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When the tough get going: Emergency Management and other considerations

First off (and apologies for the short lead time on this), but next week (February 13), CDC is hosting a webinar on the importance of assessing for environmental exposures during emergencies (and in general). While this is likely to be some useful information as a going concern, you can also earn CEUs for tuning in. A summary of the program as well as registration information, etc., can be found here. Overall, I think hospitals had a pretty good track record of emergency response in 2017, but somehow these things never seem to get easier over time…

Another issue that I see starting to gain a little traction in the survey world is dealing with concerns relating to medical gas and vacuum systems; for the most part (I’m sure there are some exceptions, but I can’t say that I’ve run into them), folks in hospitals tend to rely on contracted vendors to do the formal inspection, testing, and maintenance of medical gas and vacuum systems, which tends to keep an in-depth knowledge of the dirty details at (more or less) arm’s length. A couple of weeks ago, I received some information from Jason Di Marco of Compliant Healthcare Technologies (many thanks to Jason!) that I thought would be worth sharing with you folks. Of primary interest is a downloadable guide to medical gas systems (available here in exchange for your email address) that really gives a good overview of the nuts and bolts (as it were) of your med gas system. Jason also publishes a blog on the critical aspects of medical gas and vacuum system inspection, testing, maintenance, compliance, etc., where I found a fair amount of useful information. Again, I can see the regulatory compliance laser focus starting to turn in the direction of all the systems covered under NFPA 99 and I can also see some of those prickly surveyor types trying to pick at the knowledge base of the folks managing these processes. So, in the interest of never having too much information, I would suggest getting a little more intimate with your medical gas and vacuum systems.

Breathe deep the gathering gloom…

As part of our (seemingly) never-ending quest to find topics of interest for you folks, we turn to the fascinating world of utility systems management, in particular, the management of aerosolizing water systems. As a safety generalist, I am always on the lookout for resources that will help increase my understanding of certain subjects and I try to pass on to you those that I find most useful (particularly over time). That said, I feel I have been somewhat remiss in not alerting you to a resource that I have been following for a fairly long time (it might even extend back to my days as a hospital safety manager—so we’re talking well into the safety Mesozoic era—love those birdsongs!). While the focus is Legionella prevention and education, there’s a lot of information regarding the management of risks associated with the aforementioned aerosolizing water systems—possibly the most risky (in terms of potential impact on patients, staff, and visitors) of the various high-risk utility systems.

The resource of which I am speaking is HCInfo; one of the highlights (at least for me) is that you can sign up for periodic e-mail updates; I find the updates, at the very least, to be thought provoking. The most recent blog posting on the site covers the potential impact on litigation relative to cases of Legionnaire’s disease in the wake of CDC’s release of its guidance for developing a water management program to reduce Legionella in buildings (you can find that august offering here). As noted in the blog entry, the CDC has come up with some very specific recommendations that could very well be the next bludgeon used by our regulatory friends. While the focus of the blog is on the litigious nature of things, there are a couple of take-home messages:

 

  1. “You should develop a water management program to reduce Legionella growth and spread that is specific to your building” (page ii of the CDC toolkit);
  2. “Legionella water management programs are now an industry standard for large buildings in the United States (ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta).”
  3. “This toolkit will help you develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” (page ii of the CDC toolkit)
  4. “Environmental testing for Legionella is useful to validate the effectiveness of control measures.” (page 21 of the CDC toolkit)

 

So, while not quite “marching orders,” there is enough certainty lurking within the pages of the toolkit to push for having some sort of plan in place for the management of your aerosolizing water systems (TJC has had a long-standing requirement to minimize pathogenic biological agents in aerosolizing water systems, the CDC toolkit may increase specific focus on this area). The one area that would seem to represent something of a sea change is the “useful”-ness of environmental testing for Legionella. Back in 2003, when CDC published its Guidelines for Environmental Infection Control in Health Care Facilities, there was just enough wiggle room to more or less dismiss the need to do environmental testing for Legionella (to test or not to test, that is the question—and it appears to hinge on what one might consider due diligence). I think partially due to the amount of bureaucratic language in the recommendations section, the sense was that the regular testing was not only just optional, but not really recommended (again, lots of room for interpretation). The current toolkit language definitely makes the case for testing as a means of validating the effectiveness of your control measures. But (as always appears to be the case), it is up to the individual facility to determine frequency, etc. But there is a way to get to that:

 

One of the key components of the CDC toolkit is (wait for it…) a risk assessment of your facility to help determine the applicable risks in your facility. The question then becomes: how long before our regulatory fiends (oops, friends!) start asking pointed questions about what we’ve been doing in this regard. As always, I provide this as information, but as the survey process continues to evolve (mutate?) in how infection prevention concerns are covered, this one really feels like something we need to button down as soon as possible. No doubt there are those of you who have already embarked upon this journey, so if you have any useful war stories that you could share, I’m sure everyone would benefit from your insight. I think this stands a good shot at being next in the line of hot button survey topics—and it’s an important one. My prediction is that everyone will be in reasonably good stead relative to the recommendations in the toolkit (this could be a very timely—and useful—performance improvement initiative for the EOC Committee), but I would encourage you to take whatever steps are required to be certain that you are in good shape.

The answer, my friends, is blowing in your facility

As I think everyone is aware, there has been a lot (okay, perhaps quite a lot) of focus during our pas de deux with the regulatory survey groups running around our hospitals on the various and sundry environmental conditions (temperature, humidity, air pressure relationships) for which there are various and sundry requirements (we’ve discussed those general considerations in the past, but if you need a refresher, feel free to dig through the archives at Hospital Safety Center). But a recent issuance from the CDC really starts to point to some of the ways in which the whole air pressure thing can actually influence the effectiveness of the management of immunocompromised patients as a function of air pressure relationships. There’s also an interesting study done by the folks at Johns Hopkins that speaks to the amount of time the doors to surgical procedural rooms are open during cases. I think we can all agree that keeping the doors shut during cases should probably be on the list of good ideas, but I suppose there can be a lot of coming and going—enough to de-pressurize the room. I’ve always felt that it is important to have some sense of how long it takes to de-pressurize and re-pressurize some of these critical areas; you want to make sure that folks are checking the pressure relationships when you have your greatest chance of success, recognizing that these rooms all “breathe” to one extent or another (and some of them come very close to wheezing…).

At any rate, information like this will likely only increase the attention paid to these areas during our survey encounters, with the added dynamic of this information being representative of the time-honored “smoking gun.” So, certainly acting on the CDC’s recommendation that immunocompromised patients not be placed in negative-pressure environments is something we can implement right away, but you’re probably going to want to come up with some sort of methodology for identifying those patients that rule in for that demographic (I’m thinking that our patients would tend more towards the immunocompromised side of the coin than not). We certainly don’t want to inadvertently put patients at elevated risk for infection, etc., by placing them in an inappropriate environment, so I think my immediate advice would be to look really closely at the information from the University of Pittsburgh Medical Center cases. If the end result looks an awful lot like a risk assessment, then I think you’re in the right place—and your patients will be, too!

 

We can be heroes

Very much a quick peek this week at more of the latest offerings from our friends in Chicago as they turn to some updated emergency management references. For those of you that have not yet book marked it, first and foremost, you can find the Joint Commission Emergency Management portal here.  The portal homepage includes links to information already published, including a Q&A blog from John Maurer’s 2013 presentation at the JCR Annual Ambulatory Care Conference; while the questions primarily relate to ambulatory settings, some of the general concepts certainly carry over. As I look over the materials, I hope that Mr. Maurer finds more opportunities to write (maybe he could fill in for Mr. Mills once in a while); I don’t know about you, but I like to read different “voices” from time to time and I’ve always found Mr. Maurer very informative and useful in helping folks understand what compliance can look like. At any rate, three’s lots of links to lots of stuff—definitely worth checking out (though I will say that perhaps it’s time to remove the 2013 date from the Joint Commission requirements section at the bottom of the home page; I know that 2013 was the last time that the standards were revised, but it makes things look a little dated).

So, on to the new stuff. First up is an update of general references; this includes links to the CDC Hospital Disaster Preparedness Budget Model, which is an Excel-based tool to assist in estimating resource needs across key departments and to help calculate funding reserves that would be needed for response and recovery (I think a lot of folks are good on financing response, but I’m not so sure about recovery—what say you?). Also, there’s a link to ASPR TRACIE (Technical Resources Assistance Center and Information Exchange—which came first, the acronym or the title?), which aims to provide “timely and innovative disaster information, tools and practice guidance for hospitals and community-based providers”; as well as a link to a Religious Literacy Primer for Crises, Disasters, and Public Health Emergencies. Finally for this page, there’s a link to the 5th edition of the Hospital Incident Command System Guidebook, so, basically, the latest and greatest IC stuff. I still think that the toughest thing about IC is getting consistent buy-in from leadership (sometimes it’s hot, sometimes it’s not), but perhaps edition #5 has the key to their hearts.

Lastly, but certainly not leastly, we have some information regarding the management of vulnerable populations, which can be found here.

There is a wide-ranging batch of information here (I would have liked to see a little more for adult behavioral health; they do touch on the pediatric behavioral health population, but maybe that will be in future missives), much of which I think you’ll find pretty helpful, if only to prompt discussion of the various populations served by your organization.

As with any materials published/shared by TJC, there is always the potential that surveyors will start to equate compliance with each organization’s efforts in dealing with this wealth of information. As always, not everything published is going to be as effective everywhere, so it certainly comes down (back?) to the individual organization’s to determine what preparedness looks like for their organization (and it never looks the same across organizations—even organizations that are in the same system). Emergency preparedness is very much a customizable undertaking—one size fits all does not apply very effectively across organizations (in fact, it would be much closer to one size fits none). You know what works best in your house (and, of course, you used the risk assessment process to make that determination, you clever boys and girls!), so don’t be afraid to set something aside because it is not a good “fit” for your organization. You are the best judge of what you need to do, have in place, educate for, etc. Be confident (but not cocky—that never plays well during a survey…).

Be prepared

As the flu season commences, the specter of Ebola Virus Disease (EVD) and its “presentation” of flu-like symptoms is certainly going to make this a most challenging flu season. While (as this item goes to press) we’ve not seen any of the exposure cases that occurred in the United States result in significant harm to folks (the story in Africa remains less optimistic), it seems that it may be a while before we see an operational end to needing to be prepared to handle Ebola patients in our hospitals. But in recognition that preparedness in general is inextricably woven into the fabric of day-to-day operations in healthcare, right off the mark we can see that this may engender some unexpected dynamics as we move through the process.

And, strangely enough, The Joint Commission has taken an interest in how well hospital are prepared to respond to this latest of potential pandemics. Certainly, the concept of having respond to a pandemic has figured in the preparation activities of hospitals across the country over the past few years and there’s been a lot of focus in preparations for the typical (and atypical) flu season. And, when The Joint Commission takes an interest in a timely condition in the healthcare landscape, it increases the likelihood that questions might be raised during the current survey season.

Fortunately, TJC has made available its thoughts on how best to prepare for the management of Ebola patients and I think that you can very safely assume that this information will guide surveyors as they apply their own knowledge and experience to the conversation. Minimally, I think that we can expect some “coverage” of the topic in the Emergency Management interview session; the function of establishing your incident command structure in the event of a case of EVD showing up in your ED; whether you have sufficient access to resources to respond appropriately over the long haul, etc.

Historically, there’s been a fair amount of variability from flu season to flu season—hopefully we’ll be able to put all that experience to work to manage this year’s course of treatment. As a final thought, if you’ve not had the opportunity to check out the latest words from the Centers for Disease Control and Prevention (CDC) on the subject, I would direct your attention to recent CDC info on management of patients and PPE.

I suppose, if nothing else, the past few weeks of our encounter with Ebola demonstrates something along the best laid plans of mice and men: it’s up to us to make sure that those plans do not go far astray (with apologies to Robert Burns).

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?