical environment, I truly believe that, at least for the folks who are typically responsible for managing the physical environment, this topic is by far the more complicated—very much in line with the prevention of healthcare-acquired infections—and, interestingly enough, there can be a crossover, but more on that in a moment.

The story deals with a “delusional” (my quotes) patient who, in the course of his stay in a hospital (you can find out a lot of the details by listening to the episode, which can be found here) encountered a situation in which he did indeed contract an HAI because of an exposure to lead, namely a bullet fired by a police officer in this patient’s hospital room. Now (trying not to sound too old), back in my days of operational responsibility, I have overseen dealings with behavioral health patients, on-duty police officers discharging their weapons in the ED, folks injured as a result of physical encounters with patients, etc. But I have to tell you (and at least some of this is the power of the storytelling in conjunction with the story being told), the sequence outlined in the episode is about as harrowing as you could imagine: not very good decisions are made and sustained; family members are perhaps not embraced as a source of useful information (I’m trying to avoid more editorializing—but tell me the story doesn’t ring some bells with you, particularly  if you’ve had operational responsibility for security), staff are perhaps not as well-prepared as they might otherwise be—a real cluster of ugliness.

I know things are never as cut and dried as they seem to be in the aftermath; you might find the “official” response from the hospital a little curious (I did as well, but I understood the forces in play—sounds like there might still be some lingering litigation), but this type of confluence of events is all too easy to imagine. I think it’s definitely in the best interests for the safety/security community to advocate for the management of these types of patients based on the underlying causes (mental illness, behavioral health issues) and not just a panicked response to the symptoms. Yes, we will always have that quotient of patients who are just [insert epithet of your choice here]. But safe care can’t be sacrificed in the rush—safe for the patients, safe for the staff.

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…