RSSAll Entries Tagged With: "infection control"

A little mo’ from the Mighty O (ccupational Safety & Health Administration)

As they are wont to do, the folks at OSHA periodically issue safety alerts and it would seem that the ongoing challenges of managing the ongoing occupational health and safety aspects of COVID-19 is ripe for alerting. You can find the complete list of alerts on OSHA’s COVID-19 homepage.

Interestingly enough, OSHA has not (as of this writing) issued an alert specific to hospitals, but they did recently issue an alert aimed at nursing homes and long-term care facilities, the elements of which are, at the very least, instructive for other folks in the healthcare demographic; you can find the alert in its entirety here. I just wanted to plant a seed relative to a few of these:

  • Maintain at least 6 feet between workers, residents, and visitors, to the extent possible, including while workers perform their duties and during breaks.
  • Stagger break periods to avoid crowding in breakrooms.
  • Always follow good infection prevention and control practices. Consult OSHA’s COVID-19 guidance for healthcare workers and employers.
  • Provide handwashing facilities and alcohol-based hand sanitizer with at least 60% alcohol throughout facilities.
  • Regularly clean and disinfect shared equipment and frequently touched surfaces in resident rooms, staff work stations, and common areas.
  • Use hospital-grade cleaning chemicals approved by the Environmental Protection Agency (EPA) from List N or EPA-approved, hospital grade cleaning chemicals that have label claims against the coronavirus.
  • Ensure workers have and use any personal protective equipment (PPE) they need to perform their jobs safely.
  • Continually monitor PPE stocks, burn rate, and supply chains. Develop a process for decontamination and reuse of PPE, such as face shields and goggles, as appropriate. Follow CDC recommendations for optimization of PPE supplies.
  • Train workers about how to protect themselves and residents during the pandemic.
  • Encourage workers to report any safety and health concerns.

I don’t know that there’s anything on the list that doesn’t make sense, but I do think it might be useful/beneficial to keep an eye on these (and the other elements) to ensure you and your folks are not at elevated risk for exposure. Admittedly, there is still a lot we don’t know about the epidemiological aspects of COVID-19 and it may result in additional levels of guidance and/or protection (remember those halcyon days when masks were not required—seems like only months ago—oh, wait, I guess it was…). I also think it’s important to hear folks out if they voice frustrations with process, etc. A fair amount of this stuff is learning as we go—and making the best decisions we can based on the available information—in full recognition that being a leader in healthcare can mean having to put up with some unpleasant feedback. I think some folks in the field remain super concerned and super attentive to the decisions others are making on their behalf, so it’s important to keep things on an even keel.

Until next time, continue to stay safe—and keep rocking it!

Logic doesn’t always prevail…a luxury you can’t afford!

By my observations over time, I’ve found that, all-too-often, logic finishes a distant third behind self-interest (which sometimes manifests itself as crimes of convenience) and panic. Unfortunately, if you currently work in the healthcare industry, you must cling to the bastion of logic as those “other” winds threaten to pull you under.

But sometimes even bureaucracies manage to act judiciously; the good folks at the Centers for Medicare & Medicaid Services (CMS) have elected to curtail some of their “regular” survey activities to afford healthcare organizations the opportunity to focus on COVID-19 preparedness (you might want to bookmark the CMS FAQ page—they’ll be updating frequently). While this doesn’t mean CMS is going to halt all survey activity, it outlined how it would be prioritizing survey activities over the next little while:

Effective immediately, survey activity is limited to the following (in priority order):

  • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death or harm) and allegations of abuse and neglect
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
  • Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities)
  • Any revisits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy

While that does narrow down the field somewhat, those last two possibilities might be well-served by digging out any survey reports from the past couple of years to see if there are any IC-related issues lurking in the weeds.

According to the information provided to surveyors, the aim is to keep on-site survey time to no more than two days, with a particular focus on (you guessed it!) infection control, particularly as it relates to COVID-19 preparedness. You can see the meat and potatoes of the CMS memos to providers here:

https://www.cms.gov/files/document/qso-20-12-allpdf.pdf-1

https://www.cms.gov/files/document/qso-20-13-hospitalspdf.pdf-2

https://www.cms.gov/files/document/qso-20-14-nhpdf.pdf

As a final note for this week’s entertainment, our friends at ASHE have dedicated a webpage to provide COVID-19 information and resources; some of the materials require membership to access, but this is probably another page you’ll want to visit regularly as the next few weeks unfold.

If this isn’t a holdup, why are so many people wearing masks?

I suspect this is as much a confluence of any number of (seemingly/probably) unrelated elements, including a presidential election year in a certain North American nation, but it does seem to demonstrate, on a fairly significant scale, the power of fear to motivate folks to, and in some instances, past, the point of panic. There is no question that COVID-19 represents a significant turn of events in the epidemiological world and certainly has the potential to cause real havoc across the globe (I’ve always maintained that the bugs can evolve faster than we can). But it astonishes me the lengths to which folks will go to give in to their fears.

As I type this, I am sitting in an airport that serves a large area in the Northeast (euphemistically, the home of the New English), and I am quite taken aback by the number of folks wearing surgical masks for traveling. I will admit that I have not spent a lot of time recently (or, indeed, ever) watching the doom and gloom (or is it gloom and doom?) pronouncements of the various news organs—I tend to rely on the folks whose job/charge is to keep an eye on this type of stuff—folks like the CDC. I know that there are those for whom the CDC carries not much in the way of authority, but (being comprised primarily of human beings), perfection is the goal, but not necessarily the reality. But there are certain (to my mind) inescapably logical elements:

  • CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory diseases, including COVID-19.
  • Facemasks should be used by people who show symptoms of COVID-19 to help prevent the spread of the disease to others.
  • The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings (at home or in a healthcare facility).
  • Stay home except to get medical care.
  • Stay home: People who are mildly ill with COVID-19 are able to isolate at home during their illness. You should restrict activities outside your home, except for getting medical care.
  • Avoid public areas: Do not go to work, school, or public areas.
  • Avoid public transportation: Avoid using public transportation, ride-sharing, or taxis.

So, if you should only wear a mask if you are sick and if you are sick, you should stay home except to get medical care (a very reasonable chain of reasoning), then why am I seeing masks at the airport?

I do believe that everyone gets to make their own way in the world, at least to the degree that the impact of that “way” does not have a negative impact on everyone else’s “way.” But there are already reported shortages of supplies and it just seems to me that such actions are not (at least not yet) supported by the data. But there is something that can be done—and I’ve not seen enough of this CDC recommendation in action:

Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.

As I think about it, wearing a mask doesn’t absolve anyone of the responsibility to wash their hands, but hand hygiene numbers in the public sector are not nearly where they should be. Which leads me to this question: What’s the best way of shaming the hand-hygiene deficient? I’d love to hear any stories you might have.

Ground Control to Major Compliance: EOC, baby!

As September brings around the unwinding of summah, it also brings around The Joint Commission’s annual state of compliance sessions in locations across the country, better known as Executive Briefings. And, one of the cornerstone communications resulting from the Briefings is the current state of compliance as a function of which standards have proved to be most problematic from an individual findings standpoint.

Yet again (with one exception, more on that in a moment), EOC/Life Safety standards stand astride the Top 10 list like some mythical colossus (the Colossus of Chicago?), spreading fear in the hearts of all that behold its countenance (OK, maybe not so much fear as a nasty case of reflux…).

You can find the Top 5 most frequently cited standards across the various accreditation programs; you’ll have to check out the September issue of Perspectives for the bigger compliance picture, which I would encourage you to do.

At any rate, what this tells us is that (for the most part) the singular compliance items that are most likely to occur (for example, we’ve already discussed the loaded sprinkler head hiding somewhere in your facility—way back in April) are still the ones they are most likely to find. According to the data, of the 688 hospitals surveyed in the first six months of 2019, 91% of the hospitals surveyed (626 hospitals) were cited for issues with sprinkler/extinguishment equipment—and that, my friends, is a lot of sprinkler loading. I won’t bore you with the details (I think everyone recognizes where the likely imperfections “live” in any organization), but (at least to me) it still looks like the survey process works best as a means of generating findings, no matter how inconsequential they might be in relation to the general safety of any organization. I have no doubt that somewhere in the mix of the Top 10 list, there are safety issues of significance (that goes back to the “no perfect buildings” concept), particularly in older facilities in which mechanical systems, etc. are reaching the end of their service life—I always admired Disney for establishing a replacement schedule that resulted in implementation before they had to. It’s like buying a new car and having the old one still on the road: Are you going to replace the engine, knowing that the floor is going to rust through (and yes, I know that some of you would, but I mean in general)? But if the car dies on the way to the dealer to pick up the new one, you’re not going to do anything but tow it to the junkyard. But we can’t do that with hospitals and it’s usually such a battle to get funding/approval for funding/etc. that you can get “stuck” piecing something together in order to keep caring for your patients. It sure as heck is not an ideal situation, but it can (and does) happen. Maintaining the care environment is a thankless, unforgiving, and relentless pursuit—therein is a lot of satisfaction, but also lots of antacid…

One interesting shift (and I think we’ve been wondering when it would happen) is the appearance of a second infection control (IC) standard, which deals with implementation of an organization’s IC plan. I personally have always counted the IC findings relating to the storage, disinfection, etc. of equipment as being an EOC standard in all but name, but I think we may (finally) be seeing the shift to how appropriately organizations are managing infection risks. According to Perspectives, 64% of the hospitals surveyed in the first six months of 2019 were cited for issues relating to implementation, but not sure how the details are skewing. Certainly, to at least some degree, implementation is “walking the talk,” so it may relate to the effectiveness of rounding, etc. Or, it may relate to practice observed at point-of-care/point-of-service. I think we can agree that nosocomial infections are something to avoid and perhaps this is where that focus begins—but it all happens (or doesn’t) in the environment, so don’t think for an instant that findings in the environment/Life Safety will go gentle into that good night. I think we’re here for the long haul…

Reusables vs. single-use: The next round in the World Series of Risk Assessments?

As summer starts its (hopefully) gradual fade into the record books and the marathon of the baseball season starts its kick to the finish line, it seems that we are (yet again) faced with some guidance from the federales that I think will be best served by having a risk assessment in your back pocket.

Over the past few years (truly, more than a few, but we can focus on the most recent past), there has been a lot of scrutiny regarding the management of endoscopes, including how much of a role clinical engineering might play in managing the scopes as devices, how to ensure effective processing of the scopes once they have been used, etc. And just the other day, I encountered an article discussing the FDA’s recommendation to begin transitioning to scopes with disposable parts, nominally to ensure the efficacy of the post-use processing process (don’t you just love a processing process!). You can find the meat and potatoes of the FDA’s recommendation here. I’d encourage you to read this very carefully as there is mention of process elements, such as the use of adenosine triphosphate (ATP) test strips to assess scope cleaning—a use that is not currently sanctioned by FDA—to the point that the FDA is asking facilities not to rely on the ATP test strips to assess scope cleaning. There’s some other stuff that is worth consideration, so (again), please check it out.

The recommendation does indicate (and, to a certain extent, provides for) a period of transition to the disposable scopes, but now that the proverbial horse is out of the barn, I think it is only a matter of time before our friends in the various accreditation organizations start digging into the transition process as a function of patient safety (I don’t think there’s any among us that would dispute this as a patient safety concern), particularly as to how we are keeping folks safe during the transition period. And how do we typically provide evidence of the process for mitigating risks? Why, it’s our old(er) friend the risk assessment process. I think it is crystal clear that this serves as yet another example of the collaborative process between infection control, clinical engineering, perioperative services—and I encourage you to make good use of the risk assessment process. Even more so, if you are scheduled for an accreditation survey any time in the next 12-18 months (until the use of single-use scope technology is more pervasive), I would get this on your to-do schedule as soon as possible. As with so many things, you may have lots of data to support that your existing procedures, etc., are not putting anyone at risk, but (as these things tend to devolve) we’ve already seen how a really (and I mean really, really) small incidence rate (that of risk de ligature) drive a veritable cornucopia of significantly painful survey findings. And there’s every reason to include this in the list of contenders for the next heavy duty survey focus area.

Like water for opportunistic organisms: Protecting patients through utility systems

As a wise individual once noted, “water always wins” (at risk of betraying my nerd status, you can find the entire quote here), and it seems like water in its numerous forms is giving facilities professionals a run for their money this year. From mold in an OR in the Northwest to the constant battle (or so it seems) with Legionella prevention, this is as challenging a time as I can recall for facilities. And that doesn’t even take into account the ongoing impact of minor intrusions—leaks, condensation, overflowing toilets—it is an almost endless list of troubles.

My intent was to provide the above as information, with my usual encouragement to leverage point-of-care/point-of-service staff in the early identification of trouble spots, but I’m also thinking that perhaps someone out there in the field has been able to develop an effective plan for the proactive management of water woes. Certainly, I know of folks with fairly predictable “rainy seasons” and then there are those locations in which rain is a constant threat, not to mention the intrusion of humidity by various (and sometimes nefarious) means. So, what do you do that works (recognizing that this is not a one size fits all proposition)? Do you have any useful/effective strategies you can share with the blogosphere? I generally only hear about stuff that doesn’t work, so it would be a treat indeed to tout someone’s intuitive brilliance.

As a final note for this week, those of your laboring under the yoke of TJC accreditation might do well to give the August issue of Perspectives a look (it’s become less of a regularly useful read for me, but every once in a while). In the Consistent Interpretation column/article, there’s a lot of discussion (under the guise of the Infection Control standards) of PPE use/availability/education, etc. Again, the findings are falling under the IC standards from a past survey result standpoint, but I don’t think it’s a stretch for some (or almost any) of these to be applied as Hazardous Materials & Wastes Management findings. Again, not everything applies, but I think if we’ve learned nothing else over the years, it’s the funky application of survey concepts from one are of scrutiny to another. Stranger things have happened…

Try to keep things cool over the second half of the summer!

Walking in the shadow of the big man: CMS isn’t done with emergency preparedness

Imagine that!

The turn of February brought with it the latest epistle from our friends at CMS as they continue to noodle on the preparedness of the nation’s hospitals. I don’t know that this represents a ton of hardship for folks and I do know, for at least some folks, the latest directive is fairly straightforward as a function of their emergency preparedness programs, activities, etc. As we’ve discussed once or twice over the years (decades?!?), emergency preparedness is a journey, it is not a destination. And while we do have the opportunity to plot our own course on this, it seems that the regulatory oversight piece will never be very far away.

So, the first piece of this (you can find the whole missive here) is the pronouncement that planning for using an all-hazards approach to emergency management (and who isn’t?!?) should also include consideration of emerging infectious disease (EID: Influenza, Ebola, Zika, etc.) threats. The guidance goes on to indicate that planning for EIDs “may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective measures.” I think my immediate inclination would be to include EID threats as a separate line item for your HVA (my fear being if you integrate things too well into your existing, then you’ll be that much harder-pressed to “pull out” the EID portion of your organizational analysis). And/or if you combine all the IC stuff into one, then you might make changes to your plan to address the higher-risk stuff and create some operational challenges for your “normal” stuff. It’s early in the game on this one, so we’ll see how the process matures.

Next up we have some discussion relative to the use of portable/mobile generators as part of our emergency preparedness activities. It would seem that a lot of folks reached out to CMS to see if they were going to have to replace portable/mobile generators with the typical generator equipment found in hospitals, and (hooray!) the answer to that question is no, you don’t have to: unless your risk assessment indicates that you should. Apparently, there were other questions relating to the care and feeding of portable/mobile generators and the ruling on the field is that you would have to maintain them in accordance with NFPA 70 (and, presumably, the manufacturers’ IFUs), which includes:

  • Have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3.
  • Be designed and located to minimize the hazards that might cause complete failure due to flooding, fires, icing, and vandalism.
  • Be located so that adequate ventilation is provided.
  • Be located or protected so that sparks cannot reach adjacent combustible material.
  • Be operated, tested and maintained in accordance with manufacturer, local and/or state requirements.

It also mentions that extension cords and other temporary wiring devices may not be used with the portable generators, so make sure that you have those ducks in a row.

There are a few more things to cover, but I think those can wait until next week. See you then!

It’s been a quiet week in Lake Hazard-be-gone: Water and Legionella

Not a ton of “hair on fire” stuff in the news this week, so (yet again), a quick perusal of something from the “things to consider” queue.

It seems likely that Legionella and the management of water systems is going to continue to have the potential for becoming a real hot-button issue. I suppose any time that CMS issues any sort of declarative guidance, it moves things in a (potentially) direction of vulnerability for healthcare organizations. That said, it might be worth picking up the updated legionellosis standard from ASHRAE to keep up with the current strategies, etc. I don’t know that there’s any likelihood of eradication of Legionella in the general community (by the way—and I’m sure this is the case, but it never hurts to reiterate—those of you with responsibilities for long-term care facilities are definitely in a bracket of higher vulnerability). But there remains a fair amount of risk in the community, as evidenced by the most recent slate of outbreaks. Water is definitely the common denominator, but beyond that, this can happen anywhere at any time, so vigilance is always the end game when it comes to preventive measures.

As a final thought for the week, I wanted to share a blog item (not mine) that I found very interesting as food for thought (the concept is very powerful, though you may have a tough time convincing your boss to embrace it, as I think you’ll see): treating failure like a scientist. You can find the whole post here, but the short take is that you may have a positive or a negative result of whatever strategy you might employ—each of which should be considered data points upon which you can make further adjustments. Not everything works the way you thought it would, but rather discarding something outright if it doesn’t succeed, try to figure out the lesson behind the failure to make a better choice/strategy/etc. moving forward. The blog covers things more elegantly than I did here, but I guess my closing thought would be to have the courage (maybe “luxury” is the better term) to really learn from your mistakes—if we were perfect, there would never be a need for improvement.

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

I got those travelin’ code compliance blues…

One occupational hazard (or probably more correctly an occupational preoccupation) I find is a constant awareness of code violations wherever I go. It seems that there are an awful lot of airports, concert venues, and the like that are engaged in upgrading facilities, and often, there are plenty of opportunities to look up into the areas above the ceiling envelope. Now I absolutely understand why healthcare gets a lot of scrutiny relative to concerns of life (and general) safety—far too many folks incapable of self-preservation to put them at risk. But as I wander around looking at stuff, I’m thinking we’re dealing with a whole mess of folks (euphemistically called passengers) in almost a collective daze, mesmerized by their cell phones, etc., who would be difficult to manage in the event of an emergency (I also have no doubt that the folks in charge in these various venues have already considered this and have plans in place).

At any rate, just this morning, I was privy to a number of open junction boxes, cabling attached to sprinkler piping, the odd penetration (don’t have the life safety drawings to hand, so I can’t say), in areas just outside of the main construction zone(s)—and no, I didn’t see a posted infection control risk assessment, but it does make one wonder whether it might not be such a bad thing. Presumably things are well-isolated from an HVAC standpoint, though certainly less so from a noise standpoint, but the whole thing does periodically give one (or at least gives me) pause. It is generally acknowledged that healthcare is a heavily regulated industry, and while I think we could certainly engage in extensive debate about the prioritization of risk when it comes to some of the minor imperfections that have become so much a part of the typical survey report, I don’t know that I would alter the accreditation process (which is kind of self-serving as helping folks manage the process is how I make a living).

In the end, this probably a little ado about nothing, but sometimes one is charged with channeling one’s inner curmudgeon…

One item as we close out this week, Health Facilities Management is soliciting input on the operational challenges relating to various monthly inspection and testing items (exit signs, elevator recall) as a function of (more or less) “if you already have a reduced resource pool with which to work, how are you going to manage these.” Check out an article discussing this in general, which includes links to the surveys for each area of consideration. ASHE has been a very effective advocate over time when it comes to compliance activities, so I think it would be good to make your voice heard.