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Mac’s Safety Space: Life Safety Code retractable hooks

Q: I had a Life Safety Code question I was hoping you could help me with when you get a chance. Specifically, our nursing staff wants us to mount retractable stainless steel hooks on the inside of our patient room doors to be used with “gait belts” for physical therapy and for turning patients in their beds. These patient room doors go directly from the patient room into the corridor without any intervening room(s), and the door opens inward (into the patient room). None of these doors are part of a rated smoke or fire wall assembly.

All of our patient room doors are 1 and ¾ inch thick, solid-bonded core wood doors that resist the passage of smoke for up to 20 minutes and have a metal frame. Our hospital is NOT fully sprinkled, which means that some of these doors are in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section of Chapter 19, Existing Health Care Occupancies, of the Life Safety Code of 2000, while some are not.

The hooks are mounted on a 4-inch by 4-inch wide stainless steel platform that stands 1 inch high. The platform would be secured to the door by four sheet metal or wood screws that would extend into the door about 1 inch, but would NOT come out the other side. The hook retracts very easily because it is designed to prevent suicides.

Unfortunately, I do not have a manufacturer name or model number, because our nursing department purchased them without checking with us first and now want us to install them. Again, we have a concern about securing this or any other device to corridor doors, but I can’t find a specific reference to this in the Life Safety Code, which is why I’m asking for your help.

A: Happy to be of service. I ran this by my Greeley colleague Brad Keyes and we are in agreement that as long as the doors in question are not fire rated doors or doors that serve a smoke compartment barrier (which you indicated was the case), then there should be no problem from a Life Safety Code perspective . Corridor doors to patient rooms are only required to resist the passage of smoke, regardless whether the smoke compartment has a sprinkler or not.

That said, whenever I encounter folks who are engaging in these types of modifications, I encourage them to check with the local AHJ to run it by them. You certainly know your AHJ better than I do, so you definitely have a better sense of how to (or even if to) approach this. I’ve just seen too many folks that went ahead with the modification without checking with the locals, only to have to undo everything when someone gets a hair across their posterior because they weren’t consulted (and I suspect you know if you have that type of a personality in the mix).

California hospital will be able to withstand an 8.0 earthquake

An innovative building design will allow the brand new Mills-Peninsula Medical Center in San Mateo, CA, to shift 30 inches in any direction during the event of an earthquake, preventing it from toppling down.

The hospital is set to open its doors May 15 and will be stable enough that people within the hospital won’t feel a 4.0 magnitude earthquake or less, reports the San Mateo County Times. Quakes that reach 8.0 on the Richter scale will feel more like 4.0 quakes inside the building.

The new building has 176 base isolators that will allow it to move up to 2.5 feet with the movement of the earth. Anything weighing more than 20 pounds in the hospital will be bolted down to avoid any accidents.

The hospital will be able to stay open and operable for 72 hours after an earthquake due to storage tanks in the basement that store water and fuel.

What plans does your facility have for natural disasters such as earthquakes? Let us know in our comment section.

GPS device used to keep track of newborns

Colorado uses anklet devices to ensure infant safety, but Pennsylvania is using security tags on umbilical cords.

Harrisburg (PA) Hospital has implemented a GPS-like device for its infants, alerting staff if the baby is taken off the floor. A small computer chip inside the security tag does the trick. If the alarm goes off, the system shuts down the elevators that lead to the maternity floor, reports ABC27 of PA.

The infant security system has been in place for 14 months, and according to nurses, it makes parents feel safe. Additional safety precautions in place include surveillance cameras and other secret security measures. According to ABC27, nurses have seen no security problems.

How does your facility ensure no infants are being taken off the maternity ward? Let us know in our comment section.

Mac’s Safety Space: Electric blankets in patient care occupied rooms

Q: At my hospital, we do not allow electric blankets in patient rooms. Several Charge Nurse’s did ask where the reference was located regarding this issue. I could not find in anything referenced in The Joint Commission standards or in NFPA 101 LSC that referenced the use of electric blankets. Obviously, there is referenced information on prohibited use of electric space heaters. So can electric blankets be used in patient care occupied rooms?

Steve MacArthur: Well, it sounds like we’re in agreement that the thought of electric blankets is equally undesirable, but in looking at the regulatory landscape, there is no specific prohibition of the little blighters. So, the default setting is for them to be treated as any other piece of electrically-operated medical equipment that comes into contact with the patient, which means consideration has to be given to identifying a proper frequency for inspection, and then establishing a program for training end-users on the proper care and use. That said, some other considerations (courtesy of my esteemed colleague, Brad Keyes, CHSP) would be:

  • Why do the nurses want to use electric blankets? That implies a problem with maintaining adequate temperature for the patient, which is a violation of EC.02.06.01, EP 13. It seems to me to be a conundrum: You are not prohibited from using electric blankets, but if you do, that implies that you’re not maintaining proper temperature levels for the patient which is a violation of EC.02.06.01, EP 13.
  • What about the logistics of the electric cord? You can’t just drape it across the floor to an electrical outlet where someone can step on it or trip over it. You also would have the potential problem of the wheel on the bed rolling across the cord and pinching it, which is an electrical hazard. I absolutely agree with Brad’s points regarding the management of patient temperature, and I can tell you from personal experience (and you can try this at home) that clinical staff frequently do not use thermal blankets correctly. They just pile them on top of each other, resulting in one patient having five blankets and there being none on the linen cart for the rest of the unit. A single thermal blanket and a single sheet are really all you need to keep someone pretty toasty—the “holes” in the thermal blanket allows air flow, but if there’s nothing solid to cover the holes, the warmth just escapes.

In poking around the web, I don’t know that I found any evidence of a device that would be safe to use in the patient vicinity (within six feet of the patient). Also, in stumbling across the Electric Blanket Institute website ( they have a number of recommendations, one of which is not to use electric blankets on automatic beds because of the pretty significant risk of pinching damage.

Apparently there is also anecdotal information that electric blankets can have a deleterious effect on pacemakers, but they could provide no hard data in either direction. I think it comes down to there being no strict prohibition or a strict endorsement, which places it firmly in the land of the risk assessment. That said, if it were my house, I would say no, as much because there is no endorsement of the use of this product in hospitals. Now if someone were to identify one that is “safe” for use in hospitals, then we could have further discussion, but for the time being, I say stand firm and try the thermal blanket/sheet combination—low tech for sure, but if the patient is even “warmable” (and you know what I’m talking about), that should do the trick.

Infant security program added to Colorado medical center

Tiny security devices are being put around infants’ ankles at the Vail Valley Medical Center in Colorado to set off an alarm if newborns are taken outside of a designated area.

The new security system, Hugs Infant Protection Service, allows staff to monitor the newborns. The ankle device is waterproof, reusable, non-allergenic, and comfortable, reports Vail Daily.

Doris Kirchner, president and CEO of the medical center, says 582 births took place at the hospital last year. The medical center is adding the Hugs program to its current infant security program, which includes educating parents and staff about preventing infant abductions as well as security drills.

Does your facility have an infant security program? Let us know in our comment section.

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.)

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.

Mac’s Safety Space: Linens in the ENT clinic

Q: We have been having a discussion about the linens in our ear, nose, and throat (ENT) clinic. This clinic has an esthetician who uses spa wraps and smocks on the patients. Wouldn’t these linens have to be laundered the same as the hospital, as our clinics are under our hospital accreditation and license?

Steve MacArthur: I guess the question I’d have at this point is how are those items being laundered at the moment? It is possible to do a low-temperature wash (<160 degrees F) if appropriate chemicals are used. I’m thinking that we’re generally not dealing with an immune-compromised patient population in this context and maybe a risk assessment and a blessing from Infection Control would suffice.

The other thought I had is to either go with disposable wraps and smocks or perhaps the patients could keep their smocks, maybe as a marketing strategy. As I think about it, is the esthetician providing services under the auspices of the hospital’s accreditation or is it more like when they have hairdressers come in for patients in long-term care, which is sort of like a concession? I think the place to start is finding out what’s happening currently and working from there.

I think a credible risk assessment under the guidance of IC should be able to address any concerns that might come up during survey. Strictly speaking, this probably functions as an offshoot of palliative homeopathic care. I think as long as you approach the whole process in a thoughtful, methodical way, the surveyors will only be impressed at the level of service you are providing to patients. The IC standards all revolve around assessing risk and implementing prudent strategies for managing those risks, so why should this be any different. In fact, the acid test would be for you to submit the question to the SIG—and I bet you’ll get the same “figure it out for yourself” answer.

Healthcare provider uses technology to keep criminals away

Face recognition software is being used by a healthcare system to scan visitors entering the facility to detect whether they are “safe” or “dangerous.”

Atlantic Healthcare serves northern New Jersey and metropolitan New York and it instituted the technology to keep its staff and patients safe. Some of its buildings have 50 or 60 doors through which people can access the building, meaning the hospital chose to rely on technology because it simply does not have enough security guards, reports Security Director News.

Face recognition software has been installed in the emergency department that identifies high-risk people contained within the hospital database. Hospital staff upload photos of people who pique their interest so they’ll be alerted if these people enter the facility. The hospital is also able to identify whether a person has a criminal history by paying a monthly fee to access this information.

How does your facility keep out dangerous people? Let us know in our comment section.

Mac’s Safety Space: Joint Commission standards on mop and rag laundering

Q: We’re concerned about whether the way our mops and rags are laundered are up to Joint Commission standards. At this point, we’re laundering them ourselves in bleach in our washer. The temperatures are hot, but not 160 degrees. Are these mops and rags considered “linen” and do they have to be washed up to the same standards as the rest of the linen?

Steve MacArthur: The quick and dirty response (small pun intended) is that The Joint Commission has no standards relative to the processing of mops and rags, and even the CDC Guidelines for Environmental Infection Control make no specific mention of these items, and as far as a time and temperature equation (temperatures greater than 160 degrees F for more than 25 minutes), they indicate that that applies only when hot-water laundry cycles are used.

They do make chemical detergents for warm-water laundry cycles (less than 160 degrees), so that might be a consideration as well. That said, as they nominally do not come into contact with patients, I don’t think that there would be a compelling reason to consider mops and rags as “linen,” so they could probably tolerate a somewhat lesser level of sanitization, but what that level is would have to be determined.

A couple of things spring to mind. One avenue would be to contact the vendor from whom you obtain mops and see whether there are manufacturer recommendations for laundering the mops. The rags, unless you are purchasing them as a specific consumable, are probably the vestiges of patient linens past their usefulness in that context.

Not being sure what type of washing machine you are using for this process, it might be of value to consider the purchase of a commercial-grade washer. From personal experience, few things “kill” a household-grade washing machine faster than washing mops, particularly in bleach. Also, with a commercial washer, you can probably provide a sufficient time and temperature mix that would perhaps even suspend the need for bleach (bleach is no friend to fabric, I can tell you). Certainly the commercial route is an expensive start-up, but you can probably figure out whether the return on investment is worth it.