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Smoke ‘em if you got ‘em, but be careful where you install them…

Every once in a while, someone will “challenge” me relative to something I “know” is the real deal. Now, just so we’re clear on this, I absolutely encourage the respectful pursuit of knowledge, and it helps keep me on my toes, metaphorically speaking.

The issue in question during this recent survey was regarding the requirements for the placement of smoke detectors vis-à-vis the location. Or, in the vernacular, “Where does it say that it the code?” At this particular facility (as will happen from time to time), I noted that there were several smoke detectors that were located within three feet of air supply/return vents. I fully recognize that moving such devices around can represent a not-insignificant expense, so I was happy to respond to the “nobody’s ever said anything about that before” conversation, but had to admit that I was not certain as to the chapter and verse that governed this particular metric.

So, for the purposes of furthering the knowledge base, I give you NFPA 99 – 1999 edition, which is the edition of record referenced in the 2000 Life Safety Code®:

2-3.5.1*: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Now you may have noticed that there is no specific distance indicated, just a (not particularly useful) thou shalt not. So, how do we figure out where to go with this? Luckily, the little asterisk, points in a very useful direction. And so, to the Appendix!

A-2-3.5.1: Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Which provides us with a minimum distance of 3 feet (or 36 inches, for those of you inclined to such measures). While there is still a little wiggle room (not necessarily related to the little asterisk) relative to distance from larger and/or high velocity sources (in fact, you could make the interpretive case that supply and/or return sources in hospitals might indeed be larger than those commonly found in residential and small commercial establishments), this gives us the means of drawing a line in the sand beyond which we shouldn’t traverse. As a final thought, for those of you eagerly awaiting the opportunity to embrace the 2012 edition of The Life Safety Code®, the 2010 edition of NFPA 99 provides this little piece of the regulatory pie under

What I did on my summer vacation…

While I was on vacation a few weeks back, I used some of my “leisure” time to read the daily paper, and I came upon an article regarding the sentencing of a woman who had abducted an infant back in 1987 and raised the infant as her own child. One of the things that struck me is how the abduction scenario (or as much as can be discerned from the news account) involved an infant that had been discharged following delivery and had then been readmitted to the hospital a couple of weeks later. I reflected on how “useful” this scenario could be in developing abduction exercises, and I wondered how often folks are testing response in areas other than the mother-baby unit.

So, I ask you dear readers – what “other” areas have you identified as being at risk for potential abductions – inpatient, outpatient, how about in the home when mother and baby have been discharged. How are we educating staff and patients to the very real risks that exist in way too many places (in my humble opinion)? What do you think? How “far” do you take your responsibilities in this regard?

Soul kitchen

In the August 2, 2012 edition of the fabulous HCPro e-newsletter Hospital Safety Connection, the weekly tip discussed the various merits (or not) of whether kitchens ought to be considered hazardous areas. This discussion apparently engendered much debate, though mostly as a function of what would be considered a hazardous area under the Life Safety Code® (LSC).

While I can understand the interpretive aspect of this from an LSC perspective, my opinion has always been that if you were to consider a mental list of the various and sundry safety risks and hazards that one might encounter as a healthcare worker, the kitchen area has the potential for just about all that would be included in that “mental” list (let’s see. Fire? Check. Sharps? Check. Burns? Yup. Slips, trips, falls? Check, check, check. Need I continue? I think not). And if you extend the kitchen environment to the food services folks who deal directly with patients, then there aren’t too many potential risks that would not be in the mix.

So, while the designation of kitchens as a hazardous area may be debatable from a Life Safety Code perspective, from a pure safety/risk management perspective, it would have to be considered a most (potentially) hazardous area. What say you?

How do you handle …

This is a condition/practice I’ve noticed at any number of facilities.

In facilities that have stairwells that go up past the highest occupied floor (generally leading up to some sort of mechanical/penthouse type area), folks have frequently installed a chain across the stairs leading up as a barrier to unauthorized traffic. In one particular, but by no means unique, instance, a “not an exit” sign” was placed on the chain to reinforce that upward travel at that point was for authorized persons only. Now those of you keeping track of the intricacies of NFPA 101 will note that the wording of the sign in question is not in strict compliance with what is required by (a compliant sign would consist of the words “no” and “exit,” with NO written in letters 2 inches high and EXIT written in letters 1 inch high, with the word EXIT being below the word NO.) And interestingly enough, there is a specific performance element in the Joint Commission standards that addresses this (LS.02.01.20 EP #30).

But during a recent survey of the facility in question, the condition noted above generated a finding, though not under EP #30 (it ended up under EP #32, which is sort of the Life Safety Code® general duty clause egress-related bucket), and also included the citation that the chain impedes exiting from the level above. How about them apples!?! [more]

Infant abduction drills

There’s nothing I like more than questions from the studio audience, so this week I thought I’d field a question on one of those risks that never seems to go away completely, as much because there are not very many specific requirements. So, let’s consider abduction drills.

The current situation at this particular organization involves what I think is a pretty good cross-section of activities: campus-wide drills, suspicious person(s) on the unit drills, mother/baby-specific drills, as well as random quizzing of staff throughout the organization on their role(s) in the infant abduction policy (they have to answer 10 questions about the policy), and a monthly operational test of the infant security alarm system. Again, I think that’s a very good start to things. But it does sort of beg the question as to what requirements exist? Well, dear reader, I beg you, please read on.

Strictly speaking, The Joint Commission (TJC) does not have a great deal that could be characterized as requirements in this regard. EC.02.01.01 EP #9 requires hospitals to have written procedures that can be acted upon in the event the hospital experiences any security incident, including abductions of infants of pediatric patients. That’s pretty much all there is in the standards. I’m presuming that you have a written procedure for responding to an infant and/or pediatric abduction incident, so we’re off to a good start. [more]

Mirror, mirror on the wall … is that me?

One of the curious things I encounter on an increasingly regular basis is the Dorian Gray-like (but in reverse) effect of the ID badges of folks who’ve worked at an organization for a rather long time. So long, in fact, that they really don’t look like their ID pictures any more. I know you’ve seen it too.

Now, I’ve always considered the hassle of having folks wear ID badges as being an important component of our security management strategies. As a general consideration, we do have an obligation to ensure that we’re not giving any interlopers a chance of breaching our security (and don’t get me started on those folks who are not nearly as careful about their ID badges as they should be. I know it makes me sound petulant, but we really ask so little of folks in this regard).

So, I ask those of you responsible for the ID process, have you established criteria for an update of photo IDs? Weight loss or gain, hair color changes, the aging process (all potentially contentious topics for discussion)? Or, like the motor vehicle registry folks, do you re-take pictures after a certain amount of time, maybe contingent on how much a person has changed in the ensuing period. Any feedback or discussion would be most appreciated.

Keep the home (and OR) fires not burning

I was not able to attend the recent NFPA conference in Las Vegas, but I have heard tell that there was some indication that beginning this year (2012) organizations can anticipate some closer attention being paid to all things in the surgical fire realm. I don’t know that this is one that has ever really gone away (fairly surveyor-dependent from my experience), but it appears that this will increase as a topic of survey conversation. (I suspect that the EC-LS survey process is going to continue to focus on the surgical environment-lots and lots of risks to be managed and not necessarily the easiest audience to capture when it comes to safety and related education).

Among the items that will likely surface in conversation:

  • Fire drills and education for surgical staff
  • Fire response procedures
  • Risk assessments to minimize the risks of surgical fires and/or injuries
  • The roles and responsibilities of physicians in the management of the above-noted considerations

As a final thought in this regard, don’t forget that the grand ol’ folks at CMS take this pretty seriously and there have been instances in which an inadequate response from frontline surgical staff (the metaphorical equivalent of the “shrug,” maybe even metaphysical as well, but we’ll leave that for another time) drove an Immediate Jeopardy finding. When it comes to areas of greatest risks for conflagration, the surgical environment is right there at the top of the pyramid. So, we need to make sure that everyone in that environment understands the whole picture: preparedness, mitigation, response. This is way too important to leave to chance, so let’s get to it!

It’s so easy, it’s so easy, it’s so easy (repeat ad infinitum)–so doggone easy!

When you compare it to sustaining improvement, actually making the improvements to start with is rather like the proverbial piece of cake.

One of the common themes I’ve been running across (and sometimes running into) in my consulting work is the frustration that comes with encountering conditions and/or practices that the organization thought had been resolved. And it’s generally not big ticket stuff and it’s generally not the types of things for which additional education is going to be making a significant difference. [more]

Permission comes in all shapes and sizes

Quick question—do you folks have conditions or practices in your facilities that might be a little squishy relative to a strict interpretation of regulatory codes, but your local AHJ has seen fit to grant you permission to engage in that pursuit? And, if so, have you also used that permission to request a traditional equivalency from TJC?

You haven’t?!? Well, my advice would be to do so with all due haste (you can request an equivalency either using snail mail or as an online submittal through the electronic Statement of Conditions on the Joint Commission Connect site). [more]

How is your generator like a Great Dane (and no, I’m not referring to Hamlet…Marmaduke, maybe)?

I was recently looking over some survey results in which a finding was generated (small pun intended) because there was a “black substance coming out of the exhaust manifold” which was equated with evidence of wet-stacking. The finding went on to indicate that the condition needed to be addressed to prevent the potential for engine failure, while also indicating that all maintenance and testing had been performed as required.

Now, I will freely admit that I am in no way an expert when it comes to engines and the like, be they emergency generators or whatever. But, I am reasonably certain that if maintenance and testing activities are being performed as required, this “black substance” may very well have an explanation that does not necessarily point to some sort of catastrophic failure event.

And so, I have become introduced to the concept of exhaust manifold and/or engine “slobber.” [more]