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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!

You may want to smoke during surveys

I could have sworn that I had covered this last year, but I can find no indication that I ever got past the title of this little piece of detritus, so I guess better late than never.

One of the more interestingly painful survey findings that I’ve come across hinge on the use of a household item that previously had caused little angst in survey circles—I speak of the mighty tissue paper! There has been any number of survey dings resulting from tissue paper either being blown or sucked in the wrong direction, based on whether a space is supposed to be positive or negative. And this lovely little finding has generated a fair amount of survey distress as it usually (I can’t say all, but I don’t know of this coming up in a survey in which the following did not occur) drives a follow-up visit from CMS as a Condition-level finding under Physical Environment/Infection Control.

The primary “requirements” in this regard reside under A-Tag 0726 and can be found below. Now I’m thinking that tissue paper might not be the most efficacious measure of pressure relationships, which (sort of—give me a little leeway here) begs the question of whether you should be prepared to “smoke” the doorway/window/etc. for which the tissue paper might not be as sensitive to the subtleties of pressures. I think it’s a reasonable thing to plan for—as much because there can be a whole lot at stake.  So, I’ll ask you to review the materials below and be prepared to discuss…

A-0726

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

Interpretive Guidelines §482.41(c)(4)

There must be proper ventilation in at least the following areas:

• Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;

• Locations where oxygen is transferred from one container to another;

• Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);

• Pharmaceutical preparation areas (hoods, cabinets, etc.); and

• Laboratory locations.

 

There must be adequate lighting in all the patient care areas, and food and medication preparation areas.

Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy.

The hospital must ensure that an appropriate number of refrigerators and/or heating devices are provided and ensure that food and pharmaceuticals are stored properly and in accordance with nationally accepted guidelines (food) and manufacturer’s recommendations (pharmaceuticals).

Survey Procedures §482.41(c)(4)

• Verify that all food and medication preparation areas are well lighted.

• Verify that the hospital is in compliance with ventilation requirements for patients with contagious airborne diseases, such as tuberculosis, patients receiving treatments with hazardous chemical, surgical areas, and other areas where hazardous materials are stored.

• Verify that food products are stored under appropriate conditions (e.g., time, temperature, packaging, location) based on a nationally-accepted source such as the United States Department of Agriculture, the Food and Drug Administration, or other nationally-recognized standard.

• Verify that pharmaceuticals are stored at temperatures recommended by the product manufacturer.

• Verify that each operating room has temperature and humidity control mechanisms.

• Review temperature and humidity tracking log(s) to ensure that appropriate temperature and humidity levels are maintained.

 

Kind of vague, yes indeedy do! Purposefully vague—all in the eye of the beholder. Lots of verification and ensuring work, if you ask me, but this should give you a sense of some of the things about which you might consider focusing a little extra attention.

Wait there’s more – three men in black said don’t report this…

So, we’ll start this week’s coverage with that pesky little Infection Control (IC) finding (yes, I do recall saying that I would make sense of this as a function of the EC/LS continuum):

Managing the risks of infections associated with medical equipment, devices, and supplies (#5 on the list of top-cited standards, with 39% of hospitals having been cited – IC.02.02.01)

This primarily has  to do with the various and sundry methods of disinfection that are used in the healthcare environment, from low-level disinfection (EP 1), which includes the presence of expired product (i.e., spray disinfectant, disinfectant wipes) to ensuring that staff are knowledgeable of how long they have to keep the surface wet in order to disinfect said surface. And that’s not just the folks in EVS, that’s everybody who wipes something down with a disinfectant. If the goal is to disinfect the surface (which is different than cleaning – cleaning doesn’t take as long), then everyone who uses the stuff has to know how long the surface has to stay wet.

The next component is the intermediate- and high-level disinfection and sterilization processes, particularly when it comes to the manual disinfection of medical equipment. We’ll be chatting about this more in the future, but (and I will eventually reiterate – but don’t I always?), if there are folks in your organization who are performing manual disinfection of patient care devices/instruments, most frequently using an OPA product – you need to make sure that the process has been evaluated  as a function of what is actually required by the manufacturer.  This is a very complicated process (with lots of steps to go awry), and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…did I say perfect? Indeed, I did!

You also have to make sure that you are properly disposing of medical equipment, devices, and supplies – which means it is vewwy vewwy important that everyone understands what constitutes medical waste – how bloody, etc. do things have to be before they go into the red bag.

Finally, this one deals with the storage of medical equipment, devices, and supplies. This could be any number of things, one of which is not particularly negotiable – outdated stuff – no real defense there. But it could also be any one of those bugaboos – storage under the sink, uncovered linen carts, cardboard, non-solid bottom shelves of storage carts, etc. If I’ve said this once, I’ve said it a million times – there are no (nationally promulgated – check your local listings for regulations near you) rules about these. Each of these is a case of self-determination on the basis of a risk assessment – each represents an infection control risk. Our obligation is to identify the most effective means of managing those risks.

So, as you can see, this is all stuff that fits ever so neatly into the EC world – always more to keep an eye on, don’t you know.

LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke (#7 on the top-cited list, with 36% of hospitals having been cited)

As the list of non-surprise issues continues, we find ourselves facing non-intact smoke barriers (Can you say “penetrations” again? Good!) and door issues. Hopefully, you all are starting to become familiar with the specifics (you’d better be); EP16 – 23 are providing the most compelling fodder for survey findings. Also, findings relative to the protection of hazardous areas – once again, door latching issues, doors that don’t self- or auto-close and latch (maybe because they’ve been wedged open or had a latch taped over), maybe the odd penetration – pretty basic stuff, all in all.

LS.02.01.35 – Fire extinguishing system requirements (#8 on the list, with 35% of hospitals having been cited)

Eighteen-inch storage leads the parade, but other things to keep an eye out for are:

  • Cabling and other materials draped over/attached to sprinkler piping (including the supports) – chances are you’ve got some of this somewhere in your building – it’s up to you to find it before TJC does.
  • Dust and/or other materials (including grease) on sprinkler heads – gunked-up sprinkler heads don’t work nearly as effectively as those that are pristine. By now, you (or your sprinkler contractor) should have a pretty good idea of which heads are susceptible to build-up of ca-ca.
  • Missing escutcheons – if we only knew where the blessed things went. It’s like some sort of black hole or extraterrestrial event – they disappear and we’re on the hook.

And look, we haven’t even quite finished with the top 10 yet , but rest assured…

Dry your eyes – but don’t dry those wipes!

A quick note of interest from the survey world –

A recent survey resulted in a hospital being cited under the Infection Control standards (IC.02.02.01 on low-level disinfection, to be exact). In two instances, someone had the temerity to forget to close the cover on a container of disinfectant wipes. Can you believe such risky behavior still exists in our 24/7 world of infection prevention? It’s true, my friend, it is true!

The finding went on to say that, as the appropriate disinfection of a surface depends on wet contact with the surface being disinfected, leaving the cover open would partially dry out the next wipe, impairing the ability of the wipe to properly disinfect the surface. Now, I suspect that the person to use that next wipe might somehow intuit that the moisture content in the wipe was not quite where it needed to be and maybe, just maybe, go to the lengths of (wait for it) – pulling out an additional wipe (or two, or three). Now my experience has been that sometimes those wipes are not what I would call particularly well-endowed in the moisture department. And  the use instructions for these products usually indicate that you should use as many wipes as it takes to ensure that the surface to be disinfected stays wet long enough for disinfection to occur.

I’ve always been a pretty big fan of the slowly-becoming-less common sense, so I’m not quite sure how we’ll be dealing with this one – thoughts, anyone?

Do you remember? Or even yesterday…

Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)

One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.

The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.

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.

All we are is dust in the…

One of the critical processes when one embarks upon a program of construction and/or renovation is the management of infection control risks, particularly if the work is to be done in, or adjacent to, occupied patient areas. Now, I’m sure that you are all more than familiar with the infection control risk assessment (ICRA) matrix (you can find one in HCPro’s Infection Prevention Policy and Procedure Manual for Hospitals as well as in a number of locations on the Web). One question I’ve encountered recently is not so much about the risk assessment piece itself, but rather how one determines the amount of oversight (including how frequently IC rounds would be done in construction areas, and who would be qualified to conduct those rounds, etc.) and operational considerations like waste removal (i.e., frequencies and methodologies), cleaning floors (i.e., frequencies and methodologies), what types of walk-off mats to use, and stuff like that.

Now, if we know anything about anything, we know that there is not generally a great deal of guidance when it comes to the specifics of these types of things. And by now, we also know that there’s going to be some sort of risk assessment when it comes to making those decisions. So, the question I put to you folks in the field, in the spirit of sharing: How are you working through these types of operational decisions? Have you done anything that worked really well? Anything that worked so poorly that you get hives just thinking about it? The ICRA will help us determine what we have to do. How then do we take the next step to effectively implementing those identified strategies?

I look forward to hearing from you all, even if it’s to ask pointed questions. Operators are standing by…call now!

Mac’s Safety Space: Transporting blood and urine samples

Q: A question about transporting blood and urine samples. Do the samples need to be in a biohazard bag when transported either by hand, on a cart, or via a tube system that can go both to the lab and the pharmacy?

Steve MacArthur: I think the simple response to your question is yes, based on the requirements in the Bloodborne Pathogens Standard. First off, we start with the section on specimens on OSHA’s website:

1910.1030(d)(2)(xiii)

Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

Now we could certainly discuss the merits of urine as a function of “other potentially infectious materials”, but in these days of Standard Precautions, the assumption we make is that it is presumed infectious until proven otherwise. We could also discuss the merits of the zip lock plastic bag as a function of leakage prevention, which will clearly depend on what the specimen is in; plastic would nominally be OK, while glass is probably a little less safe, depending on the method of transport, which would be another consideration.

So moving on to labeling, it seems pretty clear that some sort of unique identifier is in order and since the “standard” for that would be the biohazard symbol, I think we can safely identify that combination as the way to go.

1910.1030(d)(2)(xiii)(A)

The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility.

In the interest of full disclosure, I’m including the items under paragraph (g)(1)(i) below, just in case there is something than clicks with your particular situation:

1910.1030(g)(1)

Labels and Signs –

1910.1030(g)(1)(i)

Labels.

1910.1030(g)(1)(i)(A)

Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).

1910.1030(g)(1)(i)(B)

Labels required by this section shall include the following legend:






1910.1030(g)(1)(i)(C)

These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a contrasting color.

1910.1030(g)(1)(i)(D)

Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.

1910.1030(g)(1)(i)(E)

Red bags or red containers may be substituted for labels.

1910.1030(g)(1)(i)(F)

Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).

1910.1030(g)(1)(i)(G)

Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.

1910.1030(g)(1)(i)(H)

Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated.

1910.1030(g)(1)(i)(I)

Regulated waste that has been decontaminated need not be labeled or color-coded.

Hopefully, that helps answer your question; I think as long as you have something that is specifically identifiable to all who would be handling the specimens, you should be fine.

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.