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Shoo beedoobee – splattered, splattered!

In the never ending discourse on the subject of emergency eyewash stations, I’d like to take a moment to remind folks that it appears that the TJC surveyors have access to the ANSI Emergency Eyewash and Shower Equipment Standards and they have become very diligent in ferreting out (apologies to the ferrets in the audience – I don’t mean to offend) practices that are not consistent with the “recommendations” contained therein. And so, let me say this:

If your organization has chosen to maintain your emergency eyewash stations on a lesser frequency than weekly, then you had best conducted a risk assessment to demonstrate that you are ensuring the same level of safety that you would if your were maintaining them on a weekly basis. Water temperature, water pressures, “cleanness” of the flushing liquid, whether access to the equipment is obstructed – these all need to be considered in the mix, because, and I can tell you this with a great deal of certainty, if you are doing these inspections less than weekly, you will be cited during survey. If you have not conducted the risk assessment to demonstrate that the lesser frequency is appropriate, then you will have to move to the weekly program. (Sort of a “you can pay me now or you can pay me later” kind of deal.) But rest assured that eyewash stations are definitely in the mix, so make like a Boy Scout (do I really need to finish that thought? I didn’t think so…)

By the way, I’ve also caught wind of the invocation of AAMI standards when it comes to the placement of emergency eyewash equipment in the contaminated section of central sterile. (Also, don’t forget to keep those pressure relationships in check. Clean central sterile should never be negative to dirty central sterile). Now I will freely admit that I am not as conversant with the AAMI standards as I am with, say, OSHA standards, and perhaps even the ANSI standards dealing with this stuff. Again, the rhetorical question becomes: How many rocks do we need to turn over before we can safely determine that there isn’t some funky consensus standard lurking in the weeds that is not in strict concurrence with accepted practice? Why can’t these guys just get along…jeez!

From the muddy banks of compliance

Let’s break from form a little bit and start with a question:

How often are you (and by you, I mean your organization) screening contracted staff, including physicians, physician assistants, nurse practitioners, etc.?

A recent TJC survey resulted in a finding under the HR standards because the process was being administered on a biannual cycle. The finding vaguely referenced OSHA guidelines in identifying this deficiency, but the specific regulatory reference point was not provided (though apparently a call to Chicago validated that this was the case). Now, anyone who’s worked with me in real time knows that I have an exhaustive (and, at times, exhausting) curiosity about such matters. The deficiency “concepts” are usually sourced back to a “they;” as in, “they told me I had to do this” “they told me I had to that.” I am always, always, always curious as to who this “they” might be and whether “they” were good enough to provide the applicable chapter and verse. The answer, more often than not, is “no.” Perhaps someday we’ll discuss the whimsical nature of the” Authority Having Jurisdiction” (AHJ) concept, but we’ll save that for another day.

At any rate, I did a little bit of digging around to try and locate a regulatory source on this and in this instance, the source exists; however, the standard is not quite as mandatory as one might first presume (If you’re thinking that this is going to somehow wrap around another risk assessment conversation, you are not far from wrong). So, a wee bit of history:

Back in 1994, the CDC issued their Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, ( which, among other things, advises a risk-based approach to screening (Appendix C speaks to the screening requirements for all healthcare workers, regardless of who they work for. The guidance would be to include contract folks. The risk level is determined via a risk assessment (Appendix B of the Guidelines is a good start for that). So, for a medium exposure risk environment, CDC recommends annual screening, but for a low exposure risk environment, they recommend screening at time of hire, with no further screening required (unless your exposure risk increases, which should be part of the annual infection control risk assessment).

But, in 1996, OSHA issued a directive that indicates annual screening as the minimum requirement , even for low-risk exposure risks, and even while referencing the CDC guidance: ( with medium risk folks having semi-annual screening and high-risk folks being screened on a quarterly basis. So, friends, how are you managing folks in your environment, particularly the aforementioned contracted staff? Do you own them or is it the responsibility of their contracted employer? Does this stuff give you a headache when you think about it too much? It sure gives me one…occupational hazard, I guess. At any rate, it’s certainly worth checking to see whether a risk assessment for TB exposure has been conducted. The OSHA guidance document clearly indicates that if you haven’t, it’s the responsibility of the surveyor to conduct one for you, and I don’t know that I’d be really keen on having that happen.

I need to know – the re-rise of glutaraldehyde-based disinfectant

One of the developments of the last few years that pleased me most was the move away from glutaraldehyde-based disinfectants to safer alternatives. But now—and I am at a loss to understand what is prompting this—I am seeing a resurgence in the use of the glutaraldehyde-based disinfectants. As we are more or less familiar, glutaraldehyde is a fairly complicated environmental hazard to manage (not the most complicated, but up there on the list), with requirements regarding monitoring of conditions, ventilation, etc. For the big picture, the following link will do nicely:

So what is pushing us back toward a, oh I don’t know, certainly a more hazardous material? You’ll get absolutely no argument from me when it comes to the importance of properly disinfecting reusable medical devices; the rate of hospital-acquired infections is so much greater than we as safety professionals can live with. I had heard of some instances in which devices like endoscopes were stained following disinfection using OPA-like products, but my understanding was that any discoloring on the surface of devices was residue of proteinaceous materials that weren’t completely removed during the pre-disinfection process. (You can’t really call it staining as these devices are generally impermeable, so if it can’t sink in, it can’t stain.) So, I ask you: What up with this? I want to be able to help folks move in the right direction, and I’m not convinced that moving back toward glutaraldehyde is the right direction. If you folks are privy to something that allows this to make sense, please share. It is, after all, the time of the season. Hope to hear from you soon.

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Under Pressure – Positively Clean

In yet another dispatch from the regulatory survey landscape, one item I’ve noticed being cited during surveys are related to the surgical environment–maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships. The other concern in this realm is making sure that you have a planned response for those instances in which any of the these performance expectations cannot be met. Make sure that the end-users of the environment are clued in to those responses. Depending on where you are, the age of your building systems, etc., you may very well experience (or perhaps have already experienced) performance outside of design/expected parameters (i.e., how’s that climate change working out for your building?)

Minimally, the infection control implications can be far-reaching, and if not appropriately managed, can be devastating to your patients. Likewise, you need to keep a close eye on the pressure relationships between clean and dirty areas; a positively pressured decontamination area can play havoc with the environment in your sterile processing and supply areas. A positively pressured corridor in your surgical area  can have a deleterious effect on your OR procedure rooms.  (Notice I said “area” not “suite”– everyone knows there are no corridors in surgical suites.)

You know how complicated your building systems can be–it’s time to make sure that your end-users understand that when things are not right, we need to collaborate to ensure appropriate protection of our patients. Nobody wants to mess with the OR schedule, but as hospital-acquired infection occurrences venture ever closer to the “never event” it will take a big-time team effort to make sure that our operations (both figuratively and literally) are where they need to be.

All we are is dust in the…

One of the critical processes when one embarks upon a program of construction and/or renovation is the management of infection control risks, particularly if the work is to be done in, or adjacent to, occupied patient areas. Now, I’m sure that you are all more than familiar with the infection control risk assessment (ICRA) matrix (you can find one in HCPro’s Infection Prevention Policy and Procedure Manual for Hospitals as well as in a number of locations on the Web). One question I’ve encountered recently is not so much about the risk assessment piece itself, but rather how one determines the amount of oversight (including how frequently IC rounds would be done in construction areas, and who would be qualified to conduct those rounds, etc.) and operational considerations like waste removal (i.e., frequencies and methodologies), cleaning floors (i.e., frequencies and methodologies), what types of walk-off mats to use, and stuff like that.

Now, if we know anything about anything, we know that there is not generally a great deal of guidance when it comes to the specifics of these types of things. And by now, we also know that there’s going to be some sort of risk assessment when it comes to making those decisions. So, the question I put to you folks in the field, in the spirit of sharing: How are you working through these types of operational decisions? Have you done anything that worked really well? Anything that worked so poorly that you get hives just thinking about it? The ICRA will help us determine what we have to do. How then do we take the next step to effectively implementing those identified strategies?

I look forward to hearing from you all, even if it’s to ask pointed questions. Operators are standing by…call now!

That’s me in the corners…losing my infection (risks)

Not that long ago, I participated in a discussion regarding the terminal cleaning of surgical procedure rooms, particularly the recommended frequency of using wet vacuums and a liberal application of water to ensure appropriate results. As a function of that discussion, it appeared that the organization in question had adopted a weekly frequency for the use of wet vacs, and it also appeared that the OR rooms were noted to have a buildup of materials (you know what they are—no need to get graphic here) in the corners of the rooms. The overarching question was what the TJC survey risk might be given the current practice and conditions.

Now I honestly don’t know why people struggle so much with this, but here goes (and yes, for those of you keeping score, before we finish this conversation, I will invoke the mighty risk assessment).The Joint Commission standards do not specify any particular methodology for the cleaning of operating rooms, primarily (to my way of thinking) because there is far too much variability in the surgical environment for them to “require”  anything more than what they do now: EC.02.06.01, EP 20, which requires that “areas used by patients are clean and free of offensive odors.” And that, as they say, is that. (By the way, in case I have not previously noted this, this EP is now a Direct Impact finding and is showing up with far greater frequency in survey results. I characterize this as the “return of the white gloves.”)

Based on the conversation related above, if there is a buildup of nasty stuff in the corners, then clearly whatever frequency and/or method they are employing is not particularly effective—even if they are using a wet vac only once a week, they shouldn’t be getting a whole lot in the way of buildup in the corners, so putting my EVS hat on, there is at least some competency/education opportunities lurking in them thar corners. Will a water vac be enough? Read on…

Even the CDC, in its Guidelines for Environmental Infection Control points to other “published” guidance when it comes to the cleaning of OR’s , which, to my mind, points to the AORN recommendations (I don’t know if there is a more contemporary edition; this is from 2007, but I think the basic concepts still apply). Now there are a whole slew of things to do in the AORN guidance, including a process for before/between-case cleaning (which indicates the process would be in place even after the room is terminally cleaned). As a bit of consultative advice, I would be inclined to advise folks not to cherry-pick the “easy” pieces from the AORN guidance. If one were to consider the AORN guidance as a “best” practice, then we would need to look at is as a whole, at least as a starting point. As with all universal guidance documents, the “one size fits all” aim almost never results in universal applicability, but if we are going to adopt something along the lines of a hybrid kind of deal (wait for it!), we would need to have this framed within the context of a risk assessment.

So if, for instance, a surveyor were to cite a hospital for not following the AORN guidance (and there is not TJC standard that says you have to; good idea, yes, mandate, no),  without citing some level of failure relative to the cleaning process, then that would be an opportunity for clarification. But, if the organization can demonstrate that whatever methodology it is using is effective, based on data analysis, infection rates, etc., then who’s to say that its “strategy” is not every bit as valid as the recommendations of AORN? But, if the same hospital gets cited because it has sanitation opportunities in their OR’s, then it is dead in the water, so to speak. As something of an editorial comment, it has been a very long time since I’ve been in an OR that I would call clean; most are okay, but for instance, it is very rare indeed that the anesthesia machine does not have a buildup of dust. Now I know that the dust comes primarily from linen and the undoing of surgical packs, etc. in the room (that stuff does nothing but aerosolize lint—yuck!), which means pretty much every time an OR room gets used, we are introducing more stuff that will need to be cleaned.

In conclusion: Buildup in the corners will likely lead to a TJC or CMS finding and that is as it should be; folks who are experiencing less-than-ideal levels of cleanliness need to look at changing their process, but I don’t think it necessarily makes sense to tie your future to adopting anyone’s specific guidance, until you’ve figured out the reasons for having a deficient process in the first place. That way, if you should choose not to adopt what can legitimately be characterized as a best practice (the AORN guidance), then they better have a real good reason (which would include validation of the effectiveness of the alternative) for doing so.

This is just like the cardboard issue. There is no regulatory mandate in any direction on this, but it is a risk to be managed effectively. Nowadays, each organization’s responsibility, and, strangely enough, The Joint Commission’s expectations, is to know whether it is managing identified risks appropriately. There can truly be no more reliance on the “no news is good news” philosophy—reactive risk management will only cause trouble during survey. Improvement is a beautiful thing, but you need to understand how and why improvement occurred.

Infected water system to be replaced in Washington hospital

The water system at Providence Sacred Heart Medical Center in Spokane, WA, will be treated with chlorine in an effort to kill bacteria that can cause Legionnaire’s disease.

Since January, three cases of bacteria have tested positive in patients at the facility. In January, two occurred in patients occupying the same room, and another case occurred in March, reports The Spokesman-Review. All three patients were elderly.

It is a major undertaking for the hospital to clean its water system, reports the paper. Water samples were collected on May 5 and tests will take place in the next two weeks to confirm the bacteria have been killed.

Mac’s Safety Space: Transporting blood and urine samples

Q: A question about transporting blood and urine samples. Do the samples need to be in a biohazard bag when transported either by hand, on a cart, or via a tube system that can go both to the lab and the pharmacy?

Steve MacArthur: I think the simple response to your question is yes, based on the requirements in the Bloodborne Pathogens Standard. First off, we start with the section on specimens on OSHA’s website:


Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

Now we could certainly discuss the merits of urine as a function of “other potentially infectious materials”, but in these days of Standard Precautions, the assumption we make is that it is presumed infectious until proven otherwise. We could also discuss the merits of the zip lock plastic bag as a function of leakage prevention, which will clearly depend on what the specimen is in; plastic would nominally be OK, while glass is probably a little less safe, depending on the method of transport, which would be another consideration.

So moving on to labeling, it seems pretty clear that some sort of unique identifier is in order and since the “standard” for that would be the biohazard symbol, I think we can safely identify that combination as the way to go.


The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility.

In the interest of full disclosure, I’m including the items under paragraph (g)(1)(i) below, just in case there is something than clicks with your particular situation:


Labels and Signs –




Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).


Labels required by this section shall include the following legend:


These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a contrasting color.


Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.


Red bags or red containers may be substituted for labels.


Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).


Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.


Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated.


Regulated waste that has been decontaminated need not be labeled or color-coded.

Hopefully, that helps answer your question; I think as long as you have something that is specifically identifiable to all who would be handling the specimens, you should be fine.

Mac’s Safety Space: Temperature and humidity in the operating room

Q: My engineering manager is telling me that they only have to monitor temperature and humidity in the operating rooms on a quarterly basis. Can this be true? What’s the industry standard?

Steve MacArthur: Brace yourself: there is no specific requirement or standard that indicates the frequency with which one would monitor temperature and humidity in anesthetizing locations.

There are numerous guidelines that come into play for this: NFPA 99 Standard for Healthcare Facilities; the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) Standard 170 – Ventilation of Health Care Facilities; and the CDC Guidelines for Environmental Infection Control, none of which speak to monitoring temperature and humidity, never mind indicating a frequency, though in the CDC Guidelines, they do indicate that activities should occur in accordance with engineer or manufacturer recommendations for the system. To be honest, the only place that even hints at a monitoring requirement is in the Conditions of Participation Interpretive Guidelines, and even there the only indication of a requirement is that surveyors are instructed to review the temperature and humidity logs during a CMS survey.

To be honest, with what I know about the folks conducting the environmental surveys, in some instances their background is extremely limited and tends to reside around basic fire safety concepts. That’s not to say that a clinical surveyor might not ask the question, but as there is no specific frequency requirement (unless there’s something in the state regulations–they should probably check to make sure), quarterly may be acceptable. I would say that in a small majority of hospitals with building automation systems, they pretty much keep a constant record of building conditions, including temp and humidity in the ORs. But I find equally as often that they have no real process in place to respond to out of range conditions, so you have them print out the data (and nobody really looks at this in real time. This is really an inconsequential pressure point until there is a requirement to have some sort of alarm signal, etc. to indicate when levels are out of compliance) and ask them “what happened on such and such date when the humidity was at 72%” and they have no response.

Most of the “management” of this issue revolves around the personal comfort of the occupants as much as anything, so if nobody squawks that it’s too hot or too damp, it is generally not noted.

All that said, I would advise them to document a risk assessment that provides sufficient evidence that a quarterly frequency of monitoring temperature and humidity is effectively managing the environment (Infection Control has a role to play here, and actually have ultimate veto power when it comes to decisions that could impact infection rates, etc.)