All Entries in the "OSHA" Category

Can’t get no protection…

I’m not sure if you folks follow my HCPro colleague David LaHoda’s OSHA Healthcare Advisor e-newsletter and blog, but there’s an item this week that I think bears bringing to your attention in case you didn’t see it.

Now I think we can all agree that there is a great deal of attention being paid (and rightly so) to issues of workplace violence and how can we be assured that we are doing all we can to protect the front line folks from assaults, etc. And I think many, if not most, of us recognize that acts of violence by patients are definitely not diminishing over time. The variables are wide-ranging—the economy, the reduction of behavioral health resources, etc.—and endlessly complex.  We must manage these variables in as proactive a manner as possible.

So, how are you folks out in the safety community addressing these types of concerns? What education are you providing and to what staff demographic groups are you targeting with that education? Are you mandating education in certain areas, or are you letting folks participate as they feel necessary? Who has a program that’s working well, and what monitoring and measures have you put in place to ensure that the program you have is getting the desired results? I think this is a dialogue that’s going to be with us for a while, so please weigh in on what you’re doing/facing/dreading.

As a final thought, back in the day before we had “standard precautions,” there was the term “universal precautions” based on the concept that you can’t tell whether a person is an infection risk just by looking at them, so you have to manage everyone as if they had the potential. Is it time for a truly “universal” approach to the potential for violence when it comes to patient management? What do you think?

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, (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf) 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: (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=1586) 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: www.osha.gov/Publications/glutaraldehyde.pdf

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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Reasons (not) to be cheerful, part 3

Or perhaps it should be “hit me with your Joint Commission stick”?

What follows is a compendium of recent survey findings, some from The Joint Commission (TJC), some from me. So in no particular order:

• Rooftop isolation exhaust fans and other “biohazard” areas should be appropriately labeled to identify the hazard. I’d expand this a little to include soiled utility rooms (particularly in outpatient settings) in which medical waste is collected and stored.
• If you have key utility components (e.g., emergency generators and the like) outside your building, make sure that they are appropriately secured from unauthorized entry. And once you’ve determined what “appropriately secured” means for your organization, document the risk assessment, so if a surveyor just happens to disagree with how you are managing things, you have the basis for a clarification of the finding. Same goes for your solid waste compactors—make sure nobody can monkey with them (all due respect to monkeys).
• Make sure everyone in the kitchen can locate and explain the operation of the fire suppression system. This is kind of a follow up from an earlier blog post outlining the monthly inspection of the kitchen fire suppression system. TJC recognizes that we, the primary stakeholders in the management of the care environment, have our act together. More and more, the focus has gone to the point of care/point of service staff. Safety lives in the trenches. We need to keep those folks in the loop.
• Make sure your main supply shutoff valves, including your main oxygen valve, are appropriately labeled. And if you should choose to decide that, for reasons of security, that is not an appropriate strategy, make sure you document the risk assessment that led you to that determination.
• Make sure you know where you need to have eyewash stations and where you don’t and why. Not every potential exposure requires an eyewash station—OSHA is very specific in that regard—potential exposure to corrosive materials is the determining factor. If you want to adopt a slightly stricter standard, the American National Standards Institute expands things to include corrosive and caustic materials. Beyond that, including blood and other potentially infectious material, you don’t “have to” have eyewash stations for exposure response. As a related aside, try to convince the folks in environmental services (and by extension, infection control) to promote the use of cleaning products that are not corrosive or caustic—that will help you identify an appropriate response capability.
• Don’t forget those pesky compressed gas cylinders—other than penetrations and doors not latching, I think the most frequently cited specific condition is the unsecured cylinder. And please promise me you won’t say that you have to do additional education. Folks know they’re not supposed to leave the cylinders hither and thither. Find out the root cause of why they can’t do the right thing. And if you find out anything useful in that regard, please let the rest of us know.

Th-th-th-that’s all folks. For now…

One more from the mailbag

Q: Regarding patient/nonpatient care areas, what about performing site visits to off-site doctor offices run by the medical center? Once yearly or twice yearly?

A: That’s one that could go either way; strictly speaking, the two per year requirement is in the standards specific to hospitals and various assorted healthcare occupancies, but you could make the case that it’s best practice to extend that to physician office practices. What you could do is, if you decide to adopt the once a year, go at it as a function of a risk assessment and leave the option of increasing the frequency if conditions dictate, then wrap the whole thing up as part of the annual evaluation of the program scope. The other thing you could do (and this might be a good compromise) is to create a 10 to 15 item checklist (it can be less, I wouldn’t do more) that someone in the office can do and then do an “official” site visit to make the two per year. Generally speaking, physician office practices don’t endure a lot of variability, so the safety conditions, etc., while not exactly static, are of a much more manageable pace that the acute care setting, so it is entirely appropriate to administer the program accordingly.

What is a nonpatient care area?

Catching up on some recent e-mail questions, there was one regarding hazard surveillance activities and the oversight of off-site buildings (not identified under the hospital’s license) where there are no patient services provided. So the question became whether these locations had to be included in the hazard surveillance program and whether they would be subject to a Joint Commission visit during survey.

So, taking a look at the Joint Commission “role,” while it is most unlikely that the survey team would visit an off-site location with no patient services (not quite 0%, but something very close to that), a pain-in-the-butt surveyor might check the hazard surveillance round documentation vs. the list of hospital departments. Now the standard/elements in question, EC.04.01.01, EPs 12 and 13, only refers to patient and nonpatient care areas, so I think the thing to do is to be very specific in identifying locations in the scope of your management plans (I mean, what exactly is a nonpatient care area? A nonpatient area—got that; a patient care area—got that. But this hybrid is a little vague). Ultimately, the whole process sets up based on what you’ve identified as the appropriate inclusions, etc., so you can certainly make the determination of what would rule in to the program, or indeed rule out of the program.

That said, I have a concern in the event that OSHA were to rear its ever so lovely head. It would be of critical importance to demonstrate some sort of oversight; one strategy that comes to mind would be to develop a self-inspection process for those areas and fold that into the formal surveillance process. As a safety professional, I’m having a hard time saying that these “other” locations can be culled out of the main process (in my experience, it is never a good thing for people to think that they are somehow being ignored or not appropriately tended). I think the thing to do is to set up a less-invasive process that will allow some sort of feedback loop if environmental issues crop up in these other locations. Better you find out about issues than to have somebody drop a dime to the big “O.”

No violations found in incident involving heavy equipment that injured two

OSHA found no violations in an incident at Advocate Good Samaritan Hospital in Downers Grove, IL, where a 3,000 pound piece of equipment came crashing down in a maintenance corridor, injuring two workers.

Kathy Webb, an OSHA area director in Aurora, IL, told The Chicago Tribune’s TribLocal of Downers Grove that OSHA will not issue any citations because there are no standards that cover removing air conditioning and heating equipment, which happened to be what fell on top of the men.

OSHA officials looked at the guidelines, as well as accepted industry practices and standards, and could not come to an agreement on the proper way to remove equipment that large.

How do you think OSHA should have handled the situation? Should citations have been issued? Let us know in our comment section.

California Children’s hospital fined for safety violations

California’s Division of Occupational Safety and Health (Cal/OSHA) fined Children’s Hospital and Research Center Oakland on February 22 for failing to offer policies and controls follow a violent, unsafe situation.

The safety violations were related to two separate incidents that occurred in the facility. In July, a homeless man took an employee hostage with a gun in the emergency room , while in October, a victim with a gunshot wound was left at the hospital entrance rather than the emergency room entrance, leaving nurses feeling unsafe, reports the San Francisco Chronicle.

The total cost for the citations is $10,350 and hospital officials plan to appeal. Officials blame unresolved union negotiations for the citations.

Is the hospital right to appeal the violations? Let us know in our comment section.

Massachusetts facility fined for electrical safety issues

Northeast Hospital Corp., located in Beverly, MA, is facing a $63,000 fine after an investigation by OSHA.

The investigation was prompted by a worker’s complaint that hospital employees didn’t have or use personal protective equipment when handling electrical equipment.

OSHA also found that the hospital’s electrical protective equipment wasn’t tested regularly and electrical safety procedures were not executed properly.

OSHA issued a repeat citation for failing to prove unused openings in electrical panels and cabinet motor control centers had been closed since being cited in May 2010

The facility has 15 business days from the day of its citation, February 15, to comply with hospital safety standards.

What practices does your facility follow in electrical safety? Let us know in our comment section.