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Spread out! A Stooges primer on cylinder storage

One group of findings that I have seen with increasing frequency in survey reports are those relating to the segregation of stored compressed gas cylinders. Now I think we can agree that the general concept of enforcing the appropriate segregation of cylinders makes some sense. We certainly would not want to put folks in a position where they would have to hunt around for a full cylinder in an emergency—or worse, grab a nearly empty cylinder when responding to an emergency (and yes, I understand everyone’s belief that grabbing a not full cylinder would never happen “in their house,” but I also know that there is a great belief that nothing could ever get into the MRI magnet field, etc. and I know that sometimes the human element doesn’t work exactly as you would prefer).

I’ve seen many different strategies: “full” and “empty” signs on the storage racks or on the walls above the storage racks; racks painted different color (red for the empties, green for the fulls), etc. There is no specifically prescribed method for ensuring appropriate segregation, but I can tell you one thing: if you have locations for full and empty storage in close physical proximity, it is inevitable (in my experience, natch) that the separation will become blurred and you’ll end up with in use or empty cylinders (more on that in a moment) stored in your full rack. I think the strategy that gives you the best shot at compliance is having the storage racks in completely separate spaces (if the room is big enough for separation, that may work, but I’m really talking one room for the fulls and another room for the empties).

One sticking point in this whole magillah is: how do we manage the cylinders that are not full, but not yet empty? Oxygen ain’t cheap and nobody wants to be in the position of returning partially filled cylinders to their vendors—it’s kind of wasteful. So when you come right down to it, we’ve really got three “classes” of cylinders to manage: full cylinders, in-use cylinders, and empty cylinders. But somehow the code doesn’t necessarily capture the in-use cylinders as a specific concept (NFPA 99-1999 4-3.5.2.2 (b)(2) says: “if stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.” (By the way, I think this particular code reference tacitly supports having the full and empty cylinders in separate rooms) But our friends from Chicago (aka The Joint Commission) provide us with a little more specificity; in the December 2012 issue of Perspectives, we find the following passage “(r)acked full cylinders must be segregated from those that have been opened or used (see NFPA 99-1999 4-3.5.2.2.(b)(2)). There should be no confusion for health care personnel who need a cylinder for patient care about which cylinder to select. If empty and full cylinders are comingled in the same rack without clearly separating the two groups, staff might accidentally retrieve a partially full or empty cylinder rather than a full cylinder.”

So, the acid test, so to speak, is keeping the full cylinders separate from “those that have been opened or used). To that point, I think the way to move forward on this is to establish a policy (you might consider a little risk assessment at the front end) that clearly indicates compliance as a function of the full cylinders being in their own location and once a cylinder is used, moves to a location separate from where the full cylinders are stored. That way you can start to measure compliance with your policy as a function of a compliance rate; you collect data during hazard surveillance and safety rounds (maybe even during fire drills). Once you start tracking your compliance rate, even if there happens to be a misplaced cylinder during a survey, you can use the historical compliance data to support clarification of the finding. This is one of those compliance shortfalls that can come up during survey that can almost always be clarified—as long as you know what your compliance rate is over time. Think of it this way, for every cylinder you might find in the wrong spot (or even not properly secured), there was (I hope!) way, way more that are being appropriately managed—that’s the compliance number that you want to track. It will help get you out of survey trouble!

You lift me up!?!

As I wander around the countryside visiting hospitals of all shapes and sizes, there are a few common challenges that seem to give just about everyone fits. And probably among the most common of commonalities is the challenge of managing patient lifting and all the inherent risks of that frequently occurring occurrence (that would be a FOO for you in acronym-land).

At any rate, while catching up on some conversations on one of the safety listservs (this particular listserv focuses on colleges and universities, but there are some healthcare folks in the mix as well) and I found reference to a very interesting article on patient lifting.

The most useful thing about the article (and it’s pretty gosh-darn useful) is that it includes a link to a protocol that can be used (very quickly so it seems) to effectively forecast the patient care and financial impact of patient lifting changes. Now I know from my past experiences that it can be really tough to “sell” the C-suite on avoided future expenses based on a little technology investment in the now. I’m not sure where you all are in relation to this as a focus item, but on the off chance that it might be helpful…

Steak tips, turkey tips, and compliance tips—such a deal!

I’m not entirely certain what to make of this, but I always try to share anything I come across that might prove useful to you folks in the field. Back in July (yes, I know we are now edging towards the wintry portion of our year—we’ve had a lot of stuff to discuss), in one of the regular editions of Joint Commission Online, there was a list of compliance tips for the most frequently cited Life Safety standards.

Nothing wrong with that, as a going concern, but where I kind of got bogged down when I looked at the tips is that they weren’t necessarily in reference to stuff I’ve seen most in the field. All code compliance tidbits, to be sure, but again, not necessarily the type of stuff with which I’ve seen folks struggle.

As an example, the first tip deals with the required clear width of doors to sleeping rooms, egress doors, and doors to diagnostic treatment areas (existing construction must have at least 32 inches of clear width; new construction must have at least 41½ inches of clear width). Now I can think of a few instances in which I’ve encountered doors that were a might on the narrow side, but I’m also thinking door width is driving this particular standard (LS.02.01.20—egress requirements) to be among the most cited in all of survey land? I don’t know, which is why I’m not sure what to make of this. At any rate, make of it what you will—just make sure you grill those tips to your liking.

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!

Do we really hafta?

Recently I received a question from the field regarding whether employers are required to provide antibody testing at the conclusion of the Hepatitis B vaccine administration process. Now, this is an interesting one in that the guidance is a wee bit circuitous, but I think we can navigate the murk and arrive at a point that makes things somewhat more clear.

In looking at what OSHA has to say about the Hepatitis B vaccine (you can find the OSHA Fact Sheet here), it only mentions the antibody testing in the context of pre-screening employees to see if they need the vaccine (employers are not required to provide the antibody testing as a means of pre-screening, so if new employees don’t know if they have the antibodies, they would have to have the testing done on their own). However, the Fact Sheet indicates that the vaccine must be administered in accordance with the recommendations of the United States Public Health Service (USPHS) that are current at the time the procedure takes place. The Fact Sheet goes on to indicate that “To ensure immunity, it is important for individuals to complete the entire course of vaccination contained in the USPHS recommendations.”

That sends us off to find the USPHS recommendations. A quick search of the Web takes us back in time to June 2001 when the USPHS recommendations were last updated. In the recommendations of the USPHS, while there is not a specific mandate regarding the antibody testing, it is recommended that the testing occur: “HCP who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested 1-2 months after completion of the 3-dose vaccination series for anti-HBs.” So, we have USPHS saying the testing “should” happen and we have OSHA saying that the vaccine “must” be administered in accordance with the USPHS recommendations. To my way of thinking (putting my occupational safety/risk management hat on), while the antibody testing is not specifically mandated by OSHA, they mandate administering the vaccine in accordance with the USPHS recommendations, which recommend antibody testing. Again, somewhat circuitous, but I feel very strongly that failing to administer the antibody testing in accordance with the USPHS recommendations would not pass the compliance test with an OSHA inspector.

How many feet in a mile? How many square feet in a smoke compartment?

I recently came across a survey finding that I thought would be worth sharing with the class. In this particular survey, an organization was cited because it had not identified the square footage of their smoke compartments on its life safety drawings (this was a Direct Impact finding relative to maintaining a current e-SOC). In looking over the information published in the October 2012 issue of Perspectives (See the highlight box on p. 12 entitled “What to Include in Life Safety Code Drawings.” Please check it out if you have not yet done so; anything that shows up in Perspectives is enforceable as a standard!), I clearly see that there is a requirement to include the square footage of any areas designated as suites.

The only mention of smoke compartments indicates that they are required to be identified by location, but there is no mention of the square footage. Now this would seem to be a case of a surveyor interpreting (perhaps even over-interpreting) a requirement based on information that has not appeared in either the standards manual or in Perspectives (square footage for smoke compartments isn’t mentioned in the February 2012 issue of Environment of Care News either). I think this would be a good survey finding with which to practice using the clarification process and I suspect that the organization in question is going to make good use of that process.

Many too many…high numbers

In looking through the ol’ e-mail bag, I received a request for info relative to what the “magic number” was to be able to “count” an influx exercise in compliance with the Emergency Management standards. In looking at this question, I thought to myself that I don’t know that we’ve tackled this one yet here in the blogosphere and since my experience has generally been that questions like this rarely occur to just one set of folks, I figured there’s no time like the present. And so…

In looking at the performance element in question, all it says is that at least one of the two emergency response exercises includes an influx of simulated patients…and that’s all it says (you can go check!) Which means, in the parlance of the survey world, it is up to each organization to define what level of incoming patient volume is sufficient to be characterized as requiring implementation of the emergency response plan. In short, there is no “magic number” to guide us, so it becomes something akin to a risk assessment in that we need to determine what number and acuity (in some ways, acuity is the more important metric when discussing such matters) of incoming patients pushes our “normal” response capabilities past the point where response would still be considered normal. For smaller hospitals, the influx number is likely to be smaller; one really sick or injured patient might be enough to tip the scales where larger organizations might be able to manage volumes in the tens (I’m thinking hundreds is a bridge too far for the purposes of this conversation) without breaking a sweat.

To be honest, my experience has been that a lot of hospitals (perhaps even most hospitals) “do” influx on a regular basis. Volume is rarely a static reality—it ebbs and flows like the tide, though not nearly as predictably. And since it is for all intents and purposes impossible to predict what types (illness/injury/level of acuity) of patients your organization might have to manage, you have to employ some level of response flexibility.

Getting back to the magic number, it’s going to be pretty much up to each organization to determine what constitutes an influx. To complete the thought relative to managing influx on a regular basis, I’m not entirely certain why the standards-based requirement hasn’t morphed (Evolved? Mutated?) into a requirement for an evacuation exercise. We do influx all the time; evacuation, not so much. So what’s your magic number?

Now that the world is going to (legalized) pot…

A number of states have passed (or are in the process of passing) laws legalizing the use of medical marijuana. Now, I don’t really have a dog in this fight as far as it goes, but I do think it may present some challenges for security professionals in hospitals as to how best to manage cannabis as a personal possession. What was once a fairly straightforward “it’s not legal” situation could now become rather a point of contention when someone wants to know what happened to their prescription pot (I’m thinking that this could bring a whole new meaning to medication reconciliation…).

At any rate, to those of you in the studio audience who are in (various) states of legalized marijuana: How are you managing this as a potential customer interaction? How have you managed this type of contraband in the past and how are you going to manage it in the future? Back in the day, confiscated pot could be turned over to the local police; are they even interested anymore?  The DEA still classifies medical marijuana as a Schedule I substance and I suspect that there are any number of hospitals that are licensed only for Schedules II-V, so your pharmacy director may have some insight into a way forward. At any rate, if anybody out there has actually been able to come to grips with this issue, I would love to hear what you’ve got going.

Catch a waiver and you’re sitting on top of the world

Lots going on in the regulatory landscape lately—much of it potentially very beneficial to you folks out there in radioland.

On August 30, the folks at CMS issued a whole new set of waivers for consideration including such party-ready favorites as:

  • Medical gas master alarms
  • Openings in exit enclosures
  • Emergency generators and standby power systems
  • Doors (just doors, not The Doors)
  • Suites
  • Extinguishing requirements
  • Clean waste and patient record recycling containers
  • Clarification of the process for adopting the March 9, 2012 waivers

We’ll be discussing some of the ins and outs of the whole waiver scene in coming weeks, but I didn’t want to let too much time go by without letting you folks kick this around. Which reminds me: If anyone has any particular questions on any of the above-noted topics, please feel free to weigh in as we go through them. Not sure that we’ll be doing one per week (maybe two per week—depends on how long-winded I get), but I’d love to include any thoughts or concerns you folks might have.

Finally, if you want to start the required reading in this regard, an excellent starting point would be with the ASHE folks (if you’ve not already tapped into that resource).