briefings on hospital safety - hcpro.com · blood or other potentially infectious materials. ......

The terms handwashing, handhygiene, and hand gel perhapsmuddied the field on how exactlyhospitals workers should protectthemselves from infections. Afterall, clinicians, housekeepers, andothers just want to stay healthywhile caring for patients.

But some confusion arose whenthe Centers for Disease Controland Prevention (CDC) released itsrevised hand hygiene guidelinesin October 2002, which pushedthe idea of using antiseptic, alco-hol-based gels to wash hands inmany situations rather than con-

stant scrubbing with soap andwater.

At least a few hospitals expressedconcern that the CDC guidelinesconflicted with the OccupationalSafety and Health Administration’s(OSHA) bloodborne pathogens stan-dard (1910.1030), which mandateswashing hands with soap and wateras an important way to limit bloodexposures.

More guidance comingIn this case, the answers seem tolie in the nuances of how soiled aworker’s hands are.

—INSIDE—

Vol. 11 No. 3March 2003

In just a few weeks, all accreditedhospitals will need to comply withthe 2000 version of the Life SafetyCode (LSC).

In preparation for the changeoverdate of March 1, the Joint Commis-sion on Accreditation of HealthcareOrganizations (JCAHO) released itsupdated Statement of Conditions(SOC) online.

Remember, hospitals need to com-plete an SOC as a means of demon-strating compliance with the LSC.

Infection control

Safety committees will helpshoulder added pressurefrom the Joint Commissionwhen it comes to infectioncontrol in 2003. See p. 3.

Disaster planning

Technological problemsmight bring disaster traininginto a completely new lightfor many of you. See p. 7.

Top 10 list

This chart looks at the Occupational Safety andHealth Administration’s most frequent citations inmedical and surgical hospitals. See p. 9.

Tip of the month

Here are some more strategies to help you betterprepare your security officers for handling patientviolence. See p. 12.

Enclosed

With your issue is a 16-pagespecial report that looks atsafety and accreditation concerns in the respiratorycare department.

> p. 2

OSHA: Handwashing requirementsdon’t clash with antiseptic gel optionsFormal interpretation is in the works

BRIEFINGS on HOSPITAL SAFETYBRIEFINGS on HOSPITAL SAFETYThe Newsletter for Hospital Safety Committees

Grab the 2000 LSC and don’t let goHow the new edition fits into the SOC

A chapter shakeupThe revised SOC features the latestLSC references, most notably theswitch of the health care require-ments to Chapters 18–21. Unlessyou’re a whiz at remembering spe-cific references, it’s a good idea toprint a copy of the newer SOC.

“The chapters all changed and thenumbering system changed in the2000 edition of the LSC,” says DeanSamet, CHSP, associate director in the JCAHO’s department of standards.

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978/750-8400. > p. 4

section d(2), employers must provide hand-washing facilities, or, if such facilities aren’tavailable, provide antiseptic hand cleansers.Employees must wash their hands as soon aspossible after using antiseptic cleansers andafter their gloved hands come in contact withblood or other potentially infectious materials.

• OSHA’s upcoming interpretation letter—Workers should continue to wash with soapand water if their gloved hands come in con-tact with blood or other potentially infectiousmaterials. Antiseptic hand gels are an appro-priate option for cleaning in other cases.

Briefings on Hospital Safety—March 2003© 2003 HCPro, Inc.

www.healthsafetyinfo.com

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

As a result, OSHA plans to publish a new interpreta-tion letter to clear things up, says Amber Hogan,MPH, an industrial hygienist in the agency’s office ofhealth enforcement and the author of the upcomingletter.

The letter will likely state that when a health careworker’s gloved hands are visibly soiled with bloodor other potentially infectious body fluids, the em-ployee should wash his or her hands with soap andwater.

Otherwise, antiseptic gels are acceptable as a clean-ing choice, Hogan says.

Don’t stop the pressesThis information isn’t really a revelation as much asa clarification. The CDC’s guidelines clearly recom-mend that workers shouldn’t use antiseptic gels iftheir hands are noticeably contaminated with bloodor other body fluids.

And OSHA’s bloodborne standard mandates soapand water only if one’s hands are clearly soiled,

“which gels with the CDC guidelines,” Hogan says.

If there is no visible contamination, the handwashingprovisions of the bloodborne standard don’t kick in,which allows hospital workers to use hand gels whilestaying clear of any regulatory problems.

The bloodborne standard assumes workers havegloves on their hands as part of required universalprecautions. The regulation also mentions antisepticgels as a secondary option if handwashing sinks aren’timmediately available—but again, this language re-volves around visible blood on gloved hands, whichin all cases should result in washing with soap andwater as soon as possible.

As an interesting side note, the bloodborne patho-gens standard requires hospitals to use the most cur-rent U.S. Public Health Services guidelines, regardlessof the standard’s revision date.

That puts the onus on hospitals to observe the latestCDC guidelines and also allows OSHA in some senseto enforce those recommendations, Hogan says.

Handwashing < p. 1

What the regulators say

Here’s a quick look at hand hygiene requirementsfrom the Occupational Safety and Health Admin-istration (OSHA) and the Centers for DiseaseControl and Prevention (CDC):

• Guideline for hand hygiene in health caresettings—The CDC recommends that healthcare workers use an alcohol-based hand rubfor routinely cleaning their hands if they aren’tvisibly soiled. When hands are visibly contam-inated, workers should wash them with soapand water.

• Bloodborne pathogens standard—Under

Briefings on Hospital Safety—March 2003 © 2003 HCPro, Inc.



New JCAHO messages in 2003

Less infections and forced forms, please

Safety committees will helpshoulder added pressure from the Joint Commis-sion on Accreditation of Healthcare Organizations(JCAHO) when it comes to infection control (IC).

IC will be a big focus for 2003 and beyond, asproven with the recent Sentinel Event Alert on hos-pital-acquired infections and information stressedto surveyors during the JCAHO’s annual trainingconference held January 2–6 in Chicago.

The JCAHO asked surveyors toexamine hospital-acquired in-fection rates, says a source closeto the accreditor. In a new twist,surveyors will look at evidence-based practices to improve onIC.

So get ready to network andresearch proven best practices, and to show surveyors how adopting them helps reduce infections.

It’s in your hands nowExpect the JCAHO to look at infection solutions inpatient care areas, laboratories, linen storage, foodservice units, employee health areas, and anesthetiz-ing locations, says Steven Bryant, practice directorof accreditation services for The Greeley Companyin Marblehead, MA. Greeley is a division of HCPro,Inc., the publisher of BHS.

Further, the Sentinel Event Alert recommends thathospitals adopt the revised hand hygiene guide-lines from the Centers for Disease Control andPrevention, which include provisions for usingalcohol-based hand gels.

“You want to have a heightened awareness ofhand hygiene,” Bryant says. To read the Alert

online, go to www.jcaho.org, scroll down to the“Latest Newsletters” heading, and click on “Sen-tinel Event Alert.”

Whose form is that, anyway? Here’s something that might perk your interest:Effective immediately, surveyors can’t give youtheir own forms to fill out, the JCAHO observersays.

For example, surveyors oftendevelop their own checkliststhat show maintenance datesfor a facilities director to betterexplain what he or she does.

Or a surveyor will ask a phar-macist to fill out a form on nar-cotics with an additional recordreview that is not always appro-

priate, the observer adds.

Surveyors can still require you to complete an of-ficial JCAHO form, and they may also hand outtheir own forms as examples.

The move is good news for hospitals since staffmembers won’t have to do extra “homework” re-lated to these unofficial forms.

Some surveyors, on the other hand, won’t be asthrilled.

“Surveyors love those forms,” the observer says.“But the homework assignments shouldn’t be apart of the survey.”

If a surveyor hands you a non-JCAHO form to fillout, you can say no, the observer says. “This willmake a lot of people happy, since it has beenfrustrating,” he says.

“You want to have a heightened

awareness of hand hygiene.”

—Steven Bryant, The Greeley Company




2000 LSC < p. 1

“So the numbers are now different in the SOC, butthe content itself—the meat, shall we say—of theCode requirements is overall unchanged for all in-tents and purposes for health care occupancies,” hesays.

You don’t have to chuck your old copy of the SOC;the JCAHO will still accept it if it is accurate and upto date, Samet says.

He adds that hospitals should complete a new ver-sion of the SOC under either of the following twoconditions:

• They want to reconfirm that their buildings complywith 2000 LSC requirements

• They build a new addition or perform a major renovation where related construction documentsreceived approval after March 1, typically fromstate authorities

Breaking it down Let’s look at some specific changes between the1997 and 2000 editions of the LSC and where thoserequirements show up in the revised SOC under Part3A (existing hospitals). The following list isn’t all-inclusive:

• Question 1F in the SOC requires Class A or Binterior finish of walls and ceilings (Class A fornew finish installed after January 1, 2003).

This provision refers to 19.3.3.2 in the LSC, whichfeatures a slightly reworded exception that allowshospitals to use Class C interior finish in rooms pro-tected by sprinklers, as long as the walls and ceilingsmeet the proper separation requirements elsewherein the LSC.

• Question 2A requires corridor walls to have a fireresistance rating of at least half an hour in compli-ance with 19.3.6.2.1. An exception to that LSC pro-vision allows the walls to be non-rated in smokecompartments protected by sprinklers, as long asthe ceiling limits the transfer of smoke.

New annex material to this exception in the LSC fur-ther explains what characteristics should be in such aceiling, and hopefully this will appease authoritieswith differing opinions on the issue, says consultantDouglas Erickson, a member of the LSC’s technicalcommittee on health care, who spoke during the Na-tional Fire Protection Association’s conference inAtlanta in November 2002.

• Question 2I states corridor doors should haveundercut clearances of 1 in or less. This is a newprovision to the LSC (see 19.3.6.3.1), though theJCAHO has recognized the 1 in limit for some time.

In the past, the Joint Commission went with the ideaof an average 1 in undercut, rather than set that fig-ure as a maximum. The JCAHO will look at this situ-ation on a case-by-case basis nowadays, Samet says.

Also, Question 2I requires corridor doors to have

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positive latching, meaning that someone must turn aknob or lever to open it. This refers to 19.3.6.3.2,which ideally intends for hospitals to have positivelatches on doors.

That paragraph prohibits roller latches on corridordoors in buildings not protected by sprinklers, thoughexception 2 states that existing roller latches mayremain if they withstand a specific force applied tothem. A roller latch is a device that keeps a door closedthat a person can release by pushing or pulling onthe door, as opposed to turning a knob.

The LSC doesn’t want new roller latches installed,though a reworded annex note to this paragraph saysthat repair or maintenance of roller latches doesn’tcount as a new installment.

By the way, existing roller latches became a stickingpoint in the Centers for Medicare & Medicaid Services’(CMS) adoption of the 2000 LSC. See the story on p. 6 for more on that situation.

On another related note, though it’s not specificallyreferenced in the SOC, paragraph 19.3.6.3.3 nowallows hold-open devices on corridor doors as longas they release when someone pushes or pulls them.Friction and magnetic catches are two ways to meetthis provision.

• Question 4B lists requirements for linen andtrash chutes. This question now points to theentire section of 19.5.4 in the LSC, rather thanspecific paragraphs of that section, though therequirements from the JCAHO haven’t changed.

• Question 5B requires exit corridors to be at least4 ft wide in existing hospitals, which traces backto 19.2.3.3. This paragraph of the LSC also talksabout unobstructed corridor width, and newannex material expounds on this idea.

The LSC doesn’t intend for corridors to be clear at alltimes, specifically mentioning cases when workersbring in items such as gurneys or crash carts, the an-nex states. Such practices are acceptable as long asstaff members don’t store these items in a corridor.

• Question 5J requires doors to remain unlocked

in the means of egress.

The corresponding LSC reference is 19.2.2.2.4, whichcontains a slightly reworded exception that allowsdoor-locking without delayed egress when the clinicalneeds of patients justify it. In such cases, staff mem-bers must be able to unlock the doors at all times.

Now for new constructionNew health care facilities complete Part 3B of theSOC, which reflects requirements for new construc-tion in the LSC.

Changes in Part 3B are similar to Part 3A in the re-vised version, but not exactly th same in all cases.The following questions under 3B received the samerevisions as their counterparts in 3A:

• Question 2A (though the annex material for newhealth care falls under A.18.3.6.2)

• Question 2I (just the undercut clearance provision;new construction can’t use the roller latch excep-tion noted above under Part 3A)

• Use of hold-open devices on corridor doors under18.3.6.3.3

• Question 4B• Question 5B• Question 5K, which is question 5J under Part 3A

Where can I find the new SOC?In its environment of care standards (EC), theJoint Commission on Accreditation of HealthcareOrganizations will require compliance with the2000 Life Safety Code (LSC) on March 1.

This requirement comes under EC.1.5.1, whichrequires hospitals to complete a Statement ofConditions (SOC) as a way to demonstrate LSCcompliance. A revised SOC that references thelatest LSC chapter numbers is available nowonline and will go into effect March 1 as well.

Go to www.jcaho.org/accredited+organizations/hospitals/index.htm to download the new SOC.You may also call the Joint Commission to re-quest a copy at 630/792-5811.




2000 Life Safety Code

CMS adoption should ease validation surveys

Now that the Centers for Medicare & Medicaid Serv-ices (CMS) finally adopted the 2000 Life Safety Code(LSC), what does it mean for hospitals?

If your facility doesn’t hold accreditation from theJoint Commission on Accreditation of Healthcare Or-ganizations (JCAHO) and instead relies on CMS orstate inspections for Medicare funding, the changewill be significant. That’s because CMS used the 1985edition of the LSC, and the Code evolved greatly inthe ensuing years.

But for many of you who do re-ceive accreditation, dealing with anoccasional Medicare validation sur-vey is a more likely scenario.

In the past, despite the JCAHO sur-veying your hospital with the 1997LSC, CMS inspectors reviewed you on a different setof fire safety requirements from the 1985 edition dur-ing a validation survey.

The Federal Register published the CMS adoption onJanuary 10. To read it, go to www.access.gpo.gov/su_docs/fedreg/a030110c.html and scroll down tothe CMS heading.

Late summer timeframeThe effective date for the adoption is March 11, thoughCMS inspectors won’t begin enforcing it until Sep-tember 11. Hospitals don’t need to comply with twoparticular sections of the adoption until 2006.

A big difference between CMS and JCAHO visits isthat the Joint Commission’s building tour centersaround the seven environment of care plans, whileCMS inspectors focus heavily on LSC issues such ascompartments and separations.

In past visits, some facilities faced tens of thousandsof dollars in repairs and retrofits after CMS departed.

With both regulators set to use the 2000 LSC in 2003,it should streamline validation visits from CMS and

eliminate the need for hospitals to seek certain waiversfrom the agency because of the 1985 edition.

CMS highlighted two notable areas from the 2000 LSCas part of its adoption that hospitals need to complywith the following:

1. Roller latchesRoller latches are items that keep a door closed; aperson releases it by pushing or pulling on the door,

as opposed to turning a knob. CMSsays hospitals will need to removethem from corridor doors to com-ply with the 2000 LSC becausefacilities historically haven’t main-tained them properly.

Data collected by CMS indicates“doors that include roller latches

are consistently one of our most cited deficiencies,”according to the published adoption.

Such replacements could cost health care facilities asmuch as $47.6 million, so CMS extended the dead-line for compliance with this particular provisionuntil March 13, 2006.

This move by CMS butts heads with an exception toparagraph 19.3.6.3.2 (existing health care) in the 2000LSC. Though that paragraph prohibits roller latches oncorridor doors in buildings not protected by sprink-lers, exception 2 states that existing roller latches canremain provided they withstand a specific force ap-plied to them.

2. Emergency lightsCMS requires hospitals to observe paragraph 19.2.9in the LSC, which mandates that existing facilities in-stall emergency lights that will illuminate exit routesfor at least 90 minutes during a power outage.

These upgrades will cost hundreds of health carefacilities a total of $5.9 million. Because of this finan-cial burden, CMS extended the deadline for comply-ing with this provision until March 13, 2006.

CMS says hospitals will

need to remove

roller latches from

corridor doors.




Disaster planning

Paper backup records need speed on their side

Emergency management isn’t always about a tornadoswooping down or a terrorist contaminating your out-door air intakes. Technological problems in a hospitalmight bring disaster training into a completely newlight for many of you on the safety committee.

On a Wednesday in late 2002, Beth Israel DeaconessMedical Center in Boston began experiencing a com-puter system slowdown. Eventually, the networkcrashed, and it wasn’t until Sunday night that hospitalstaff members were able to access online records. Thesolution was to switch to backup paper records. Butthe real key is to take such actions quickly; Beth Israelfell back on its hard copies when the slowdown firstoccurred.

“If it’s clear there’s an outage that could be of substan-tial length, move your hospital to manual systems soyou have one work flow,” says John Halamka, MD,chief information officer for CareGroup, the healthsystem that oversees Beth Israel.

“It is far worse to keep switching back and forthbetween automated and manual,” he says. “It’s thechange of work flow that can cause medical errors.”

A dose of comfortWhile it may be painful to go to paper, it guaranteesthat you’ll provide high-quality patient care becauseyou won’t be dependent on whether the network isup or down, Halamka says. That makes everyone’sjob less stressful during trying times.

What also helped was that the whole hospital wentinto emergency mode, including top managers, saysGerry Abrahamian, RHIT, director of health infor-mation management for Beth Israel.

“The chief operating officer was there the whole timeand held meetings regularly to see how everythingwas going,” Abrahamian says. “That brought every-one together.”

A big concern was making sure physicians could get

paper copies of the records they needed, she says. “Without the online medical records, they really need-ed the paper records,” she adds. “We were scramblingto make sure we could find them. Our record sign-out system is on the computer, so it took a lot ofdigging to find the charts.”

A capable responseAfter the terrorist attacks of September 11, the hospi-tal concentrated on developing an emergency plan,and network contingencies were part of that discus-sion, says Abrahamian.

“Going back to a paper system and being in the emer-gency mode went very smoothly,” she says. Physicianswere able to see all patients who came to the emer-gency room and every surgery went forward. Betterstill, the hospital did not lose any data.

A key point in that effort is to have phone linesavailable that are independent of the network, saysHalamka.

“We put in phone lines and created alternate waysto connect to computers,” he says.

Make sure the important clinical areas of the hospi-tal—such as the laboratory, pharmacy, and intensivecare unit—can access your systems via phone lines,in case of a catastrophic network failure.

“Our transcription system is separate, so we could getthe discharge summaries we needed and fax themdirectly to the floors,” says Abrahamian.

“The discharge summaries are updated in our system,but we also have a stand-alone personal computer.That was really helpful.”

Hospitals might also find it useful to unearth oldyear-2000 plans because they probably referencedsome paper-based alternatives to theorized masscomputer system outages associated with the datechange of January 1, 2000.

of the top 10 citations.)

Wiring problems?Electrical citations in two categories—wiring methodsand systems design—drew a combined 34 citationsand $30,644 in penalties, which are noticeable fig-ures, says Steven MacArthur, safety consultant forThe Greeley Company and BHS’ contributing editor.

“What is it they’re finding relative to electricalwiring?” MacArthur asks. (We’ll look into this topicfor a future story.)

New to the hit list this year are three standards: theaforementioned electrical systems design, respiratoryprotection, and machine guarding.

Gone from the top 10 are standards for respiratoryprotection from tuberculosis, recording occupationalinjuries, and medical services/first aid.




Bloodborne citations rise with greater awarenessOSHA’s top 10 list holds fairly steady

For at least the third year in a row, bloodborne patho-gens violations are the most common citations givento hospitals by the Occupational Safety and HealthAdministration (OSHA).

More eye-catching is the increase in citations. In 2002,twice as many bloodborne pathogen violations wenton the books compared to the year before.

But OSHA isn’t necessarily getting tougher during itsvisits to hospitals.

Rather, inspectors have a greater grasp of blood-borne problems, and health care workers are morelikely to file complaints with the agency.

“It is absolutely due to increased awareness becauseof the passage of the Needlestick Prevention Act” inlate 2000, says Amber Hogan, MPH, an industrialhygienist in OSHA’s office of health enforcement.

The federal law specifically requires hospitals to usesafety needles and other engineering controls, andmandates that facilities maintain a sharps injury log.

It’s in the statsFor the period of October 1, 2001, to September 30,2002—the latest information available on OSHA’s Website (www.osha.gov)—44 hospitals received 115 blood-borne violations totaling $75,380 in fines. That’s anaverage penalty of $655 per violation.

During the same period from a year earlier, OSHAissued 54 bloodborne violations at 24 sites. The goodnews is the average fine last year was almost the same,at $657 per citation.

So it’s not costing hospitals more money for a viola-tion, but it seems the risks are higher of receivingone.

Overall, the agency issued 362 citations to 93 generalmedical and surgical hospitals, and levied $200,088 infines. (See the chart on the next page for a rundown

Top citations in psychiatric andspecialty hospitals

The following information comes from inspectionsconducted by the Occupational Safety and HealthAdministration (OSHA) from October 2001 throughSeptember 2002:

Psychiatric hospitals—OSHA issued 30 citationsat seven sites ($21,795 total in fines). The top-cited standards were bloodborne pathogens,woodworking machinery requirements, and ab-rasive wheel machinery requirements.

Specialty hospitals*—OSHA issued 14 citationsat six sites ($3,608 total in fines). The top citedstandards were bloodborne pathogens and hazardcommunication.

* Specialty hospitals include sites that primarilyprovide services such as cancer treatment, chil-dren’s care, eye/ear/nose/throat, orthopedics,and drug and alcohol rehabilitation.




Top OSHA citations in medical and surgical hospitals

Violations in the bloodborne pathogens standard top the list of citations by the Occupational Safety andHealth Administration (OSHA) in general medical and surgical hospitals. The statistics do not cover psy-chiatric and specialty hospitals, such as children’s or cancer hospitals. This information only covers hos-pitals under federal OSHA requirements, not state OSHA plans.

OSHA issued these citations from October 2001 through September 2002. The listed standards are fromsection 29 of the Code of Federal Regulations.

Standard Number ofcitations/

inspections

Penalties* Description Priorrank^

1. 1910.1030 (blood-borne pathogens)

2. 1910.147 (lockout/tagout)

3. 1910.305 (electricalwiring methods andcomponents)

4. 1910.1200 (hazardcommunication)

5. 1910.303 (electricalsystems design)

6. 1910.37 (means ofegress)

7. 1910.132 (personalprotective equipment)

8. 1910.1047 (ethyleneoxide)

9 (tie). 1910.134 (respiratory protection)

9 (tie). 1910.212 (general requirementsfor machines)

115/44

21/9

20/9

16/9

14/9

12/9

11/8

10/4

8/5

8/7

$75,380

$6,115

$16,279

$4,985

$14,366

$15,066

$7,969

$7,088

$1,500

$4,119

Controlling exposure to blood or otherpotentially infectious materials

Avoiding exposure to hazardous energy,such as electricity, steam, or chemicals

Properly installing and protecting elec-trical wires, cables, and associatedequipment

Reporting risks of chemicals to employ-ers and employees (including labelingand training)

Protecting workers from electricalequipment hazards

Protecting and maintaining means ofegress

Choosing and using appropriate per-sonal protective equipment

Preventing exposure to ethylene oxide

Developing a respiratory protection pro-gram with provisions for respirator use

Providing guards from machine haz-ards, such as rotating parts or sparks

1

2

8

4

23

7

9

6

22

18

* The penalty column reflects any settlement actions that took place after OSHA originally issued a citation.^ The last period ranked was October 2000 through September 2001.

Source: OSHA.




Editor’s note: Receive the latest health care safety head-lines weekly through our free e-mail newsletter, SafetyConnection. Go to www.hcmarketplace.com/free/emailnls/ to sign up.

EPA cools its enginesAt the very least, the oil spill prevention plan regula-tions we told you about in our January special reportwill be delayed until April 2003.

But it could turn even sweeter. In issuing the tempo-rary reprieve, the Environmental Protection Agency(EPA) also put out a second draft delay that couldkeep the revised oil spill requirements off the booksuntil February 2004.

Why the change? The EPA realizes that with its origi-nal deadline to revise oil spill plans by February 17,it faced a cavalcade of extension requests from hos-pitals and other affected industries, says Don Grant,an oil spill enforcement coordinator for the EPA’sRegion I office in Boston.

The interim delay will let everyone settle down longenough to discuss the more significant delay that’sup for proposal. The interim delay says facilities openfor business on or before August 16, 2002, now haveuntil April 17, 2003, to review and update their exist-ing oil spill plan.

Stay tuned to these pages or go to www.epa.gov/oilspill/index.htm for the latest information.

‘Don’t worry, I’ll stay put’Can’t you see Dennis Franz acting this one out onan episode of NYPD Blue?

In January, a woman arrested on a warrant complain-ed of stomach pains while she was in the jail, so policeofficers took her to Piedmont Medical Center in RockHill, SC. At the hospital, an officer removed thewoman’s leg shackles, put them around a chair, andthen handcuffed her left wrist to the shackles, thelocal newspaper The Herald reports. The officer leftthe room and returned a few minutes later to discover

the woman missing and her handcuffs on the chair.

An alert went out, and someone saw the suspectleaving the hospital in a blue car. Shortly after, policepulled the vehicle over and arrested the woman again.The driver of the car told officers the woman flaggedher down outside the hospital, according to The Herald.

No word on how Houdini’s apprentice escaped herhandcuffs.

New ergonomics resource onlineOregon’s Occupational Safety & Health Division recent-ly added a new ergonomics section to its Web site.The link contains information specific to ergonomicshazards in health care settings and includes a 47-pageback injury prevention guide in PDF format.

Go to www.orosha.org/consult/ergonomic/ergonomics.htm to see what’s there.

A pair of patient problemsRegardless of who’s at fault, this type of publicity can’tfeel too good for a hospital.

First, on January 17, a former patient entered ParkwayRegional Medical Center in North Miami, put on adoctor’s uniform, and—lock the operating room!—allegedly announced she was going to perform sur-gery, according to The Miami Herald. Police arrestedthe would-be physician.

Then the next day, family members of another femalepatient alleged that the hospital lost track of the womanafter telling relatives she was at a clinic when in factshe wasn’t there. Police later found the woman at asecond clinic.

A spokesperson for Parkway Regional told the Heraldthe hospital released the patient under her own ac-cord after police brought her there for possible treat-ment. The hospital provided transportation for thewoman to another clinic as a courtesy. The first clinicrefused to let her in, so she ended up at the secondsite.

Bits & briefs




Survey addresses construction projectsA recent online survey of health care professionalsindicates that 31% are concerned—but not very con-cerned—about infection control (IC) during construc-tion and renovation projects.

The poll asked respondents to rate their concern levelon a variety of IC topics, including hand hygiene, blood-borne pathogens, and personal protective equipment.

With construction activities and IC, 28% of the respon-dents say they are somewhat concerned, 27% say veryconcerned, and 13% say they aren’t concerned at all.HCPro, Inc.—the publisher of BHS—conducted thesurvey, which included 475 respondents.

Assault charges bring review questionsPolice arrested a surgeon at the University of Cali-fornia at San Francisco Medical Center who alleged-ly drugged and/or assaulted three female patientsin 2001 and 2002.

Meanwhile, the California Medical Board plans to lookinto how the university dealt with the first two incidentsin 2001. University officials reviewed those cases, butuniversity police only became involved with the trio ofevents after the most recent allegation from the thirdvictim, according to the San Francisco Chronicle.

The surgeon denies the charges and members of hisdepartment at the hospital have publicly supported him.

Smallpox vaccines might not be a blessing, but . . .

If your hospital seeks volunteers for smallpoxvaccinations, here’s one position you might nothave thought about: clergy.

Mount Clemens (MI) General Hospital told theDetroit News that it planned to inoculate clergymembers who serve in the facility.

The thinking behind this move is that priests andother members of the cloth could be among thefirst folks to comfort victims of smallpox, theirfamilies, or affected health care workers.

Meanwhile, at presstime in late January, therewas growing public pressure on President Bushand national health officials to create some sortof compensation program for health care work-ers who volunteer to receive the smallpox vac-cine and endure subsequent side effects.

The Institute of Medicine—an influential boardthat provides health policy advice—says it sup-ports efforts to resolve the compensation debatefor vaccine recipients, household members, andother people such as patients who suffer adverseeffects due the program.

Also, the Massachusetts Nurses Association wasamong several trade organizations to publiclyoppose the smallpox vaccine plan until somechanges come about in terms of education andworkers’ compensation.

In related items:• In an interesting twist, the same nurses group

says the needles used for the vaccinations areunsafe and fail to comply with the NeedlestickSafety and Prevention Act of 2000. There aresafety needles on the market for smallpox vac-cines, but the Centers for Disease Control andPrevention (CDC) avoids them.

On its Web site, the CDC says the vaccine kitsdon’t contain safety needles because the Foodand Drug Administration (FDA) approved onlytraditional needles without safety features forthe administration of this vaccine. A spokes-person for the FDA confirmed this to BHS.

• Also, the CDC published a lengthy report onthe symptoms and treatment of smallpox in-fections. Go to www.cdc.gov/mmwr/preview/mmwrhtml/di52cha1.htm to read more.




an individual” goes a long way, Hernandez says.Also, use verbal commands early on so that pa-tients know what you expect of them.

• Try to find out the history of problem patients.The more information you find out, the betterprepared you are. “Naturally, if the police bring[a patient] in handcuffs, then that’s a red light,”he says.

• Keep a safe distance from potentially violentpatients if possible. That distance should be farenough so the patient can’t kick you, and youshould always keep an escape route open, addsHernandez. If you’re alone with the patient, don’tlock the door to the room and let another staffmember know your location.

• Be wary of direct eye contact with patients.Based on his 11 years in health care, Hernandezfinds that staring at certain people sets them off.

In the February BHS, we talked about ways to betterprepare for assaults on staff members by patients, suchas by developing use-of-force policies for security teamsto use if faced with a combative patient:

Jose Hernandez, safety officer at Mercy Medical Cen-ter in Roseburg, OR, has some additional thoughts onprotecting the well-being of health care workers.

Hernandez offers the following tips to thwart patientassaults:

• Arrange for staff anger management training ifnecessary. “That’s what I harp on my guys: Nomatter what, you are the professionals and youhave to keep control of the situation,” he says. “Peo-ple are going to spit, kick, and possibly throw stuffat you.”

• Talk to potentially violent patients to build arapport. “A lot of times, just talking pleasantly to

Tip of the month

And now for a little more about preventing patient violence

Briefings on Hospital SafetyEditorial Advisory Board

Publisher/Vice President: Suzanne Perney Group Publisher: Bob CroceSenior Managing Editor: Scott Wallask [email protected] Editor: Steven MacArthur, consultant, The Greeley Company, Marblehead, MA [email protected]

Steven BryantPractice Director, Accreditation ServicesThe Greeley CompanyMarblehead, MA

Murray L. Cohen, PhD, MPH, CIHRisk Management ConsultantAtlanta, GA

Cherryl M. Crouch, CSPSafety Officer, Northwestern Memorial HospitalChicago, IL

Mark E. Furlane, JD, MBAPartner, Gardner, Carton & DouglasChicago, IL

Hugh P. GreeleyChair, The Greeley CompanyMarblehead, MA

David N. Hill, RPA, CFM, BAEIM, MSHSADirector of Support ServicesHazelden Foundation, Center City, MN

Janine Jagger, MPH, PhDAssociate Professor of NeurosurgeryDirector, International Health Care WorkerSafety Research and Resource CenterUniversity of Virginia Medical CenterCharlottesville, VA

Linda D. Lee, MS, REMDirector, EH&SUniversity of TexasMD Anderson Cancer CenterHouston, TX

Ray W. MoughalianPresidentRM Associates Inc.Haverhill, MA

John L. Murray Jr., CHMM, CSPSafety Director, Baystate Health SystemSpringfield, MA

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Safety in respiratory

care: A guide to the JCAHO requirements

Safety in respiratory

care: A guide to the JCAHO requirements

A supplement to HCPro publications

Safety in respiratory care: A guide to the JCAHO requirements2

Table of contents

Make sure your facility complies with JCAHO s patient, environmental safety standards . . . . . 3

ENVIRONMENTAL SAFETY

Hazard surveillance form: Use one to evaluate compliance in your department . . . . . . . . . . . .5

Hazard Surveillance Detection Survey for Respiratory Care Department/Services . . . . . . . . . . 6

The Joint Commission allows a range of options for medical equipment maintenance . . . . . . . 8

In use v. in storage is an important distinction for oxygen cylinders . . . . . . . . . . . . . . . . . . . 9

Prepare your staff for terrorist attacks with thorough emergency, disaster plans . . . . . . . . . . . 10

10 tips for emergency and disaster readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PATIENT SAFETY

Take steps now to prevent ventilator deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Oxygen safety is crucial to prevent medical errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Ensure that all staff have adequate knowledge of equipment to prevent errors . . . . . . . . . . . . .15

Dear reader:

The JCAHO’s changing standards for safety can be difficult to navigate, and it’s not always easy to tellwhether a standard even applies to the respiratory care department. That’s why we’ve identified the safetyissues surveyors have focused on recently, and compiled the following stories to help you comply.

This special report will help you identify your department’s strengths, improve on your weaknesses, andprepare for your next survey.

We at HCPro wish you success in your efforts to make your respiratory department as safe as it can be.

Sincerely,

Lauren McLeodSenior Managing Editor

Safety in respiratory care: A guide to the JCAHO requirements 3

Every hospital department has to worry about safetyissues and JCAHO standards. But with explosive chem-icals and machines that make the difference betweenlife and death a part of the routine in respiratory care,surveyors may scrutinize your department’s safety moreclosely.

Karen J. Stewart, MS, RRT, assistant administrator,medicine services at the 947-bed Charleston (WV) AreaMedical Center, rifled through the standards manual,sorted out the ones most relevant to RTs, and addedclarifying comments to each standard. The AARC hasmade available the full text of her work on its Web site.

Topping Stewart’s safety list are Environment of Carestandards EC.1.1–1.7, which call for the hospital toprovide a safe and secure environment and developplans for hazardous waste management, fire preven-tion, utility and medical equipment, and emergencymanagement (which has come under more scrutinysince September 11).

Once the hospital designs these plans, EC 2.1–2.8require implementation and staff orientation abouttheir responsibilities in each plan.

That means managers must know the hospital-widepolicies and spell them out to their staff so they un-derstand how to use the various plans, according toStewart. Department-specific policies and proceduresconcerning safety should be included in a depart-ment version of a safety manual.

Handling equipment Before a survey, it’s a good idea to review processesfor handling equipment—in policy and in practice,says Steve MacArthur, a consultant for The GreeleyCompany in Marblehead, MA, and former managerof safety and security for Brockton (MA) Hospital.Respiratory care workers can trip up in a JCAHOsurvey by mishandling oxygen tanks.

“A hospital in Rhode Island got supplemental recom-mendations under the ‘Environment of Care’ [section]

Make sure your facility complies with JCAHO’s patient,environmental safety standards

because of unsecured gas tanks. One in the emergencyroom was on top of a stretcher, and another was a heli-um tank in the gift shop that they used to fill balloons,”MacArthur says. “If a surveyor were to find enough un-secured gas tanks floating around, you might get allthe way to a Type I [recommendation].” (See p. 9 formore information on oxygen tank storage.)

EC.3.2 calls for the hospital to provide “an environ-ment with appropriate space and equipment.” Spe-cifically, you should be able to show that there isenough space to clean equipment without contami-nating other hardware, Stewart says.

Maintaining equipmentRecently surveyed respiratory care managers reportthat surveyors have been looking at preventative main-tenance when it comes to equipment safety. Theywant to know: Is there a plan, and has it been exe-cuted? (See p. 8 for more information on equipmentmaintenance)

“Whether it’s been done internally or externally, onan annual basis [surveyors want to know] you’vedone electrical safety checks and that you’ve checkedthe equipment,” Stewart says.

Planning for the worstIn the wake of the September 11 terrorist attacks, the Joint Commission has increased attention onemergency and disaster plans. JCAHO has discussedbackup power supplies, alternate means of hospitalstaff communications, and nuclear, chemical, andbiological terrorism attacks in recent publications andteleconferences.

Although specific new standards have not been re-leased, Stewart points out that JCAHO is trying todetermine how its existing standards, especially thosefor utilities management and emergency programs,can be best interpreted to help bolster preparedness.

It will be up to respiratory care managers to educatestaff on how the standards relate continued on p. 4


Safety standards continued from p. 3

to their daily routines. (For more on emergency anddisaster plans, see pp. 10–11)

Handling sentinel eventsRecent JCAHO standards require leaders to perform“failure modes and effect analysis” (referred to asFMEA) on high-risk processes, says MacArthur. Thatmeans rehearsing possible scenarios and understandingthe results. “In the past, a lot of times, it’s been morereactive,” MacArthur says. “But now the Joint Commis-sion is moving toward more of a proactive stance.”The goal is to do everything possible to preventsentinel events, and minimize the effects when onedoes occur.

The JCAHO’s expectation is that by the time of survey,all organizations have looked at the Joint Commission’sSentinel Events publication and determined what theirrisk is for each one and what they can do to mitigatethem in their facility, MacArthur says.

That means respiratory care managers should con-sider the sentinel events that might happen in theirdepartment, such as an oxygen tank explosion, saysMacArthur. “That’s probably something [JCAHO] would-n’t be looking at organizationally too soon, but thatmight be something that a respiratory therapy de-partment would want to do . . . as an educationproject for FMEA.”

Leading the way in patient safetyPatient safety is a hot issue in recent surveys, “noton the top of the plate, but close to it,” Stewart says.

Missed treatments and medication control are highon the list. JCAHO wants hospitals to define missedtreatments, track them, and consider unjustifiedmissed treatments medical errors.

As long as your facility can prove it is trackingmissed treatments and trying to cut down on them,“you’re in pretty good shape before JCAHO,” saysStewart.

Medication safety—especially for medications need-ing refrigeration—is also a big JCAHO concern right

now. Keeping on top of expiration dates and moni-toring cold-storage temperature should be top pri-orities, she adds. Managers should pay particularattention to JCAHO leadership standards, whichfocus on patient safety, Stewart says. They call fordepartment leaders to do the following:

• Provide staff with the basic training on—andadequate time to participate in—patient safetyactivities

• Provide the processes by which departmentstaff identify and manage sentinel events

• Measure the effectiveness of their own actionsto improve patient safety

• Develop a plan for implementing hospital-wideperformance improvement and recommenda-tions in their departments

MacArthur points out that managers “worth theirsalt” will initiate department-specific safety measureson their own. But don’t forget that you have an allyand expert consultant in your facility’s safety officer,who can help you meet JCAHO’s expectations.

Preparing for a surveyStewart encourages respiratory care managers to setaside a regular time each week or month to review afew standards and consider their departmental com-pliance. The JCAHO manual includes self-testing toolsthat help you determine how much work, if any, youneed to do to bring your department up to snuff.

New JCAHO policies taking effect this year make ita little harder to know exactly when surveyors willshow up. If surveyors find a facility to be non-com-pliant, it can lead to unannounced follow-up visits.

“If your survey is not very good, you have a certainamount of time to respond to the way [JCAHO has]typed you,” Stewart says. “And then, my under-standing is that they can just do a pop-in to see ifyou’ve really complied. It’s going to be an interest-ing world.”


Hazard surveillance form: Use one to evaluate compliance in your respiratory care department

When it comes to making your respiratory depart-ment safe by JCAHO and Occupational Safety andHealth Administration (OSHA) standards, it’s oftenhelpful to conduct a “hazard surveillance detectionsurvey”—a thorough examination of safety issuesthat might need improvement.

Medical Consultants Network offers forms in its SafetyManagement Policies and Procedures Manual thatcan help you uncover your department’s weak spots(See pp. 6–7.)

“This will [help] take care of your big-ticket items inthe environment of care,” says Steve MacArthur, aconsultant for The Greeley Company and former man-ager of safety and security for Brockton (MA) Hospital.“You can verify that [staff] education is working andyou have an environment that is physically safe.”

The form will help you evaluate staff knowledge of ar-eas such as hazardous waste management and remindyou to double-check oxygen and equipment storage.

Its questions can help remind you of safety concernsthat aren’t always in the forefront of your mind. Forexample, question 1 in the “Physical Hazards” sectionaddresses the layout of equipment in your departmentand could inspire staff to move little-used items outof the way in order to create more space for fre-quently used hardware.

The form can help evaluate staff work habits andability to help create a safe environment for caringfor patients. You can also use the form to test staffknowledge—just as JCAHO surveyors might. Recenttrends show surveyors are interviewing frontline staffmore often, managers far less.

Review it at least once a yearThe items on the form should be checked once eachyear at minimum, MacArthur says. Standards dictatethat hospitals evaluate patient care areas twice a yearand ancillary areas once a year. Most respiratory caredepartments are considered ancillary areas, he says.

“Organizations should be doing something akin to this already,” MacArthur says. This falls underJCAHO standard EC.4.1, which calls for the hospitalto collect information about deficiencies and oppor-tunities for improvement in the environment.

But for recently promoted department managers orthose who have never conducted a hazard surveil-lance survey, it’s a good idea to complete this re-view on a quarterly basis. Once you’ve addressedmost of the problems the survey reveals, once peryear is sufficient.

If the hospital makes changes in emergency plans orthe physical plant, go over the form to make sureyou’ve addressed the relevant questions in yourdepartment.

MacArthur recommends conducting the hazard sur-veillance in cooperation with the hospital’s safetyofficer—especially if you’re a new respiratory de-partment manager.

“For the first seven questions . . . the safety officer isgoing to have a larger knowledge base,” he says.

Don’t let the ‘no’ answers slideIf you answer “no” to one or more questions, don’tpanic. It doesn’t mean your department is automati-cally going to receive a Type I recommendation thatwill be blamed on you. Some of the items—such asposting evacuation routes—aren’t required at all, butare still best practices.

A deficiency indicated by a “no” answer could becompletely overlooked by JCAHO inspectors. How-ever, it’s better to be safe than sorry and rectify each“no” as soon as possible. Also, share the informationabout the deficiency with the safety officer, becauseit might indicate a hospital-wide problem that needsto be solved.

“Any ‘no’ is a potential exposure point,” MacArthursays.


Source: Safety Management Policies and Procedures Manual, published by Medical Consultants Network.Reprinted with permission.


The Joint Commission allows a range of options for medical equipment maintenanceYour safety committee can explore many options in its quest to meet JCAHO requirements

Gone are the old days when technicians had totrack down every piece of medical equipment inthe hospital for an annual inspection to satisfysurveyors.

Revised environment of care (EC) standards allowmore flexibility when maintaining such items, par-ticularly under EC.1.6 and EC.2.10.3.

When the JCAHO revised these requirements lastJuly, it indicated that improved technology and per-formance eliminated the need to treat every pieceof equipment the same.

Instead, the JCAHO offered hospitals a variety ofways to ensure that medical machines operatedproperly.

The Joint Commission believes that medical equip-ment is safer today and features more self-testing,says Patricia Schnoor, CBET, a quality, compli-ance, and regulatory specialist for GE Medical Sys-tems, headquartered in Waukesha, WI.

Schnoor, who spoke at an audioconference for TheGreeley Company, conducts surveys to assess med-ical equipment management at hospitals throughoutthe country. Greeley is the sister company of OpusCommunications in Marblehead, MA, which pub-lishes RCM.

Standards still toughDon’t take the revisions as a chance to relax.

“There’s a little misconception out there that we’reon Easy Street,” says Steven MacArthur, a safetyconsultant for The Greeley Company.

The JCAHO’s changes are not meant to short-circuitmedical equipment maintenance, but rather givehospitals a greater role in developing—and lookingcritically at—their own management plans,MacArthur says.

Reviewing the choicesHere’s a quick look at some of the common med-ical equipment maintenance options:

• Annual maintenance—Most safety committeesare familiar with this method, in which youcheck a piece of equipment each year. You canstill use this option even though the JCAHOdoesn’t require it any more.

• Interval-based maintenance—This optionallows hospitals to set up their own timeframesfor maintenance or performance checks, basedon factors such as a manufacturer’s recommen-dations or history of a particular machine. “We’reused to [doing] this,” Schnoor says.

• Corrective maintenance—Here, a technicianwill conduct a maintenance check on an itemthat comes in for a repair.

• Metered maintenance—This option revolvesaround factors such as the amount of hours theequipment runs, rather than a set calendar timetable.

• Predictive maintenance—Under this option,which isn’t widespread in health care, hospitalsattempt to forecast failures in equipment basedon the history of the machine and an analysisof past failures.

It is normal to use a combination of any of theabove methods because no single maintenance pro-gram will address all equipment, she says. A facilitymay find metered maintenance works well for someequipment, while corrective maintenance gets bet-ter results on other items.

Don’t stifle creativity either, Schnoor adds. Safetycommittees might come up with a new way of con-ducting maintenance, and if it works, try it. Justmake sure your policies and records reflect anyunique methods.


‘In use’ v. ‘in storage’ is an important distinctionfor oxygen cylinders

An oxygen tank doesn’t have to be locked in acloset to be “in storage,” and it doesn’t have tobe pumping oxygen into a patient’s lungs to be“in use.”

If you place a cylinder next to a patient’s bedbecause the patient might need the oxygen atany moment, the cylinder is in use, according tothe National Fire Protection Association’s (NFPA)Fire and Life Safety in Health Care Facilities.However, if a second cylinder sits next to thebed, too, that cylinder is in storage and mustmeet storage requirements because the patientwon’t need both cylinders at the same time.

Also, if an emergency cart carries a cylinderon it, the cylinder is in use because staff mem-bers might need it at a moment’s notice, theNFPA says.

JCAHO speaks on cylindersThe JCAHO doesn’t have specific standardsthat guide facilities on oxygen cylinder storage;instead it relies on NFPA 99’s requirements,says JCAHO spokesperson Mark Forstneger.However, the Joint Commission issued an in-terpretation in 1999 about how many oxygencylinders it allows facilities to keep on a unitfloor.

In the 1999 version of NFPA 99, paragraph 4-3.5.2.1(b)25 states that facilities don’t need tostore individual cylinders associated with pa-tient care in enclosures. The 1996 edition ofNFPA 99, which the 1997 Life Safety Code ref-erences, does not contain this provision forindividual cylinders, though it’s probably fairto use the idea either way.

The problem is that NFPA 99 doesn’t put a

maximum on the amount of individual cylin-ders, the JCAHO says. A unit should haveenough cylinders on hand to meet daily clini-cal requirements.

Give me an EThe Joint Commission’s answer is to allowfacilities to keep 10 E-size cylinders in anopen-topped box subdivided into cubbyholes for the tanks. The box ensures that thetanks don’t fall over. E cylinders contain 24cubic ft of compressed gas; 10 E tanks equalthe volume of one H-size cylinder. “Ten tanksshould be sufficient to meet a unit’s clinicalneeds,” the JCAHO says in its interpretation,which it published in the November/Decem-ber 1999 Environment of Care News.

The staff members who use these cylindersneed immediate access to them to meet clini-cal needs. “The cylinders are not being storedper se; they are staged for ready use,” the JCAHOadds. If your unit needs more than 10 cylin-ders, then it’s time to find appropriate storageareas that protect against fire and keep thetanks secure.

Tag those tanksYou may want to put tags around the necksof cylinders to indicate the status of the tank,suggests Robert Westenberger, MCO, CHFM,corporate director of safety and regulatorycompliance at Saint Clare’s Health Services inDenville, NJ.

The tags should have check-off areas for cat-egories such as empty, in use, or full. Thishelps staff members track tank use andkeeps JCAHO surveyors happy, explainsWestenberge.


Prepare your staff for terrorist attacks with thoroughemergency, disaster plans

Anthrax. Sarin. Smallpox. Bioterrorism. Chemicalweapons. These words haunt us all in the wake ofSeptember 11.

These threats can be more intimidating than naturaldisasters because they’re not random.

“If you have a naturally occurring event—a flood,hurricane, ice storm—people’s tolerance of that isvery different than a man-made event,” says BarbaraBisset, director of emergency response, safety man-agement and special police at New Hanover HealthNetwork in Wilmington, NC. “The man-made eventsplay very differently, psychologically. One is Goddoing something; the other is man destroying man.”

It’s important that respiratory therapists move be-yond their fears to help prepare their facilities for aterrorist crisis. Depending on the chemical or germagent used in a terrorist attack, the respiratory caredepartment can turn into a front-line defense. Bio-logical agents such as anthrax and many chemicalweapons affect breathing function.

Even without chemical and biological agents, victimsare likely to need respiratory care. After the WorldTrade Center attacks, many rescue workers were hos-

pitalized with breathing problems related to the dustcloud created by the collapse of the buildings.

“Respiratory therapists are key members of ouremergency response team in responding to anykind of an incident where there’s a large number ofpatients,” Bisset says.

Preparing for an emergency of unknown scale,especially when hospital resources are strapped tobegin with is no easy task. Start by developing anemergency response plan. The JCAHO requires facil-ities to have emergency plans in place, and surveyorsare scrutinizing them more carefully than ever.

“Work with your suppliers and find out [the maxi-mum number of supplies] you can get on an order,”says Earl Williams HSP, the safety coordinator forBroMenn Healthcare in Bloomington, IL. “Assumethe worst-case scenario, with two or three hundredpeople showing up and needing care.”

In preparing an emergency plan for your department,consider that in many chemical attacks and some bio-logical attacks—anthrax being one of them—respi-ratory therapists are not likely to get sick merely bycaring for victims. Unless health care workers are

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directly exposed to anthrax—for example, frompieces of contaminated mail—they can’t get the dis-ease. Airborne contagions such as smallpox, on theother hand, require the same precautions as dis-eases like tuberculosis.

In contrast, chemical weapon attacks can quicklyaffect large populations, potentially bringing many vic-tims to your department’s door in a matter of hours orminutes, in some cases needing decontamination.

Emergency plans developed for chemical spills and/or large fires can form the groundwork to deal withterrorist attacks.

Dealing with many uncommon biological agents willrequire the same precautions and practices that areused frequently for more common diseases.

“We know this. We just haven’t called it anthrax before.”Bisset says. “We deal with these situations every day.”

10 tips for emergency and disaster readiness

Barbara Bisset, director of emergency response,safety management and special police for NewHanover Health Network in Wilmington, NC, andEarl Williams, HSP, the safety coordinator forBroMenn Healthcare in Bloomington, IL, offerthese principles for respiratory care managers tokeep in mind to prepare their departments forbiological and chemical terrorist attacks:

1. Routinely fit-test each staff member’s protectivegear to prepare for the worst-case scenarioswith airborne contagions.

2. Know the sterilization procedures for all equip-ment in your department and the solutions thatare safe to use to clean them. Many biologicalagents can be eradicated with simple bleachsolution. Check manufacturers’ guidelines inadvance to see whether masks and other gearcan stand such treatment.

3. Find out where you fit on your oxygen ven-dor’s priority list in case of short supply—espe-cially if you’re located in a community withseveral hospitals. If you’re not number one onthe list or if your primary supplier employs a“first come, first served” policy, line up one ortwo backup suppliers.

4. Bone up on disposal procedures for hazardouswaste.

5. Learn where you can borrow or rent backupventilators. If possible, make sure the source isavailable 24 hours a day.

6. Use the homework emergency planners in yourfacility have already done. For example, Bisset’sfacility has dealt with hurricanes, so plans werealready in place to handle events with many vic-tims and possible power outages. Williams worksin a rural, agricultural region where anhydrousammonia spills can occur, so his facility waspartially prepared for a chemical attack beforeSeptember 11.

7. Determine the scale of a possible attack in yourarea, and be realistic. It’s not out of the ques-tion that a terrorist could strike remote ruralareas, but densely populated areas are morelikely targets.

8. Keep staff informed of the emergency plan, up-dating them on a regular basis.

9. Try to channel the energy you devote to fearinto learning and constructive planning. It canhelp overcome the specter of terrorism.

10. Make sure you have up-to-date contact infor-mation for all your employees. “It sounds sim-ple, but for many departments it can be a bigchallenge,” says Bisset.


Take steps now to prevent ventilator deaths

Human error, not technical malfunction is most oftenthe cause of ventilator injury and death, accordingto the JCAHO.

The Joint Commission released a Sentinel Event Alerton ventilator deaths and injuries in February puttingrespiratory care managers on notice that ventilatorsafety has become a hot-button issue.

Don’t panic, says Susan P. Pilbeam, MS, RRT,FAARC, who literally wrote the book on ventilators.She’s the author of Mechanical Ventilation: Physio-logical and Clinical Applications and currently worksas a respiratory care educational consultant.

There are both short-term and long-term ways toimprove ventilator safety by adjusting work habits,Pilbeam says.

The particularsThe JCAHO’s report cited 23 sentinel events relatedto ventilators. All occurred in long-term ventilatorpatients. The majority of the incidents happened inintensive-care units, but a few took place in long-term care facilities and chronic ventilator units athospitals.

Four incidents put patients in comas; 19 resulted indeath. The JCAHO cited “inadequate staff orienta-tion/training” as the number-one root cause (presentin 87% of the incidents), followed by communicationbreakdown among staff (70%), and alarm problems.JCAHO also cited environmental noise, cultural bar-riers, and insufficient staffing.

None of the incidents resulted from mechanical fail-ure, according to the JCAHO.

Changing habits in the long term

Improving ventilator safety requires effort fromthe entire respiratory staff. Susan P. Pilbeam,MS, RRT, FAARC, recommends taking thesesteps:

1. Test staff on the operating procedures for eachventilator after hire and then on an annualbasis.

2. Get a copy of the National Board for Res-piratory Care (www.nbrc.org) test matrix anduse it to develop a JCAHO-friendly testinginstrument. Let staffers use it to demonstrateproper operation of ventilators. Most newmodels have teaching software.

3. Make teaching materials available for staff toreview.

4. Consider setting up closed-circuit cameras toobserve ventilator patients located in remote

rooms, as recommended by JCAHO.

5. Set up interdisciplinary teams to managepatients on ventilators and encourage commu-nication between team members.

6. Encourage RTs to assess patients on ventilatorsand share information on their condition withnurses, physicians, and other clinical staff.

7. Hold a meeting between nurses and respirato-ry care staff to share information about ventila-tor procedures. Outline the urgent situationsthat require calling each other or getting doc-tors involved.

8. Consult with other respiratory care departmentmanagers in your community and developteaching materials and documentation methodstogether to cover all your bases and avoidduplicating efforts.


In the last 15 years, ventilator development has mir-rored that of the personal computer—just as proces-sors have become faster and able to take on moreoperations, vents have also become more sophisti-cated, says Pilbeam. The last five years have seenthe most technological advancement.

“They’re very reliable,” Pilbeam says. “None of themare without some microprocessing capabilities, andthose computers are self-testing on a regular basis.They have a lot of backup and checking systems.”

The JCAHO’s report offers recommendations forimproving ventilator safety. It emphasizes educatingand testing staff, tracking outcomes of ventilatorpatients, and upgrading alarm systems.

Teach, test, and verifyTo meet JCAHO’s expectations, respiratory care man-agers must document not only that they held education-al activities, but that staff actually learned the material.

“I think what managers are going to have to do, inorder to appropriately report to JCAHO, is keeprecords on mechanical ventilation orientation theydo with employees, if they are not already doingso,” Pilbeam says. “And my guess would be, docu-ment that the training process was effective.”

That means testing staff on the particulars of how torun each ventilator and proving that each therapist canset alarms and monitor each one appropriately.

Developing a teaching and testing mechanism adminis-tered on CD/ROM or the ventilator itself and keepingtrack of the test results can help you demonstrate stafftechnical competency and understanding of hospitalventilator safety policies. Many new ventilators havesoftware programs that allow staff to learn the controlswithout a patient actually on the respirator.

Don’t forget, staff must know how to respond to alarmsas well as set them based on your hospital policy.

Everyone who works with ventilators also must knowhow to properly use patient restraints; the JCAHO indi-cates that 13% of the sentinel events were caused byrestraint failure.

Pilbeam suggests respiratory care managers in a cityor region pool their resources and help each otherpromote ventilator safety and staff competency.“Talk with your compatriots in your neck of thewoods and see what they are thinking about doing.Get together on it and start building resources.”

Keep your headThe responsibility for ventilator safety falls on thedepartment manager. Changes—especially big onesthat involve an entire staff’s work habits—can’t hap-pen overnight. Surveyors understand that.

“Do it slowly,” Pilbeam says. “I don’t care if JCAHOis coming next week. It’s not the end of the world;you’re not going to be drawn and quartered . . . ittakes time to do it right.”

Susan P. Pilbeam, MS, RRT, FAARC, recommendsthe following steps to respiratory care managerswho want to take immediate action to prevent ven-tilator injuries:

1. Review your department’s policies on ventilatormanagement to ensure you’ve addressed issuesbrought up by the JCAHO such as staffing ori-entation and alarm responses.

2. Assess ventilator management policies with staffto make sure everyone understands them.

3. Record when you’ve had an in-service meetingto review the policies.

4. Devise a checklist for each different model ofventilator in your department. Make sure everystaff member knows how to turn it on, put thecircuit on correctly, adjust controls, and setalarms appropriately.

5. Document staff members’ training and verify thatthey have not forgotten what they learned whenstudying for credentials.

Short-term fixes

• In the MRI roomKenneth Capek, MPA, RRT, director of respi-ratory care services at the 400–bed Englewood(NJ) Hospital and Medical Center, used the West-chester incident to remind the department’s 25therapists about how to handle medical gassesin the MRI room.

Capek teamed up with Joseph Sudano, MPA,RT, administrative director of radiology. Sudanoput together a fact sheet based on informationfrom the manufacturer of MRI equipment anddistributed it to every therapist.

Capek went over this sheet during a staff meet-ing, and the staff watched a video from a man-ufacturer on MRI room safety. The hospital hasthree MRI rooms—two with piped in oxygenand one without. The one without contains afew aluminum cylinders with special regulatorson plastic stands. Therapists are trained for bothtypes of rooms.


Posted on the outside of every Magnetic Reso-nance Imaging (MRI) room at Englewood (NJ)Hospital and Medical Center is a sign that reads:

1. The MRI machine (magnet) is always on! Evenif the machine seems to be off (no patient onthe table) the magnetic field is still present.

2. Never enter an MRI room without checkingwith an MRI Technologist. They will prepareyou to enter the room.

- All persons entering an MRI room must bescreened before entering the room. Thisincludes patients, visitors, nurses, doctors,maintenance staff, environmental services,and any other staff member

In an emergency situation, CAC, respirato-ry arrest, etc., the patient must be removedfrom the MRI room. Emergency procedures

cannot be conducted in an MRI room(never, no exceptions).

3. Items such as loose metal objects must beremoved before entering the MRI room. Theseinclude:

- ID badges, beepers, stethoscopes, scissors, cell phones, credit cards

- STRICTLY FORBIDDEN—oxygen tanks,pumps, monitors, ventilators, suctionmachines, and any other powered device

4. Tools used for repairs or cleaning must be“non-ferrous,” which means no iron. The mag-net will not attract them.

5. People with Pacemakers are never permitted toenter an MRI room.

6. Please observe the signs posted on all MRIentry doors.

Oxygen safety is crucial to prevent medical errors

When a staff member at Westchester Medical Centerin Valhalla, NY, brought an oxygen cylinder into aMagnetic Resonance Imaging (MRI) room in July 2001,the metal container was attracted the machine’s mag-net, propelled through the air, and killed a smallboy. The hospital staff knew better, but somehowthe accident still happened.

Both the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) and the Food andDrug Administration (FDA) voiced concern last yearabout medical gas problems, and this MRI incidentadds fuel to the fire.

The JCAHO included an article about such mix-upsin the July 2001 issue of Sentinel Event Alert, andthe FDA wrote a public health advisory in March2001 on medical gasses. It’s crucial to make sureyour therapists are well-informed about those andother dangers of medical gasses. The following aresome of the circumstances in which they shouldpay extra attention to potential gas problems:

Source: Englewood Hospital and Medical Center. Reprinted with permission.


Ensure that all staff have adequate knowledge of equipment to prevent errors

“The only thing we don’t have is an MRI ventila-tor, because we don’t often have a lot of patientswith this need,” he says. On the rare occasion thata ventilated patient needs an MRI in that room,a therapist accompanies the patient and manu-ally bag vents with a long-neck bag while thetest is given.

Capek placed small oxygen stands outside ofeach of the three MRI rooms. The stands anddoors to the rooms have signs indicating thatoxygen cylinders should be placed in the standsbefore anyone enters the room (see p. 14). Thesereminders help prevent accidents, Capek says.“The signs are helpful because they raise con-sciousness of therapists, but are also good forinstances where an intern or nurse may be han-dling a patient who is on oxygen.”

• During equipment transportGary Johnson, RRT, RCP, director of respira-tory care services at the 100–bed North CountryRegional Hospital in Bemidji, MN, says it’s easyfor equipment to fall or regulators to breakduring transport.

“When therapists are moving a patient quicklyand one throws the IV pump and oxygen tankon the bed, it can fall off. This equipment

needs to be properly secured,” Johnson says.

Equipment transport problems can harm pa-tients. Damage to regulators can alter the flowof gas to the patient, and therapists must beable to prevent this, Johnson says. His 13 thera-pists know they should use portable tank hold-ers when transporting patients and seek helpfrom additional staff members if they are strug-gling with equipment.

The solution: Training“The JCAHO’s newsletter addresses the issue of prop-er training, and I think that’s the solution,” Johnsonsays. “If you bring the issue back to therapists atten-tion, they’ll improve.”

“The AARC has clinical indicators, and managershave to look for red flags to indicate that problemsare going on in the facility,” he adds. Johnson sug-gests therapists also stay current on National FireProtection Association (NFPA) guidelines. Go towww.jcaho.org/eud_pub/sealert/sea21.html to read theJCAHO’s Sentinel Event Alert on medical gas mix-ups.

Go to www.nfpa.org/members/Member_Sections/Health_Care/Medical_gas_mix-ups/4341fnl.pdf toread the FDA’s public health advisory on medicalgasses.

One of the best ways to prevent medical mishapswith oxygen like the one that occurred at WestchesterHospital in 2001 is to ensure that staff in other depart-ments understand how the equipment works.

The transportation staff who move patients fromone floor to another often deal with patients whorely on oxygen to breathe.

If any problems arise during the transport, a basicknowledge of how oxygen equipment works is ne-cessary for patient safety.

That’s why Ken Capek, MPA, RRT, director of res-piratory care services at the 400-bed Englewood(NJ) Hospital and Medical Center, makes sure trans-porters learn the basics of oxygen equipment aspart of safety training. After the training, he teststhe transporters on their skills.

Last year was the first year of training for trans-porters, and Capek says it may become an annualevent in the future.

For now, all newly hired continued on p. 16


employees are required to undergo the training.

Many other facilities don’t require transporters toknow how to use oxygen equipment, but Capekthinks the training is beneficial.

At Englewood, therapists generally transport patientson oxygen themselves, but in certain circumstances,it’s left up to the transportation staff. “It’s a good ideafor many hospitals to have transporters trained to han-dle oxygen, because many of them will be transport-ing patients who are on oxygen,” Capek says.

At the 100–bed North Country Regional Hospital inBemidji, MN, severely ill patients are usually trans-ported by therapists, but patients just going to phys-ical therapy are likely to be moved by transporters,says Gary Johnson, RRT, RCP, director of respira-tory care services.

There’s no rule from the JCAHO or any other regu-latory body requiring the presence of a therapistwhen transporting patients on oxygen, so it’s entire-ly up to your facility to decide what to do.

“It would be interesting to find out what percentageof patient transport is done by respiratory therapists,because generally the only patients we transport at myfacility are patients who are severe cases and needconstant respiratory care involvement,” Johnson says.

Regardless of whether your transporters are fre-quently moving patients on oxygen, they shouldundergo basic oxygen training and at least know

how to turn the cylinders on and off, Johnson says.

Booklets make good referencesKristine McDonald, RCP, director of respiratorycare and HME Services at Cardinal Health SystemHomecare Services Inc., in Muncie, IN, has onlyeight therapists, but 75 nurses.

With so few therapists, it’s key for the nurses andother staff to understand the basics of oxygen equip-ment operation. McDonald keeps several of the 34-page oxygen equipment booklets given to patientson hand for nurses and any other employees whomight need to look up oxygen information in a hurry.

“These booklets are [useful for] all employees becausethey are very educational and have excellent pictures,”McDonald says. “And when nursing staff visits a homeand sees a patient who is on oxygen, not only willthey be more familiar with the cylinders, but they cangrab this book and explain it a bit better.”

The booklet covers operating an oxygen cylindersystem, using a portable cylinder system, cleaningand maintaining equipment, troubleshooting, usingthe system for pediatric patients, and more.

Having the booklets available curbs the fear of the un-known many nurses have when it comes to handlingoxygen equipment, says McDonald.

“Whether or not it relates directly to their patient careplans, it’s always nice to offer a helping hand in atime of need.”

Equipment knowledge continued from p. 15

This special report is published by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. • Copyright 2002 HCPro, Inc. All rightsreserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form orby any means, without prior written consent of HCPro, Inc. or the Copyright Clearance Center at 978/750-8400. Please notify us imme-diately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982.For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected] • Opinions expressed are not necessarily those of the editors. Mention of products and services does not constituteendorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical ques-tions. HCPro, Inc. is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations.

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