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Be prepared

As the flu season commences, the specter of Ebola Virus Disease (EVD) and its “presentation” of flu-like symptoms is certainly going to make this a most challenging flu season. While (as this item goes to press) we’ve not seen any of the exposure cases that occurred in the United States result in significant harm to folks (the story in Africa remains less optimistic), it seems that it may be a while before we see an operational end to needing to be prepared to handle Ebola patients in our hospitals. But in recognition that preparedness in general is inextricably woven into the fabric of day-to-day operations in healthcare, right off the mark we can see that this may engender some unexpected dynamics as we move through the process.

And, strangely enough, The Joint Commission has taken an interest in how well hospital are prepared to respond to this latest of potential pandemics. Certainly, the concept of having respond to a pandemic has figured in the preparation activities of hospitals across the country over the past few years and there’s been a lot of focus in preparations for the typical (and atypical) flu season. And, when The Joint Commission takes an interest in a timely condition in the healthcare landscape, it increases the likelihood that questions might be raised during the current survey season.

Fortunately, TJC has made available its thoughts on how best to prepare for the management of Ebola patients and I think that you can very safely assume that this information will guide surveyors as they apply their own knowledge and experience to the conversation. Minimally, I think that we can expect some “coverage” of the topic in the Emergency Management interview session; the function of establishing your incident command structure in the event of a case of EVD showing up in your ED; whether you have sufficient access to resources to respond appropriately over the long haul, etc.

Historically, there’s been a fair amount of variability from flu season to flu season—hopefully we’ll be able to put all that experience to work to manage this year’s course of treatment. As a final thought, if you’ve not had the opportunity to check out the latest words from the Centers for Disease Control and Prevention (CDC) on the subject, I would direct your attention to recent CDC info on management of patients and PPE.

I suppose, if nothing else, the past few weeks of our encounter with Ebola demonstrates something along the best laid plans of mice and men: it’s up to us to make sure that those plans do not go far astray (with apologies to Robert Burns).

Mounting hooks upon which physicians might hang their white coats

Touching back with the topic of healthcare worker attire increasing the potential for cross-transmission of bacteria during the working day, one of the recommendations that the Society for Healthcare Epidemiology of America (SHEA) made in its Healthcare Personnel Attire in Non-Operating-Room Settings guidance document is in regards to the continued use of white coats for professional appearances (I suspect it may be a while before the culture shifts sufficiently away from the vision of the kindly physician in the white coat). And that recommendation may very well set some teeth grinding for hospital facilities folks: “Facilities should provide coat hooks for clinicians to hang their coats up before patient contact.”

Coat hooks… isn’t that grand!?! Now I suspect that many, if not most of you, can recall those heady days when hand sanitizer dispensers first graced our facilities and how easy it was (and that little phrase can’t drip with enough irony) to figure out where those little buggers should be installed. I suspect that we’re looking at a similar cluster of decisions if this recommendation gains traction. When I first read this recommendation, I conjured up this image of a hospital corridor with rows of white coats hanging outside the patient rooms. In the Boston vernacular, that would look “pissah!” I don’t think you’ll be able to install the hooks in the room, because what would you do if it’s a precaution patient? I’m getting heartburn just thinking about it. Those of you with alcove spaces outside of your patient rooms should be okay (and may already have provisions for this), but, as we know, alcoves don’t generate a heck of a lot of revenue and so are frequently abandoned during design phases. No doubt the “hospital of the future” will have accommodations for this, but the “hospital of the now” might not be so fortunate.

Shirts and skins

In a recent edition of Infection Control and Hospital Epidemiology, the Society for Healthcare Epidemiology for America (SHEA) published an expert guidance document exploring the effect healthcare worker clothing has in the cross-transmission of pathogens. The document, titled Healthcare Personnel Attire in Non-Operating-Room Settings uses existing medical literature, perceptions of healthcare worker attire from patients and clinicians, evidence for contamination of attire and potential cross-contamination, hospitals policies and some survey information from SHEA members, with the intent being to learn about how clinicians balance their professional appearance and traditional attire with the prevention of pathogen transmission. The long and short of it is that there are a number of garment items—the ubiquitous white lab coat, neckties, and footwear—that can become contaminated with bacteria during the course of clinical care. Pretty much anything a clinician might be wearing could come into contact with bacteria, etc. during the course of patient rounding and other such activities—all surfaces, that at least as a function of an active work day in a hospital, are pretty difficult to clean/disinfect as you go. Sleeves of lab coats, the fronts of scrubs if you lean in to examine a patient (routine exams; precaution patients are already provided for in this regard), etc. all represent an opportunity for bacteria to transfer to those surfaces.

I can certainly see the legitimacy of the thought and can also see how this could be a contributing factor in the pervasiveness of healthcare-acquired infections, so it will be interesting to see what follow-up studies indicate as better practices. I guess base skin is the easiest “surface” to clean/disinfect as you go, though I somehow don’t think that tank tops will ever be adopted as professional garb. Maybe in the tropics…

You know, it’s kind of an interesting phenomenon…

A couple of weeks ago, there was a news item that caught my eye on a couple of levels. I’m sure many, if not most, of you “lived” through the initial onslaught of the hand sanitizer installation wars, and it appears that we may be in for another round of “a chicken in every pot and a dispenser every 6 inches.”

It would seem that the Columbia University School of Nursing and the World Health Organization have determined that about 20% of hospitals don’t have access to hand sanitizer at “every point of care,” thus missing the boat on opportunities to prevent healthcare-acquired infections (see the story here).

Now I can tell you from my experience that I have visited very few hospitals over the past few years in which I could not find expired containers of hand sanitizer hither and thither throughout the healthcare landscape. I think I can recall but a single instance in which I could find a hospital in which there was no expired hand sanitizer. To me, this means one of two things—either people aren’t using the sanitizer because the dispensers aren’t in the “right” location or people just aren’t using the product. (There is something of a third dynamic—hand sanitizer dispensers installed at hand washing sinks—I like to think folks are washing their hands at that point as opposed to using the sanitizer. Call me optimistic!)

The other component that may be impacting the distribution of hand sanitizer dispensers is that pesky Life Safety Code®. The safety folks know that there are limits to how much of this stuff we can have “hanging” around, which, to me, means we need to maximize the utilization of the dispensers that are already in place. If that doesn’t sound like an education opportunity…

I certainly won’t quibble with the notion that we are not doing a particularly spectacular job of managing healthcare-acquired infections, which kind of leads to the other piece of the Columbia/WHO study: not enough focus (resources and financing) on hand hygiene education. I suspect that hand hygiene education is probably covered pretty thoroughly in the orientation process and perhaps touched upon in ongoing annual education programs, but I don’t know that there’s a whole lot of focus on evaluating the effectiveness of hand hygiene education as a going concern. And, as a further thought, I think we need to find a way beyond just asking folks questions about hand hygiene. I think they know what responses are being sought. Maybe we need more black-light auditing of hands in the workplace, I’m not sure. Anybody out there have an evaluation process of which you are particularly proud?

 

 

Equipment disinfection

I suspect that at least some (perhaps even most) of you out there in the listening audience read or heard about the potential exposure of patients to a deadly brain disease (Creutzfeldt-Jakob Disease or CJD—the CDC has more info on CJD. The exposure seems to have come as the result of some specialized neurosurgical equipment that hospitals rent—and it turns out that CJD-contaminated materials are extremely difficult to sterilize/decontaminate effectively using regular processing techniques. So, this ends up being something of a perfect storm of variables that resulted in the potential exposures. And don’t forget that The Joint Commission has also weighed in on the global risks associated with CJD.

Without getting into a lengthy discussion about this particular event, tragic though it may be, the question I’d like you to ponder is relative to all the loaner/rental equipment that passes through our corridors on a daily basis. Who’s really keeping an eye on this process in your hospital? And do you (or someone in your “house”) periodically check to make sure that the process is effectively managing the safety risks involved. When you start parsing it, managing loaner/rental equipment is a fairly complicated process, one that could give a risk manager nightmares. How comfortable are you with the process at your hospital?

Uniformly clean

Reaching in once again to the viewer mailbag, we find a question regarding the laundering of staff uniforms. In this particular instance, this organization is moving from a business casual dress code for medical staff to providing scrubs (three sets each) to promote uniformity of attire (sorry, I couldn’t resist the pun). Now that the decision has been announced, there’s been a little pushback from the soon-to-be scrub-wearing folks as to whether the organization has to launder the scrubs if they become contaminated with blood or OPIM (the plan is for folks to take care of their own laundering).

So, in digging around a bit I found an OSHA interpretation letter that covers the question regarding the laundering of uniforms is raised and includes the following response:

Question 6: Is it permissible for employees to launder personal protective equipment like scrubs or other clothing worn next to the skin at home?

Reply 6: In your inquiry, you correctly note that it is unacceptable for contaminated PPE to be laundered at home by employees. However employees’ uniforms or scrubs which are usually worn in a manner similar to street clothes are generally not intended to be PPE and are, therefore, not expected to be contaminated with blood or OPIM. These would not need to be handled in the same manner as contaminated laundry or contaminated PPE unless the uniforms or scrubs have not been properly protected and become contaminated.

To my way of thinking, if the scrubs were to become contaminated, which would appear to be the result of the scrubs not having been properly protected (I’m reading that as “not wearing appropriate PPE), then the tacit expectation is that they would be handled in the same manner as contaminated laundry or contaminated PPE and since it is inappropriate for PPE to be laundered at home, then provisions would need to be made for the laundering of contaminated scrubs/uniforms. Now, you could certainly put in place safeguards, including the potential for corrective actions, if you have a “run” on folks getting their uniforms contaminated. It’s certainly possible that, from time to time, a uniform might become contaminated, but the proper use of PPE should keep that to a minimum.

How are folks out there in radio land managing scrubs that are used as uniforms (as opposed to being used as PPE)? Are you letting folks take care of their own garments or doing something that’s a little more involved? Always happy to hear what’s going on out there in the field.

And if I can take a moment of your time, I’d like to take this opportunity to remember my late colleague David LaHoda. This is the type of question he loved to answer and I loved helping him help folks out there in the great big world of safety. David, you are missed, my friend!

You may want to smoke during surveys

I could have sworn that I had covered this last year, but I can find no indication that I ever got past the title of this little piece of detritus, so I guess better late than never.

One of the more interestingly painful survey findings that I’ve come across hinge on the use of a household item that previously had caused little angst in survey circles—I speak of the mighty tissue paper! There has been any number of survey dings resulting from tissue paper either being blown or sucked in the wrong direction, based on whether a space is supposed to be positive or negative. And this lovely little finding has generated a fair amount of survey distress as it usually (I can’t say all, but I don’t know of this coming up in a survey in which the following did not occur) drives a follow-up visit from CMS as a Condition-level finding under Physical Environment/Infection Control.

The primary “requirements” in this regard reside under A-Tag 0726 and can be found below. Now I’m thinking that tissue paper might not be the most efficacious measure of pressure relationships, which (sort of—give me a little leeway here) begs the question of whether you should be prepared to “smoke” the doorway/window/etc. for which the tissue paper might not be as sensitive to the subtleties of pressures. I think it’s a reasonable thing to plan for—as much because there can be a whole lot at stake.  So, I’ll ask you to review the materials below and be prepared to discuss…

A-0726

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

Interpretive Guidelines §482.41(c)(4)

There must be proper ventilation in at least the following areas:

• Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;

• Locations where oxygen is transferred from one container to another;

• Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);

• Pharmaceutical preparation areas (hoods, cabinets, etc.); and

• Laboratory locations.

 

There must be adequate lighting in all the patient care areas, and food and medication preparation areas.

Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy.

The hospital must ensure that an appropriate number of refrigerators and/or heating devices are provided and ensure that food and pharmaceuticals are stored properly and in accordance with nationally accepted guidelines (food) and manufacturer’s recommendations (pharmaceuticals).

Survey Procedures §482.41(c)(4)

• Verify that all food and medication preparation areas are well lighted.

• Verify that the hospital is in compliance with ventilation requirements for patients with contagious airborne diseases, such as tuberculosis, patients receiving treatments with hazardous chemical, surgical areas, and other areas where hazardous materials are stored.

• Verify that food products are stored under appropriate conditions (e.g., time, temperature, packaging, location) based on a nationally-accepted source such as the United States Department of Agriculture, the Food and Drug Administration, or other nationally-recognized standard.

• Verify that pharmaceuticals are stored at temperatures recommended by the product manufacturer.

• Verify that each operating room has temperature and humidity control mechanisms.

• Review temperature and humidity tracking log(s) to ensure that appropriate temperature and humidity levels are maintained.

 

Kind of vague, yes indeedy do! Purposefully vague—all in the eye of the beholder. Lots of verification and ensuring work, if you ask me, but this should give you a sense of some of the things about which you might consider focusing a little extra attention.

Last Dance, Last Chance—Hot (& humid) Stuff…

Strangely enough, there remains some uncertainty relative to the management of temperature and humidity, particularly in the surgical environment. And the topic of this week’s conversation is: What do you do when your HVAC system is not functioning within its designed specifications? [more]

Dry your eyes – but don’t dry those wipes!

A quick note of interest from the survey world –

A recent survey resulted in a hospital being cited under the Infection Control standards (IC.02.02.01 on low-level disinfection, to be exact). In two instances, someone had the temerity to forget to close the cover on a container of disinfectant wipes. Can you believe such risky behavior still exists in our 24/7 world of infection prevention? It’s true, my friend, it is true!

The finding went on to say that, as the appropriate disinfection of a surface depends on wet contact with the surface being disinfected, leaving the cover open would partially dry out the next wipe, impairing the ability of the wipe to properly disinfect the surface. Now, I suspect that the person to use that next wipe might somehow intuit that the moisture content in the wipe was not quite where it needed to be and maybe, just maybe, go to the lengths of (wait for it) – pulling out an additional wipe (or two, or three). Now my experience has been that sometimes those wipes are not what I would call particularly well-endowed in the moisture department. And  the use instructions for these products usually indicate that you should use as many wipes as it takes to ensure that the surface to be disinfected stays wet long enough for disinfection to occur.

I’ve always been a pretty big fan of the slowly-becoming-less common sense, so I’m not quite sure how we’ll be dealing with this one – thoughts, anyone?

Do you remember? Or even yesterday…

Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)

One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.

The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.