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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.

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

IFU? No, you IFU!

As this little screed represents the closing of the 2015 blogging season (I figure there’s gotta be a lumberjack tie-in—blogging and logging are just too close for words), I’m going to try and keep it relatively brief. If brevity is indeed the soul of wit, then I tend to be rather more witless than not…

Another recent trend in survey findings relates to the management of some of your more “peripheral” patient care equipment, particularly the stuff that gets used by the good folks in the rehabilitation/physical therapy world: hydrocollators, paraffin baths, etc. While I do believe that we have things well in hand from a medical equipment standpoint (most of the equipment being cited falls very clearly into the low-risk/no-risk category), where this is skidding a bit sideways is when the devices in question are not being maintained by the end users in accordance with the manufacturer Instructions For Use (IFU). Now, I will freely indicate that some of the equipment we’re talking about is almost Biblically ancient and the IFUs might not be easily obtainable, but in the absence of a risk assessment to indicate that maintaining this stuff in a manner that is not in strict accordance with the IFUs results in an acceptable level of operational performance/reliability/cleanliness, etc. then you’re at risk for yet another of the (seems like) gazillion little imperfections that are gracing survey reports across the continuum. Interestingly enough, these findings do seem to be “clumping” under the Infection Control standards (pretty much IC.02.02.01, EP 4, which deals with the storage of supplies and equipment), so this may not be on everyone’s radar at the moment. That said, it might be a good idea to poke around a little bit—including any offsite rehab/PT locations—to see if you have any survey risk exposure. Once again, I’m not convinced that this represents a significant risk to patients, but my being convinced (or not) doesn’t necessarily keep you out of trouble during survey. We need to be very sure about where we “stand” in relation to what manufacturers are recommending and what practices and conditions provide appropriate levels of safety, cleanliness, etc. The Joint Commission doesn’t tell us how to do these things, but we need to be able to respond definitively when the questions are (and there is a certain inevitability here) raised during survey.

And on that note, I wish each and every one of you a most prosperous, safe, and successful 2016. See you next year!

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!

Same as it ever was… same as it ever was… same as it ever was…

As the back-to-school sales reach their penultimate conclusion, I look back on the year so far and am amazed at how quickly we’ve blown through fully two-thirds of 2015—yow! For a while it seemed like winter was never going to release us from its icy grasp and now we’re looking forward to its return, so I guess we have naught to do but look forward towards the onslaught of 2016. I hope, for all our sakes, it is a kinder and gentler new year.

But before the past little while takes on the rosy hue of nostalgia (as it almost always does), our friends in Chicago have provided an excellent opportunity to reflect on the “sins” of the past by revealing the most frequently cited standards during the first six months of 2015. And to almost no one’s surprise, four out of the top five most frequently cited standards (at the moment, the “reveal” is only for the top five—I guess we’ll find out about the rest of the top 10 at some point) are smack dab in the middle of the management of the physical environment, with the top three most frequently cited standards for hospitals being EC.02.06.01 (#1 with 59% of hospitals surveyed being cited), IC.02.02.01 (#2 and 54%) and EC.02.05.01 (#3 and 53%; looks like a real fight for that #2 spot), all of which reflect elements tying together the management of the physical environment with the control and prevention of infection (not everything cited is in the physical environment/infection control bucket, but from what I can gather, rather a fair amount is related to just that).

At this point (and I full recognize that this is a rather reiterative statement), I’m going to crawl out on a limb and say that the single greatest survey vulnerability for any (and every) healthcare organization is the management of the surgical/procedural/support environments. The hegemony of this aspect of the survey (and regulatory compliance) process comes very close to defying understanding. At this point, there’s no real surprise that this is an (if not the, and I would argue “the” is the word) area of intense survey scrutiny, so what’s the deal?!? Forty percent of the hospitals surveyed from January to June appear to have done okay on this, or is that number really a red herring? It would not surprise me that 100% of the hospitals surveyed ran afoul of one of the top three. Anybody out there surveyed so far this year that managed to escape, relatively, scott-free on this?

I’ve certainly done a lot of yammering in this regard over the past few months (years?) and it appears that I am raging against the dying of the light to minimal effect. I have a lot of ideas about this, but I guess I’m putting it out there: has anybody really got this under control? I think we all have a stake in this thing and the sooner we can get our hands on an effective process for managing this, the better. I will admit that it is entirely possible that, particularly given the age of a lot of hospital infrastructure components, this is not going to go away until they stop focusing as much on it. At this point, I haven’t run into too many folks that have been cited under the big three for whom infection rates are anything other than what would normally be expected—though perhaps infection control rates are higher than they “should/can” be—I guess we could be in the midst of a paradigm shift on this. I don’t want to have to wait to find out.

Letting the days go by…

On top of ol’ yellow top

As it happens, I like to share topics and concerns that I encounter while engaged in consulting activities in many of the nooks and crannies of these United States, and I’ve recently run into a common theme that I think warrants your consideration, if not action (though it may ultimately come to just that). But it does appear that this particular vulnerability has reared its shaggy head because of an improving condition relative to infection control concerns—I guess there really is a dark cloud to go with every silver lining.

Over the years, hospitals have been struggling with the management of Clostridium difficile, a very pesky germ typically identified by its street name: C. diff. And one of the key struggles therein revolves around the cleaning of the environment of patients with C. diff, for which the CDC recommends the use of an EPA-approved spore-killing disinfectant in rooms where C. diff patients are treated. And one of the more common (probably most common, but I can’t say that I’ve collected a ton of data in this regard, so this is merely an impression; feel free to validate or not) products used is one euphemistically known as the “yellow top” disinfectant wipes (I’m sure you’ve seen them, but if you’re not sure, you can find images, etc., here).

At any rate, over the past couple of weeks, I have run into a fair number of expired containers of these disinfectant wipes, enough so that it really kind of jumped out at me (and this has been the case in different parts of the country: north, south, east, and west). Inevitably, when one finds a confluence of vulnerabilities, it tends to become a topic of conversation at the various organizations in which the expired products were found (it’s always nice to be able to make some sort of determination relative to a root cause). And the results of those conversations of late leads me to the (completely unscientific) conclusion that hospitals and other healthcare organizations appear to be making some inroads in the management of C. diff patients, resulting in a reduced need for this particular product (uniformly, this product has been earmarked solely for use in cleaning C. diff patient environments, and not much else). Hence, the increased number of expired containers of this product.

So, good news on the management of C. diff patients and their environment, and the identification of an opportunity relative to the management of product expirations. I suppose you could make the case that it is ever thus when it comes to the management of conditions in the physical environment, but if your organization is using this particular product (or, I suppose, whichever disinfectant wipes you’re using for C. diff patients), you may want to issue an APB to ensure that folks are keeping an eye on those expiration dates. Yes, I know that they are, but this could legitimately be described as a recent development…just trying to keep you ahead of the curve.

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).

Mounting hooks upon which physicians might hang their white coats

Touching back with the topic of healthcare worker attire increasing the potential for cross-transmission of bacteria during the working day, one of the recommendations that the Society for Healthcare Epidemiology of America (SHEA) made in its Healthcare Personnel Attire in Non-Operating-Room Settings guidance document is in regards to the continued use of white coats for professional appearances (I suspect it may be a while before the culture shifts sufficiently away from the vision of the kindly physician in the white coat). And that recommendation may very well set some teeth grinding for hospital facilities folks: “Facilities should provide coat hooks for clinicians to hang their coats up before patient contact.”

Coat hooks… isn’t that grand!?! Now I suspect that many, if not most of you, can recall those heady days when hand sanitizer dispensers first graced our facilities and how easy it was (and that little phrase can’t drip with enough irony) to figure out where those little buggers should be installed. I suspect that we’re looking at a similar cluster of decisions if this recommendation gains traction. When I first read this recommendation, I conjured up this image of a hospital corridor with rows of white coats hanging outside the patient rooms. In the Boston vernacular, that would look “pissah!” I don’t think you’ll be able to install the hooks in the room, because what would you do if it’s a precaution patient? I’m getting heartburn just thinking about it. Those of you with alcove spaces outside of your patient rooms should be okay (and may already have provisions for this), but, as we know, alcoves don’t generate a heck of a lot of revenue and so are frequently abandoned during design phases. No doubt the “hospital of the future” will have accommodations for this, but the “hospital of the now” might not be so fortunate.

Shirts and skins

In a recent edition of Infection Control and Hospital Epidemiology, the Society for Healthcare Epidemiology for America (SHEA) published an expert guidance document exploring the effect healthcare worker clothing has in the cross-transmission of pathogens. The document, titled Healthcare Personnel Attire in Non-Operating-Room Settings uses existing medical literature, perceptions of healthcare worker attire from patients and clinicians, evidence for contamination of attire and potential cross-contamination, hospitals policies and some survey information from SHEA members, with the intent being to learn about how clinicians balance their professional appearance and traditional attire with the prevention of pathogen transmission. The long and short of it is that there are a number of garment items—the ubiquitous white lab coat, neckties, and footwear—that can become contaminated with bacteria during the course of clinical care. Pretty much anything a clinician might be wearing could come into contact with bacteria, etc. during the course of patient rounding and other such activities—all surfaces, that at least as a function of an active work day in a hospital, are pretty difficult to clean/disinfect as you go. Sleeves of lab coats, the fronts of scrubs if you lean in to examine a patient (routine exams; precaution patients are already provided for in this regard), etc. all represent an opportunity for bacteria to transfer to those surfaces.

I can certainly see the legitimacy of the thought and can also see how this could be a contributing factor in the pervasiveness of healthcare-acquired infections, so it will be interesting to see what follow-up studies indicate as better practices. I guess base skin is the easiest “surface” to clean/disinfect as you go, though I somehow don’t think that tank tops will ever be adopted as professional garb. Maybe in the tropics…

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!