june 2012 vol. 20, no. 6 - · ghs adoption has been on osha’s agenda ... back issues are...

OSHA adds GHS to Hazard Communication StandardExpected revisions align with United Nations global chemical labeling system to improve worker safety

It was only a matter of time, but OSHA has officially

revised its Hazard Communication Standard to include

the Globally Harmonized System (GHS) of Classification

and Labelling of Chemicals. The change was expected

to be announced this year after OSHA submitted the

change to the Office of Management and Budget in

October 2011. GHS adoption has been on OSHA’s agenda

for more than six years.

“Exposure to hazardous chemicals is one of the

most serious dangers facing American workers today,”

Secretary of Labor Hilda L. Solis said in a press release.

“Revising OSHA’s Hazard Communication Standard will

improve the quality, consistency and clarity of hazard

information that workers receive, making it safer for

workers to do their jobs and easier for employers to stay

competitive in the global marketplace.”

OSHA expects the revised standard to prevent rough-

ly 585 injuries and illnesses each year, and improve

productivity for businesses that regularly handle, store,

and use hazardous chemicals, with a cost savings of

$32.2 million for businesses that periodically update

safety data sheets (SDS) and labels. Complete imple-

mentation of the changes is expected by 2016; however,

employers have until December 2013 to train employees

on the system’s new requirements.

Hospitals are one of the primary businesses affected

by the revision of the Hazard Communication Standard,

which has been troublesome for healthcare facilities

even before this

change. OSHA

lists it as the third

most frequently

cited standard from

October 2010 to

September 2011.

Switching to the

new GHS system

should ultimately

make it easier for hospitals to protect employees who

regularly work with hazardous chemicals, says Bruce

Cunha, RN, MS, COHN-S, employee health and safety

manager at Marshfield (Wis.) Clinic.

“I’m usually moderately critical of OSHA and their

new rules, but I think this is a good, positive rule,” he

says. “I think it will help employees—it makes it easier

for them to understand the hazards of a chemical, and

[the change] makes for a much better rule.”

Training employees

Employee training, on both the laboratory and clinical

side, is the most immediate compliance need that safety

officers should focus on, says Kenneth Weinberg, BA,

MSc, PhD, an environmental health, safety, and toxicol-

ogy consultant with Safdoc Systems, LLC, in Stoughton,

Mass. Weinberg, who was previously the director of

“ Revising OSHA’s Hazard

Communication Standard

will ... [make] it safer for

workers to do their jobs

and easier for employers

to stay competitive in the

global marketplace.”

—Hilda L. Solis

IN THIS ISSUE

p. 7 CMS adopts sections of 2012 Life Safety CodeA memo declares CMS is accepting waivers on four sections of the Life Safety Code®, providing leeway for corridor clutter.

p. 9 Double-gloving can be both safe and effectiveAORN shows that double-gloving, particularly with an indicator glove, offers more protection during surgery.

p. 11 Learn from the past to aid the recovery processPast disasters give clues about what you need to consider for the long-term recovery process.

June 2012 Vol. 20, No. 6

www.hospitalsafetycenter.com June 2012

© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.

safety at Massachusetts General Hospital in Boston, says

clinical staff in particular might experience challenges

with hazard communication training.

“I believe this is going to be very confusing and a difficult

transition for hospital people,” he says. “I don’t think they

got the Hazard Communication Standard to begin with.”

Even though hospitals have until December 2013 to

train employees, safety officers should begin thinking about

how they will incorporate initial training into their curricu-

lum. Safety officers should provide initial notification of the

change and the basic aspects of the GHS system through

internal newsletters or emails, Weinberg says.

At Marshfield Clinic, Cunha says he typically trains

employees annually on hazard communication require-

ments. This year he plans to expand the training pro-

gram to include additional components that cover the

new revisions.

“In the past, you were required to provide hazard

communication training upon hire and repeat if you

found employees were not following the rules or if there

was a change in your process,” he says. “With GHS, you

need to add in training on the rule changes to ensure

employees understand the new system. I don't believe

that is going to be a big deal.”

According to Cunha, the health system had planned

to revamp its computer training program in June, which

would allow the system to integrate any required changes

to its hazard communication training.

Even though hazard communication training is only

required upon employment, Weinberg suggests incorpo-

rating it into fire safety training so employees get at least

a basic review each year.

Reorganizing your chemical inventory

One way to decrease the burden of the Hazard Com-

munication Standard is to go through your facility’s

chemical inventory and weed out any chemicals that are

no longer used. This cuts down on the number of hazards

and the number of GHS SDSs you need to have on file.

“I think if you’re going to go through all this, why not

do a review of your chemical inventory and do a clean

sweep of your chemicals?” Cunha says. “It amazes me

every time we’ve done clean sweeps in our facility and

we still find things we shouldn’t have anymore.”

The standard change also provides an opportunity to

separate any mixtures that may have unique hazards,

Weinberg says.

Each chemical should have a corresponding material

safety data sheet (MSDS), and manufacturers should be

preparing to send new GHS-compliant SDSs to hospitals

for each chemical.

“It’s the manufacturer’s responsibility to do that, but

Briefings on Hospital Safety (ISSN: 1076-5972 [print]; 1535-6817 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: Regular $299/year or $538/two years; Platinum $499/year; back issues are available at $25 each. • Briefings on Hospital Safety, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, outside the subscrib-er’s facility, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occa-sionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BHS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Editorial Advisory Board Briefings on Hospital Safety

Associate Editorial Director: Rebecca Hendren, [email protected]

Managing Editor: Tami Swartz, [email protected]

Editor: Evan Sweeney

Contributing Editor: Steven MacArthur, Safety Consultant, The Greeley Company, Danvers, Mass., [email protected]

Barbara Bisset, PhD, MS, MPH, RNExecutive Director Emergency Services Institute/WakeMed Raleigh, N.C.

Joseph Cocciardi, PhD, MS, CSP, CIHExecutive DirectorCocciardi & Associates Mechanicsburg, Pa.

Leo J. DeBobes, MA (OS&H), CSP, CHCM, CPEA, CHEP, CSC, EMTAssistant Administrator, Emergency Management/Regulatory ComplianceStony Brook University Medical Center Stony Brook, N.Y.

Elizabeth Di Giacomo-Geffers, RN, MPH, CSHAHealthcare ConsultantDi Giacomo-Geffers and Associates Orange County, Calif.

Zachary Goldfarb, EMT-P, CHSP, CEM, CHEPPresidentIncident Management Solutions, Inc. East Meadow, N.Y.

Ray W. Moughalian, BS, CHFRMPrincipalSaf-T-Man Methuen, Mass.

John L. Murray Jr., CHMM, CSP, CIHSafety DirectorBaystate Health Springfield, Mass.

Paul Penn, MS, CHEM, CHSPEnMagine/HAZMAT for Healthcare Diamond Springs, Calif.

Dalton Sawyer, MS, CHEPDirector, Emergency Preparedness and Continuity PlanningUNC Health CareChapel Hill, N.C.

Steve SchultzCorp. E&O Safety DirectorCape Fear Valley Health System Fayetteville, N.C.

Barry D. Watkins, MBA, MHA, CHSPSenior EC SpecialistCorporate Safety Carolinas HealthCare System Charlotte, N.C.

Kenneth S. Weinberg, PhD, MScPresidentSafdoc Systems, LLC Stoughton, Mass.

Earl Williams, HSPSafety SpecialistBroMenn Healthcare Bloomington, Ill.

Pier-George Zanoni, PE, CSP, CIHZLH Consulting St. Johns, Mich.

June 2012 www.hospitalsafetycenter.com


Do we have enough time?

as the user, it’s your responsibility to have those material

safety data sheets on hand. The other caveat to that is

if you had a guy that worked for you 12 years ago, he’s

not going to know the new material safety data sheets,

so you need to have the new ones as well as the old

ones,” Weinberg says.

Healthcare facilities should also review their hazard

communication plans. The revised OSHA standard won’t

necessarily force a hospital to drastically change its plan,

but many hospitals’ existing plans already have compliance

problems when survey time rolls around. Incorporating a

review of your plan along with the other changes should

help bolster the overall effectiveness of your program.

“My honest observation is there probably aren’t a lot

of hospitals that are truly in compliance with the hazard

communication program—that have their data sheets,

that have a chemical inventory list, that are keeping up

with that list, that are evaluating new products when

they come in and training employees,” Cunha says.

“I have my doubts. Unfortunately hospitals tend to lag

behind a little bit in the general industry category.”

Chemical labeling and SDS

The switch to the GHS system means manufacturers

will also have to switch the labels on their chemical con-

tainers. These labels will feature pictograms that provide

a summary of the hazards, readable by anyone regardless

of language.

Although the responsibility of producing these labels

falls largely on the shoulders of the manufacturer, hos-

pitals should provide information to their employees

on how to interpret them. Some chemicals will also be

reclassified under the GHS system.

“When we move to the GHS, I really do feel it’s going

to make it safer for employees,” Cunha says. “Now they

can pick up a bottle and they don’t have go get the data

sheet for more information. You’re going to be able to

pick up the bottle regardless of what language it’s in

wherever you are in the world, and you should have a

pretty good idea as to what the hazards are and what

you need to do to protect yourself.”

In addition to appropriate education, safety officers

should provide signage, particularly in laboratories, to help

employees quickly recognize the corresponding symbols.

Another change with the GHS system involves

new SDS forms. Fortunately, these are not very differ-

ent from the existing MSDS forms, Cunha says. Both

include much of the same information, although they

Does OSHA’s December 2013 deadline give employers enough time to train workers for the Globally

Harmonized System–related changes to the Hazard Communication Standard?

No

30%

Yes

70%

Source: OSHA Healthcare Advisor.



are structured slightly differently. (For more information

on GHS safety data sheets, See “Minimum information

necessary for a GHS safety data sheet” on p. 5.)

“I did a seminar on this and one of the questions was,

‘Do we have to get rid of all our data sheets and now get

the new ones?’ ” Cunha says. “And the answer is, you

should be getting those new data sheets as they are being

manufactured anyway.”

One slight caveat that may affect larger hospitals is

that any lab producing items for outside entities needs to

provide an SDS, Cunha says. For example, one of the labs

at Marshfield Clinic does 24-hour urine tests that include

a preservative. Those tests need to be accompanied by a

data sheet when they are sent out, and once the OSHA

revisions take full effect in 2016, the data sheets should be

replaced by the GHS SDS forms.

“If you have a large laboratory and you have outreach

or outside clients and you’re supplying them with formalin

containers, you have to provide them with a data sheet

since you’re the supplier,” Cunha says. “That’s something

that most hospitals might want to look at. Does your lab

provide any chemicals to any of your outside customers?”

Higher priority on a newer standard

New standard revisions usually mean more focus

from surveyors, and this standard is likely to follow

the same trend. “I think they are probably going to

want to take a look at hazard communication since

it is a new regulation change—I think they will ask a

little bit more about it,” Cunha says. “Are we going to

see more fines because there aren’t written programs?

Yeah, probably; OSHA’s been on a big enforcement

kick lately.”

But this regulatory change isn’t nearly as onerous as

a new standard, since many of the same requirements

are still in place. Hospitals still need to document compli-

ance in two main areas: hazard communication plan and

employee training.

“When an OSHA inspector comes in, one of the

first things they do is go through all your written

standards, so if you don’t have a written hazard

communication standard, you get dinged,” Weinberg

says. “Then they are going to start to check about

training and how you can prove you did the training,

so if you don’t have that, you get dinged. And now

it’s a revised regulation, so it’s like bloodborne patho-

gens when it first came up. What they are going to

do is target bigger hospitals like the UCLAs and NYUs

and Mass Generals because those are the ones to

make examples of.” n

Take the guesswork out of complying with the newly modified OSHA Hazard Communication Standard and PPE requirements

Changes to the OSHA Hazard Communication (HazCom)

Standard through adoption of the Globally Harmonized

System (GHS) of Classification and Labelling of Chemicals,

and the new Enforcement Guidance for Personal Protective

Equipment in General Industry, are two of the most significant

changes from OSHA this year. The HazCom/GHS changes

will require critical compliance and training adjustments for

healthcare facilities. OSHA is also currently citing businesses

for personal protective equipment (PPE) enforcement guid-

ance violations under the February 2011 changes to the

requirements.

In HCPro’s 90-minute audio conference from June 2011,

“HazCom/GHS and PPE Enforcement: Understanding the

New Requirements for OSHA Compliance in Healthcare,”

healthcare industry experts discuss how these changes affect

your workplace, provide a timeline for implementation, and

offer tools to help you train your staff. You’ll be able to:

➤ Determine how the proposed changes to the HazCom

standard will affect your organization

➤ Establish a timeline for implementation and staff training

➤ Understand the new PPE enforcement guidance and

how it specifically relates to healthcare

➤ Implement a compliant hazard assessment program

Visit www.hcmarketplace.com/prod-9593 for more infor-

mation and to listen to the on-demand program.



Minimum information necessary for a GHS safety data sheet

Identification of the

substance or mixture

and of the supplier

➤ GHS product identifier

➤ Other means of identification

➤ Recommended use of the chemical and restrictions on use

➤ Supplier’s details (including name, address, phone number, etc.)

➤ Emergency phone number

Hazards identification ➤ GHS classification of the substance/mixture and any national or regional information.

➤ GHS label elements, including precautionary statements. (Hazard symbols may be

provided as a graphical reproduction of the symbols in black and white or the name of

the symbol—e.g., flame, skull and crossbones.)

➤ Other hazards which do not result in classification (e.g., dust explosion hazard) or are not

covered by the GHS.

Composition/

information on

ingredients

Substance

➤ Chemical identity

➤ Common name, synonyms, etc.

➤ Chemical abstract service (CAS) number, European Commission (EC) number, etc.

➤ Impurities and stabilizing additives that are themselves classified and that contribute to the

classification of the substance

Mixture

➤ The chemical identity and concentration or concentration ranges of all ingredients which

are hazardous within the meaning of the GHS and are present above their cutoff levels

Note: For information on ingredients, the competent authority rules for confidential business infor-

mation (CBI) take priority over the rules for product identification.

First aid measures ➤ Description of necessary measures, subdivided according to the different routes of

exposure, i.e., inhalation, skin and eye contact, and ingestion

➤ Most important symptoms/effects, acute and delayed

➤ Indication of immediate medical attention and special treatment needed, if necessary

Firefighting measures ➤ Suitable (and unsuitable) extinguishing media

➤ Specific hazards arising from the chemical (e.g., nature of any hazardous combustion

products)

➤ Special protective equipment and precautions for firefighters

Accidental release

measures

➤ Personal precautions, protective equipment, and emergency procedures

➤ Environmental precautions

➤ Methods and materials for containment and cleaning up

Handling and storage ➤ Precautions for safe handling

➤ Conditions for safe storage, including any incompatibilities

Exposure controls/

personal protection

➤ Control parameters, (e.g., occupational exposure limit values or biological limit values)

➤ Appropriate engineering controls

➤ Individual protection measures, such as personal protective equipment

Physical and chemical

properties

➤ Appearance (physical state, color, etc.)

➤ Odor

➤ Odor threshold

➤ pH level



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Minimum information necessary for a GHS safety data sheet (cont.)

Physical and chemical

properties (cont.)

➤ Melting point/freezing point

➤ Initial boiling point and boiling range

➤ Flash point

➤ Evaporation rate

➤ Flammability (solid, gas)

➤ Upper/lower flammability or explosive limits

➤ Vapor pressure

➤ Vapor density

➤ Relative density

➤ Solubility(ies)

➤ Partition coefficient: n-octanol/water

➤ Autoignition temperature

➤ Decomposition temperature

Stability and reactivity ➤ Chemical stability

➤ Possibility of hazardous reactions

➤ Conditions to avoid (e.g., static discharge, shock or vibration)

➤ Incompatible materials

➤ Hazardous decomposition products

Toxicological

information

➤ Concise but complete and comprehensible description of the various toxicological

(health) effects and the available data used to identify those effects, including:

– Information on the likely routes of exposure (inhalation, ingestion, skin and eye contact)

– Symptoms related to the physical, chemical, and toxicological characteristics

– Delayed, immediate, and chronic effects from short- and long-term exposure

– Numerical measures of toxicity (such as acute toxicity estimates)

Ecological information ➤ Ecotoxicity (aquatic and terrestrial, where available)

➤ Persistence and degradability

➤ Bioaccumulative potential

➤ Mobility in soil

➤ Other adverse effects

Disposal considerations ➤ Description of waste residues and information on their safe handling and methods of dis-

posal, including the disposal of any contaminated packaging

Transport information ➤ United Nations (UN) number

➤ UN proper shipping name

➤ Transport hazard class(es)

➤ Packing group, if applicable

➤ Marine pollutant (yes/no)

➤ Special precautions that a user needs to be aware of or needs to comply with in

connection with transport or conveyance either within or outside the premises

Regulatory information ➤ Safety, health, and environmental regulations specific to the product in question

Source: OSHA, A Guide to the Globally Harmonized System of Classification and Labelling of Chemicals.



CMS adopts sections of 2012 Life Safety CodeMemo: CMS accepting waivers on four sections of the Life Safety Code, providing leeway for corridor clutter

A Centers for Medicare & Medicaid Services (CMS)

memo released in March offers some flexibility for

healthcare facilities in terms of Life Safety Code® (LSC)

compliance, particularly when it comes to corridor

clutter and combustible decorations.

The memo states that CMS will immediately allow

hospitals to adopt four sections of the 2012 LSC, also

known as National Fire Protection Association 101.

CMS is looking at eventually adopting the entire 2012

edition of the code, but is allowing hospitals to adopt

these sections now through a waiver process. The sec-

tions address the following issues:

➤ Previously restricted items that can now be placed in

exit corridors

➤ The recognition that a kitchen is not a hazardous area

and can be open to an exit corridor under certain

circumstances

➤ The installation of direct-vent gas fireplaces and solid

fuel burning fireplaces

➤ The installation of combustible decorations

CMS decided to adopt these 2012 LSC changes early

in order to appease strong lobbying groups representing

nursing homes, says Brad Keyes, CHSP, a consultant

with Keyes Life Safety Compliance.

“Apparently, owners of nursing homes want to design

new structures with some amenities that you may find

in a retirement home, or perhaps even in a nice home,”

Keyes says.

While most of the changes benefit nursing homes,

the changes were made under the general category

of “healthcare occupancy,” meaning that they will

also apply to hospitals. This will offer some leeway in

comparison to the 2000 LSC that was fully adopted by

CMS, says Steven MacArthur, safety consultant for

The Greeley Company, a division of HCPro, Inc., in

Danvers, Mass.

“CMS is cherry-picking some of the more useful

and influential standards, and allowing hospitals

and nursing homes to take advantage of the more

flexible 2012 requirements for things such as corridor

storage and the presence of combustible decorations

in the care environment, both which had very limited

application based on the 2000 edition of the Life Safety

Code, which is the current enforcement document,”

MacArthur says.

More flexibility with corridor space and

decorations

Of the four changes, corridor clutter and combustible

decorations are the most applicable to the hospital en-

vironment. Fireplaces and kitchens open to the corridor

are issues more commonly found in nursing home envi-

ronments rather than the traditional healthcare setting.

Historically, corridor clutter has been a notorious com-

pliance problem for hospitals, but the new requirements

allow for slightly more leeway, particularly with wheeled

equipment, Keyes says. Wheeled equipment is permitted

to be left unattended in the corridor for more than 30

minutes, provided:

➤ The equipment does not reduce the clear unobstructed

corridor width to less than 5 feet.

➤ The fire safety plan addresses the relocation of

wheeled equipment during a fire emergency. The

plan must identify where the wheeled equipment

will be relocated.

➤ The wheeled equipment is limited to equipment that

is in use, medical emergency equipment not in use,

and patient lift and transport equipment. Beds are not

considered transport equipment or emergency medical

equipment, so they will not be allowed in corridors.

Fixed seating may be installed in corridors that are at

least 8 feet wide, but it cannot project more than 2 feet



into the corridor. Fixed seating must also be attached to

the wall or floor and cannot be installed on both sides of

the hallway. There are size limitations and requirements

regarding sprinkler systems as well.

In terms of decorations, the 2012 LSC moves from no

combustible decorations outlined in the 2000 edition,

to allowing 20% of the wall, ceiling, and doors to be

covered with combustible decorations in non-sprinklered

smoke compartments.

“That amount goes up to 30% in smoke compart-

ments fully protected with automatic sprinklers; and

will be allowed to go up to 50% of wall, ceiling, and

doors to be covered in patient sleeping rooms that do

not exceed more than four patients, in a smoke com-

partment fully protected with automatic sprinklers,”

Keyes says.

The waiver process

The Social Security Amendment Act of 1965, which

created the Medicare and Medicaid programs, requires

any healthcare facility receiving CMS funding to comply

with the LSC. Since CMS has currently adopted the 2000

edition of the LSC, it is not allowed to simply adopt a

portion of the 2012 edition.

“If an organization cannot comply with a certain LSC

requirement, and the resolution of that LSC deficiency

would be considered a significant hardship to do so, the

organization is allowed to submit a request to CMS to

waive that portion of the LSC, which means they do not

have to comply with it, if approved,” Keyes says.

The March CMS memo is unique because the agency

is straightforwardly saying that a healthcare facility

requesting a waiver does not need to demonstrate an

unreasonable hardship to comply with the four sections

of the 2012 code.

“That makes sense, and if there was a hardship, then

they just need to fall back onto the 2000 edition, which

does not allow these four changes,” Keyes says.

MacArthur suspects that hospitals will have to ensure

their facilities have full sprinkler protection in order

to prove they are in compliance with the 2012 LSC

requirements.

“The memorandum doesn’t provide a great deal of

specific information, so this is a course that will likely

have to be plotted as we go,” he says.

The benefits of staying with the 2000 LSC

Although the four sections of the 2012 LSC allow for

more leeway concerning decorations and corridor clut-

ter, it may be more of a headache to apply for a waiver

rather than simply staying within the confines of the

more constrictive 2000 LSC requirements. The memo

does not require hospitals to switch to the 2012 LSC—it

merely gives them the option to do so if they choose.

Keyes says if he were a safety officer at a hospital, he

would not be interested in pursuing a waiver request

because allowing staff members to leave unattended

medical equipment in corridors forms bad habits, even

if the equipment does not reduce the corridor to less

than 5 feet. “My experience with staff is they will either

intentionally or unintentionally abuse the restrictions of

this new rule,” Keyes says. “Give them an inch and they

will take a mile.”

Additionally, training staff members to recognize the

nuances of the 2012 LSC can be onerous. For example,

recognizing medical equipment that is not in use versus

in storage can be difficult.

“Unless the medical equipment in storage has plastic

bags over them, then it’s pretty difficult to say whether

it’s in storage or not in use,” Keyes says. “If you can’t tell,

how do you expect a surveyor to know?”

Submitting a waiver also means your fire plan needs

to clearly state where wheeled equipment will be

relocated. A plan that states the equipment will be put

in a vacant patient room is not effective since there may

be circumstances during an emergency where all patient

rooms are full.

In the end, submitting waivers to adopt the 2012 LSC

changes may be more work than they are worth, Keyes

and MacArthur say. n



Double-gloving can be both safe and effectiveAORN shows that double-gloving, particularly with an indicator glove, offers more protection during surgery

A study published by the Association of periOpera-

tive Registered Nurses (AORN) in March focused on

the benefits of double-gloving during surgery, a practice

that has been endorsed by many associations as a means

to significantly reduce healthcare worker exposure to

bloodborne pathogens.

The results were published after a 24-month investi-

gation by researchers examining the effect of using inner

indicator gloves and the detection of tears or perforations

during surgery.

Although many organizations already support

double- gloving during surgery, this study lends addi-

tional support to the practice’s safety and efficacy, says

Denise Korniewicz, PhD, RN, FAAN, dean and

professor at the College of Nursing at the University of

North Dakota in Grand Forks.

“I think when you have the data that we presented

where you can actually demonstrate that you have more

safety resulting from use of double-gloving, I think it does

give more credence to standards and a set policy,” she says.

Professional recommendations for double-gloving

The Association of Surgical Technologists published Rec-

ommended Standards of Practice for Gowning and Gloving,

which recommends double-gloving for all surgical proce-

dures based on a review of five major studies that revealed

the following:

➤ There is no difference in the number of perforations be-

tween a single pair of gloves and the outer glove when a

healthcare worker double-gloves; however, the number

of perforations in the innermost glove is significantly re-

duced during double-gloving

➤ There is no difference in the number of perforations to

the innermost glove when double-gloving as compared

to wearing a single pair of orthopedic gloves

➤ When the innermost glove is colored when double-glov-

ing, it is considerably easier to detect perforations to the

outer glove, but the detection of perforations of the in-

nermost glove does not increase

➤ Wearing glove liners between the two gloves when

double-gloving significantly reduces the number of

perforations to the inner glove

➤ Wearing an outer cloth glove over the inner glove signifi-

cantly reduces perforations to the inner glove

➤ There was no difference in the number of perforations

to the innermost glove when wearing steel-weave gloves

compared to standard double-gloving

If a sharps injury does occur, double-gloving reduces the

amount of exposure to blood or body fluid since it is being

wiped or stripped off of the instrument as it passes through

the first glove.

In 2004, the American College of Surgeons addressed

the use of double-gloving in an article published in the

Journal of the American College of Surgeons. The authors in-

dicated that perforation rates were as high as 61% among

thoracic surgeons and 40% among scrub nurses. Subse-

quently, double-gloving reduced the risk of exposure to

patient blood as much as 87% when the outer glove was

punctured, and the volume of blood on a suture needle

was reduced as much as 95% when passing through two

glove layers. However, the authors noted that there is still

widespread perception among surgeons that double-gloving

reduces hand sensitivity and dexterity.

Overall, a large body of literature and data suggests

double-gloving is safe and effective, thus supporting the

practice.

A number of other organizations, including the Centers

for Disease Control and Prevention, the Association of peri-

Operative Registered Nurses, and the American Academy

of Orthopedic Surgeons, also support the use of double-

gloving and offer recommendations and support for the

practice.



Double-gloving has become more commonplace

in recent years, Korniewicz adds, particularly because

more organizations are publishing recommendations

as part of their policy statements or clinical guidelines.

Healthcare workers are particularly compliant with these

recommendations when they are working with high-risk

patients who are known hepatitis or HIV carriers. Now,

it’s become clearer that double-gloving provides additional

safety and equal effectiveness regardless of the patient.

Using indicator gloves

The use of indicator gloves is particularly effective when

double-gloving, as evidenced in the published study.

Indicator gloves are a different color than the outer

glove, which makes it easier to recognize a tear or perfo-

ration. The study found that the frequency of changing

gloves during surgery was significantly higher among

healthcare providers who wore dark-colored gloves under

light-colored gloves versus those who wore two pairs of

gloves that were the same color. Approximately 69%

of participants who wore indicator gloves changed their

gloves during a procedure.

“It’s automatic,” Korniewicz says. “It’s like, ‘Oh, wow,

I’ve breached the glove and I should change it.’ When you

use two white gloves or two blue gloves, that’s harder to

detect, and I think that’s the advantage of having the color

coding. When you see something right away, you do it

right away.”

Researchers found that healthcare workers expressed

positive feedback about indicator gloves because they

were able to see perforations right away rather than

discovering them after the surgery was over. As a result,

many workers said they felt safer when double-gloving.

Changing attitudes

One of the common complaints from surgeons about

double-gloving is that it hinders hand sensitivity and

dexterity. However, previous studies have shown that

position is no longer the majority opinion, especially

since manufacturers now make better-fitting surgical

gloves. As a result, surgeons are much more accepting

of double-gloving than they have been in the past.

“[Gloves] are more flexible than they were in the

past, so when you wear two gloves it’s not nearly as

burdensome,” Korniewicz says. Additionally, healthcare

facilities have created more awareness through their

annual bloodborne pathogens training, and more pro-

fessional organizations include double-gloving in their

recommendations. (For a summary of recommendations,

see “Professional recommendations for double-gloving”

sidebar on p. 9.)

“I think when the professional organizations move

forward and say it’s safer, that’s when behavior changes,”

says Korniewicz. “I don’t think it’s because of one or two

research studies that change automatically happens; I

think it takes a while in practice.” n

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Past disasters give clues into the recovery processManaging a large-scale disaster can be difficult enough, but without long-term recovery plans, your hospital is doomed from the start

When you look back at the major disasters of the last

decade, a few come to mind right away. The 10-year

anniversary of 9/11 was last September; Hurricane

Katrina struck in 2005; and most recently Joplin, Mo.,

was destroyed by a category EF5 tornado that virtu-

ally wiped out the local hospital. Overseas, Japan is still

feeling the impact of a deadly tsunami that struck early

in 2011.

Major disasters like these can ravage a community for

months or even years, but once healthcare facilities have

returned to normal operations, their experience provides

a learning opportunity for other hospitals, particularly

when it comes to disaster recovery.

Hospitals need to strike a balance between mitigat-

ing the immediate effects of a disaster in order to treat

the surge of patients and moving forward to return to

normal operations. These are decisions that are typically

made by facility managers along with hospital leader-

ship, says Mary Comerio, a professor of architecture

at UC Berkley College of Environmental Design and an

internationally recognized expert on disaster recovery.

“You are coping and you have a plan on how you’re

going to get back into operation,” she says. “It’s a two-

pronged approach. If you just cope with the emergency

and you’re not dealing with the long term, you’re shoot-

ing yourself in the foot.”

Recovery begins on day one

The immediate aftermath of a disaster will throw

every process off balance, and the following 24 hours

will focus mostly on minimizing the damage, setting up

triage units, and safely caring for existing patients.

But during that time, facility managers and emer-

gency managers should start to think about how their

decisions will affect operations in the future.

“I think the sacred saying of most people in any local

government or emergency management is that ‘recovery

begins on day one;’ this is when you have to start plan-

ning your long-term recovery even while you’re coping

with the immediate impact,” Comerio says.

Initially, the main priority is ensuring safety for all

patients. This often involves a review of basic facility

issues such as:

➤ Power

➤ Emergency generators

➤ Lights

➤ Water

➤ Evacuation or closure of units

➤ Communication

Long-term repairs, particularly architectural or design

repairs, should also be evaluated at this time, with the

understanding that major damage could take years to

fix due to all of the needed permits, engineering evalua-

tions, and—of course—financing. For example, Charity

Hospital in New Orleans took nearly five years to get

back to normal operations after being devastated by Hur-

ricane Katrina.

“All of those things take time, and I think people are

often unfortunately a bit naïve about understanding

why you can’t just snap your fingers and make it better,”

Comerio says.

Recovery planning

Planning for immediate disaster management is often

the primary focus for hospitals, but those plans should

Contact Managing Editor Tami Swartz

Telephone 781-639-1872, Ext. 3165

Email [email protected]

Questions? Comments? Ideas?



also include plans and goals for long-term recovery. “A

lot is going to be happening simul taneously, and people

need to have plans in place on how to deal with all those

things,” Comerio says.

Sometimes even the most unexpected issues can

cause major long-term problems. For example, a health-

care complex in New Zealand had to shut down entire

buildings and evacuate patients after an earthquake.

There was no visible structural damage to the complex,

but the earthquake shook the fuel in the emergency

tanks, disturbing some of the ducts and sealing off the

tanks so the emergency generators were inoperable. The

facility had to first evacuate the buildings, and then get

the tanks inspected and repaired, Comerio says.

Although all disasters are unique, incorporating long-

term recovery options into disaster drills and exercises

provides some preparation for the real event. For exam-

ple, designing scenarios where an entire wing is wiped

out allows strategic thinking on how the event will af-

fect the hospital and the time frame for rebuilding.

However, the most important part of recovery plan-

ning is deciding who gets to decide.

“You can’t always solve all of those things ahead of

time, but you really need a structure in place so there is

a clear hierarchy of who is making decisions and why,”

Comerio says. “That’s really critical. It sounds silly but it’s

really important.”

These responsibilities should be incorporated into the

hospital’s incident command chart. One or two hospital

leaders should be charged with making the final deci-

sions during disasters, with a team of staff members who

can contribute to the decision process.

Learning from the past

Healthcare facilities can learn a lot from past disasters,

particularly concerning the recovery process. One of the

primary issues that communities have learned in the af-

termath of a catastrophe is that without reliable health-

care, residents will quickly flee.

“This was really a significant lesson from Hurricane

Katrina with the closure of Charity Hospital,” Comerio

says. “Universities are trying to restart and companies are

trying to rebuild their businesses, and their workers are

saying, ‘I’m not going to stay here without any health-

care. If there is no hospital in this community, I’m not

going to put my family at that kind of risk.’ ”

This issue is particularly important in rural areas that

rely on a single healthcare facility. If a disaster impedes

the facility’s ability to safely operate, the entire com-

munity needs to prioritize getting the hospital up and

running before the population leaves.

In urban areas, healthcare facilities need to collabo-

rate to look at where their major losses are and how

they can work together to serve the health needs of

the population while also rebuilding devastated

facilities.

“In San Francisco, where earthquakes are inevi-

table, there could be one on the Hayward Fault or there

could be one on the San Andreas Fault,” Comerio says.

“ Depending on where an earthquake happens, some

facilities will be more impacted than others, so under-

standing that local network and understanding how

you can redirect and reorganize services within [those

constraints] is critical in terms of planning.”

One very specific lesson that has become clear from

past disasters: Elevators will inevitably fail. Comerio says

elevator failure can be an enormous strain on emergency

management processes. Even if they’re not broken,

something may go off track on a cable and it may take

time to have the elevators inspected and reset.

“[Elevator failure] is something that hospitals have

to plan for and they don’t,” she says. “It’s amazing how

they never think of this, but it happens in almost every

single disaster.” n

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IAHSS releases security design guidelinesNew guidelines provide resource for security directors and design teams during building and renovation

Security directors who feel out of the loop when it

comes to building and renovation projects finally have a

resource to lean on.

In March, the International Association for Health-

care Security and Safety (IAHSS) released Design and

Renovation Guidelines for Healthcare Facilities, with secu-

rity-specific guidance for projects ranging from new

facility construction to renovation of high-risk areas of

hospitals, including the ED, pharmacy, and infant and

pediatric units. (“See IAHSS General Guidelines” on p. 3

for an excerpt of the official guidelines.)

The hope is that this guideline will encourage securi-

ty and safety leaders to inject themselves into the plan-

ning stages of building and renovation projects, and

encourage architects, designers, and other healthcare

leaders to take a closer look at how their blueprints will

affect hospital security, says Tom Smith, CHPA, CPP,

director of hospital police and transportation at UNC

Health Care in Chapel Hill, N.C., and task force chair

for the IAHSS guidelines.

“What I’ve seen happen in some cases is people don’t

really start thinking about security seriously until short-

ly before or after a new facility opens, and they start

putting locks on the doors thinking about how they

are going to secure the place at night when no one is

around,” Smith says. “Or they build the stairwell in the

wrong place, so we have to leave areas open so people

can get to the emergency exit because of Life Safety Code®

requirements.”

The guidelines should also give everyone involved in

new construction or renovation projects the knowledge

and confidence to feel they can effectively contrib-

ute to pre-construction and design meetings and inte-

grate security features into their projects, says Evelyn

Meserve, CHPA, executive director of IAHSS.

“The guide-

lines are written

to provide the ba-

sic information re-

quired to allow

security to be pro-

active during the

design or renova-

tion process,” she

says. “By bringing the guidelines to the table at the initial

stage, security will be at the forefront of the thought pro-

cess throughout the project.”

Talk the talk

Sometimes simply knowing design terminology is half

the battle. The IAHSS design guidelines help break down

specific security concerns for each unit and how they re-

late to building plans.

“Some security directors or end users on the design

team are unfamiliar with the lingo and less likely to in-

terject themselves to advocate for reasonable security

features,” Smith says. “Our hope is they can tear off a

page of these design guidelines and use the principles set

forth to develop their own elements of security and safe-

ty in each project.”

The general guideline (see p. 3) sets an overall tone for

security design issues that may come up during any proj-

ect. Each subsequent chapter delves more into the specif-

ics of renovations to EDs and other high-risk areas.

For new building construction, the guidelines ad-

dress issues related to parking and the external campus

June 2012 Vol. 8, No. 6

“ By bringing the guidelines

to the table at the

initial stage, security

will be at the forefront

of the thought process

throughout the project.”

—Evelyn Meserve, CHPA

Healthcare Security Alert June 2012


environment and then move into buildings and the

internal environment.

Get involved early

The key to effectively using the building and design

guidelines is to incorporate them early on in the pro-

cess. When security gets involved late in a project, too

many issues are already overlooked, and the hospital

ends up paying for them in the long run.

“It’s so much less expensive if it’s designed in rath-

er than retrofitting it,” Smith says. “It’s good to put the

security features in early on, rather than wait until the

building is up and open.”

Getting involved early as a security director often

means getting invited to design meetings. Smith recom-

mends photocopying chapters of the IAHSS guidelines

and sending them to clinical leaders on each unit. Even

if there is no current renovation happening, being pro-

active increases the chance that they will think about in-

cluding security when the time comes.

“Initial awareness of security in the early stage pro-

vides tremendous benefit to the facility and the securi-

ty department,” Meserve says. “The awareness varies at

different facilities, but I believe the guidelines will be a

resource document that helps improve the consistency of

awareness at all levels.”

Building relationships with key unit leaders and

department heads will also help during the value

engineering period, Smith says. During this period,

clinical leaders and medical directors sometimes fail to

differentiate between wants and needs. If they favor a

particular feature over security, security will most likely

be trumped in the final plan.

“What I find most of the time is that it’s just that they

aren’t thinking about it,” Smith says. “Of course they

want security. The clinical staff—especially in the se-

curity-sensitive areas like the emergency department,

behavioral and mental health locations, and the phar-

macy—they want to keep themselves safe. It’s just that

when you’re designing it, that’s when you have the op-

portunity to remind them.”

Avoid costly mistakes by doing it right

the first time

Smith has heard dozens of horror stories about hastily

built facilities that turned out to be access control night-

mares as a result.

For example, he recalls one tale about an eight-story

healthcare building whose elevators and emergency ex-

it stairwells were configured such that occupants had to

walk through clinical areas—areas that were meant to

be secured during nonbusiness hours and not meant to

be used as a public throughway during normal business

hours. This was a fatal security design flaw that resulted

in thousands of dollars of retrofitting.

“Here was an eight-story building attached to a

major medical complex and you can’t lock the doors

when the staff go home at five o’clock,” Smith says.

“It’s a simple thing like that where it costs a lot of mon-

ey to retrofit and provide a reasonable level of security

at a later date.”

These mistakes usually happen because design and

operations leaders are thinking more about work flow

and aesthetics, rather than what happens during non-

business hours. Security directors can offer their unique

perspective to avoid a situation that creates a financial

burden down the road. n

Russ Colling, MS, CHPA, CPPHealthcare Security ConsultantColling and Kramer Salida, Colo.

Steven C. Dettman, BS, CHPADirector, Security and Visitor Support Services Mayo Clinic Hospital Phoenix, Ariz.

Linda Glasson, CHPA Security ConsultantSuffolk, Va.

Steven MacArthurSafety ConsultantThe Greeley Company Danvers, Mass.

Anthony N. Potter, CHE, CHPA-F, CPP, FAAFSMarket Director of Public SafetyNovant Health Winston-Salem, N.C.

Fredrick G. Roll, MA, CHPA-F, CPP President and Principal ConsultantHealthcare Security Consultants, Inc., and Roll Enterprises, Inc. Frederick, Colo.

Associate

Editorial Director: Rebecca Hendren, [email protected]

Managing Editor: Tami Swartz, [email protected]

Editor: Evan Sweeney

Editorial Advisory Board Healthcare Security Alert

June 2012 Healthcare Security Alert Page 3


IAHSS General Guideline

Statement: Acts of violence, the potential for crime and ter-

rorism, and the response to and mitigation of emergency inci-

dents are significant concerns for all Healthcare Facilities (HCFs).

A consideration of these concerns in the design of new or reno-

vated HCFs presents an opportunity to implement and integrate

security design elements that address the delivery of patient care

services in a reasonably safe and secure environment, and allows

for the cost-effective integration of security applications in archi-

tectural, engineering, and environmental design.

Intent:

a. The IAHSS Security Design Guidelines are intended to

provide guidance to healthcare security practitioners,

architects, and building owner representatives involved

in the design process in order to ensure that these best

practices are considered and integrated, where possi-

ble, into each new and renovated HCF space.

b. This General Guideline establishes a background and

framework for subsequent guidelines covering specific

areas of vulnerability and should be utilized as a frame

of reference and underpinning for incorporating ap-

propriate security features into the design of all new

construction and renovation projects. These guidelines

include reference materials that provide further de-

tailed subject matter elaboration.

c. The initial planning and conceptual design phase of all

newly constructed or renovated HCFs should include a

security risk assessment conducted by a qualified secu-

rity professional.

d. The size, complexity, and scope of services provided

within an HCF can vary significantly. Security design

considerations should be risk appropriate for the envi-

ronment and function, while maintaining design con-

sistency across the HCF. Design considerations should

support patient care, provide a positive employee and

consumer experience, proactively mitigate risk, and

address real and perceived security concerns.

e. The development or continuation of institutional

design standards related to the protection of vulnera-

ble patient populations, the securing of sensitive areas,

the application of security and safety systems—as well

as the infrastructure required to support these needs—

are issues best addressed early in the design process to

be most cost-effective.

f. The design of HCFs should include consultation with

the organizational security representative to identify,

design, and provide protective measures. The project

design team should prepare and submit plans to the

project security representative for review and approval,

including a comprehensive security plan that indicates a

layered approach. This plan will include zones, control

points, circulation routes, and physical security technol-

ogy locations, and should be reviewed by the security

representative prior to submittal to the planning, regu-

latory, and approval authorities. Integrating these de-

sign considerations into the development of submittal

documents and through the commissioning process will

help avoid costly security and safety retrofits.

g. The integration of these guidelines should be in col-

laboration with the entire design team. Design con-

siderations should coordinate the security plan, the

building Life Safety plan, and the regulations that have

jurisdiction in the local environment. This type of co-

ordination will ensure egress paths do not access areas

of lower security through areas of higher security.

h. Security requirements for construction, commission-

ing, and move-in will vary according to the complex-

ity and scope of services provided. A security project

plan should be developed that is risk appropriate for

the environment and function and should include:

– The impact of demolition and phasing of existing site

functions and protection efforts.

– The need for temporary security barriers such as fenc-

ing and security systems, including intrusion and video

surveillance.

– The installation of security systems should be sched-

uled for completion to allow for protection of the facil-

ity and equipment during early move-in activities.

i. An HCF’s surroundings may include open space, park-

ing facilities, and private ways, and may border other

businesses, residential properties, major transporta-

tion routes, or other areas. The design of HCFs relat-

ed to site planning is addressed within the Parking and

Healthcare Security Alert June 2012


CPTED layers may include:

– The first layer of protection should be at the perimeter of

the property, which limits points of entry. The campus pe-

rimeter should be defined by fences, landscape, or other

barriers. At certain locations, this may include the building

exterior. Campus entry points should be controllable dur-

ing emergency situations or heightened security levels.

– The second layer of protection should be at the

building perimeter and consist of doors, windows, or

other openings. Protective elements or components

may include access-control hardware, intrusion de-

tection, video surveillance, use of protective glazing

materials, or personnel for control and screening at se-

lected entrances during designated times.

– The third layer of protection should be inside the

building itself, segregating authorized and unauthor-

ized visitors. Using physical and psychological barriers

and hardware, this layer is most frequently applied in

areas of higher risk such as emergency treatment ar-

eas, intensive care units, mental health areas, pediatric

units, newborn nurseries, and recovery rooms.

– The fourth layer of protection should segregate

generally accessible public and patient areas and

staff-only areas. Using physical barriers and locking

hardware, this layer is most frequently applied to areas

that restrict all visitors and limit access to HCF staff on-

ly in areas such as nursing offices, staff locker rooms,

storage and distribution locations, food preparation,

sterile corridors, and research laboratories.

– The fifth layer of protection should further restrict staff

access to highly sensitive areas. Using physical barriers

and locking hardware, this layer is most frequently ap-

plied to areas that are limited to vetted and authorized

HCF staff. These areas frequently include the pharma-

cy and narcotic storage spaces, hazardous materials,

plant utility and information technology infrastructure,

and areas housing personal health information (PHI).

Security design considerations for such areas should

be addressed in accordance with applicable regulatory

oversight, standards, and guidelines.

External Campus Environment Design Guideline.

j. HCFs provide care to patients in both inpatient and out-

patient areas and may include non-patient care areas

such as academic and research space. These areas may

present specific risks or security concerns and the design

of HCFs related to these types of areas are addressed

within the Buildings and the Internal Environment Design

Guideline. These areas, which are addressed in specific

design guidelines, include:

– Inpatient Facilities

– Emergency Department

– Mental Health Areas

– Pharmacies

– Cashier and Cash Collection Areas

– Infant and Pediatric Facilities

– Protected Health Information Areas

– Utility, Mechanical, and Infrastructure Areas

– Biological, Chemical, and Radiation Areas

k. HCFs frequently provide both scheduled and emergen-

cy services, serve as part of local emergency response

networks, and are frequently expected to be functional,

safe, and secure for patients, visitors, and staff while re-

maining prepared for natural and man-made emergen-

cies 24/7. The design of HCFs related to these types of

issues is addressed within the Emergency Management

Design Guideline.

l. The development of the Security Design Guidelines for

Healthcare Facilities reflects the principles of Crime Pre-

vention Through Environmental Design (CPTED). These

principles, when applied early, can be integrated into

any HCF design providing layers of protection for pa-

tients, visitors, and staff.

m. CPTED defines territories and how they are controlled

and managed based on the use of “concentric rings

of control and protection.” Outermost rings are sup-

ported by additional inner rings of protection. Each

of these concentric rings will be addressed as layers of

protection within these guidelines and are intended

to sequentially deter, deny access to, and slow down

possible malefactors. In the healthcare environment,

Source: Security Design Guidelines for Healthcare Facilities, IAHSS. Published 2012. Reprinted with permission.

IAHSS General Guideline (cont.)

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