briefings on hospital safety - on meeting the joint commission’s new patient ... the emergency...

Your heart could start poundingon Valentine’s Day—but not forthe reasons you might wish—ifyou don’t update your staff mem-bers about the newest rules onshipping infectious substances.

The revisions from the Departmentof Transportation (DOT) go intoeffect February 14. Too bad there’snothing romantic about regulations.

The government’s biggest piece ofadvice is to train affected employ-ees on the changes beforehand, saysPatricia Klinger, a spokespersonfor the DOT’s Research and SpecialPrograms Administration.

“Generally, hospitals should alreadybe aware of [their] responsibilitiesunder our regulations,” Klingersays.

“Hospitals should read the newfinal rule and compare its provi-sions with current requirements toidentify changes that affect theiroperations,” she adds.

However, many hospitals simplydon’t have the staff to properly trainpeople on shipping infectious ma-terials, leaving the burden on theshoulders of the safety officer, saysBarry Johnston, president ofHighQ, a shipment training

—INSIDE—

Vol. 10 No. 10October 2002

No doubt, you’ve seen, heard, orread enough recaps about the Sep-tember 11 attacks. So, we’ll skipthe review and get right to the use-ful stuff—mainly, suggestions culledfrom the last year that may help youimprove your own emergencyplanning.

Long Island College Hospital (LICH)in Brooklyn—whose staff memberscould see the World Trade Centerburning after the attacks—foundthat improved preparation doesn’t

We’ve got answers

A panel of experts takesquestions on issues such asthe environment of care standards, drills, and emergency management. See p. 6.

Patient safety

In a follow-up to a story inour last issue, we providetips on meeting the JointCommission’s new patientsafety goals. See p. 8.

Tip of the month

OSHA references—but doesnot mandate—requirementsfor water temperature in eyewash stations and emergency showers. See p. 12.

> p. 2

How do I love transporting thee?Let me count the ways . . . DOT sets revisions on a date not to miss

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have to break a budget, says TuckerWoods, MD, assistant director ofthe emergency department.

What LICH pursued isn’t that shock-ing: new decontamination showers,a bigger disaster command room,and more respirators for staffmembers.

The upgrades to the hospital camein at under $150,000, Woods says. Although the price tag is high insome ways, “you’ve got to > p. 4

Special insert

Included with your issue is a pair of case studies that

detail how one hospitallearned from problems with

emergency planning and fire drill training.

Briefings on Hospital Safety—October 2002© 2002 Opus Communications, a division of HCPro

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company in McDonald, PA.

The law already requires employers who ship in-fectious substances to train employees in generalawareness, safety, and job-specific measures. TheDOT extended its original October deadline to Feb-ruary so that hospitals would have enough time toupdate folks on the new law.

Luckily, hospital safety departments tend to haveenough knowledge about regulations to handle theDOT revisions, Johnston says. The larger problem isgetting the word out about the changes, he adds.

Hospitals often have to ship materials that the law defines as hazardous, including infectious substancesand hazardous waste. In brief, the DOT requires ship-pers or carriers of hazardous materials to classify itemsthey’ll transport and package them appropriately.

Klinger highlighted some of the important revisionsthat hospitals should look at:

New classifications for infectious materialInfectious substances—also known in the reg-

ulations as Division 6.2 materials—are ones that con-tain, or that you suspect contain, a pathogen.

To be more consistent with international shippingstandards, the DOT now requires you to categorizeinfectious substances you transport by one of fourrisk groups. Materials in Risk Group 1 present thelowest threat of disease, while those in Risk Group 4have the highest. The risk groups come from criteriadeveloped by the World Health Organization.

“You need to know if a substance is possibly RiskGroup 4 or Risk Group 3, and the difference is a lot,”Johnston says. “Risk Group 4 is going to be in [strict]packaging.” There are more Risk Group 4 materials inhospitals than you might think, he adds. An exampleof a Risk Group 4 substance is the Ebola virus.

You determine the risk group based on a variety offactors, including the medical history of the patient,symptoms, or professional judgment.

For help in classifying substances by risk group, jotdown this Web address from the National Institutesof Health: www4.od.nih.gov/oba/rac/guidelines_02/APPENDIX_B.htm.

Substances that fall under Risk Group 1 are exemptfrom the DOT’s hazardous materials rules. But pri-marily, the DOT’s revisions put many infectious sub-stances into Risk Group 2 or 3, such as diagnosticspecimens, Johnston says. (See section 173.134 inthe revised rule for full details.)

Diagnostic specimen packagingDiagnostic materials come from humans and

animals and include substances such as blood andtissue. You transport them for diagnostic or investi-gational purposes.

A big revision to the regulations requires you to ship

DOT revisions < p. 1

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in the DOT’s revised definition falls under Risk Groups2 or 3 and triggers new bulk packaging provisions.Similar waste that falls under Risk Group 4 must betransported as an infectious substance.

You may now package regulated medical waste,other than Risk Group 4, in certain bulk packaging.You can use bulk carts or bulk outer packaging, pro-vided they meet a slew of requirements (see section173.197).

These changes will provide more options and flexi-bility, Klinger says.

Exemption for small shipmentsSmall shipments of diagnostic specimens, bio-

logical products, or regulated medical waste—otherthan those of Risk Group 4—may qualify for a newexemption for “materials of trade.”

The term refers to hazardous material, other thanhazardous waste, that a private motor vehicle carriesin direct support of a principal business that doesn’tcenter on transportation.

Hospitals could fall under this exemption becausetheir primary business is health care, not transporta-tion, the DOT says. However, medical courier vanswill most likely take advantage of complete exemp-tions under the diagnostic specimen rules (seeabove).

You must ship liquid materials of trade in leak-tightinner packaging and outer packaging that can absorbthe contents of the inner pack and resists movement.Sharps in this category must go in rigid inner pack-aging that resists punctures, along with outside pack-aging as noted in the previous sentence. (See section173.6.)

diagnostic specimens in triple packaging that features

• watertight and puncture-resistant inner packaging • watertight secondary packaging• outer packaging with padding or other material

that secures secondary packaging against themovement

The DOT imposed these revised requirements ondiagnostic specimens to further ensure safety duringtransportation, Klinger says. (See section 173.199.)

However, the DOT exempts triple packaging require-ments for diagnostic specimens that fall under RiskGroup 1 or in which you render the pathogeninactive.

Also, private carriers—such as medical couriervans—that transport diagnostic specimens in dedicatedvehicles don’t need to observe the triple packagingrequirements, the DOT says. (See section 173.134,exemption b6.)

The agency made the exemption “for the couriersbecause there are so many of them,” Johnston says. Itwould be tough if every courier had to triple packspecimens they planned to drive to a reference labo-ratory for testing, he adds.

Biological products shippingBiological products—such as viruses, vaccines,

or blood used to treat diseases—no longer enjoy asmany exemptions from shipping requirements.

The new rule says biological products known or sus-pected to contain pathogens in Risk Groups 2, 3, or 4will now have to meet shipping requirements for Di-vision 6.2 materials (triple packaging—see sections173.134 and 173.196).

However, you’ll find continued exemptions to the pack-aging requirements for biological products, includingexperimental materials, that the Food and Drug Admin-istration or the Department of Agriculture license foruse. Also, the same exemption for medical couriervans applies here.

Regulated medical wasteTechnically speaking, regulated medical waste

Briefings on Hospital Safety—October 2002 © 2002 Opus Communications, a division of HCPro


For more info . . .

A good online source for information about shipping infectious materials is the Department of Transportation’s hazardous materials safety

site at hazmat.dot.gov (note there is no “www” in this address).



put that in perspective,” he says.

Look at costs this wayFor example, a new computed axial tomography scanmachine costs about $1 million, while magnetic reso-nance imaging equipment goes for $1.5 million. Theseare good arguments to bounce off administrators iffunding turns into a debate at the board meeting.

“A hundred thousand dollars is just a drop in thebucket in the grand scheme of things, in my opin-ion,” Woods says.

With the funds the hospital had, “you can buy overa hundred decon suits,” he adds. “That [money] gaveus an opportunity to get a Geiger counter, a chemi-cal weapons detector, and the suits.”

Prudence pays offVirginia Hospital Center in Arlington, VA, also spentabout $150,000 to upgrade various aspects of itsemergency planning defenses.

“We’re a health care organization, and we have to befinancially prudent to get everything we need andmake sure we purchase it at reasonable levels,” saysCarl Bahnlein, executive vice president and chiefoperating officer.

To be fair, LICH got lucky, too—the community thehospital serves donated $100,000 after September 11.But that fact shouldn’t be lost on other hospitals thatmight obtain similar fortunes by approaching thecivic leaders of their cities and towns.

Not every hospital makes out this well. St. Vincent’sManhattan Hospital dropped a lot of dough from pur-chasing thousands of doses of Cipro for the anthraxscares, and then had to make disaster plan improve-ments on top of that, says safety officer YvonneWojcicki.

Control systems from one siteVirginia Hospital Center is just miles from the Penta-gon and received dozens of victims from the attackon that building. Officials there recognized potential

weaknesses in parts of their disaster plan and re-sponded quickly to make changes.

Among the top moves: enhanced security.

“We have the ability now, literally with the throw ofone key, to lock every [entrance] door in the hospi-tal from a central location,” Bahnlein says. The strat-egy behind a lockdown is to channel potentiallycontaminated victims to the emergency department.

The hospital also reengineered its air handling andintake vents so that employees control them from acentral site, including a segregated shutdown of thesystem if officials believe a contaminated substancecould infiltrate the building through the air system.

Mutual aid orderedWhile hospitals near New York City and Washingtontook the brunt of medical response efforts Septem-ber 11, sites elsewhere stood ready to help.

St. Vincent Hospitals & Health Services in Indian-apolis prepared to receive casualties as part of theNational Defense Medical Service, which commitsthe hospital to having 100 beds open for federalemergencies.

The problem was the facility didn’t have that manybeds available, says Thomas Huser, MS, CHSP,manager of health and safety.

It didn’t become a major point because so many victimsnever made it to any hospital. But in the aftermath,the chief executive officer of Central Indiana HealthSystem—which St. Vincent is part of—mandated thatthe hospital develop a mutual aid agreement with oth-er facilities in case support ever became necessary.

As the largest hospital in the system at 700 beds, St.Vincent acts as the central contact point in the mutu-al aid agreement. Participating hospitals can activatethe agreement only after assessing local and regionalresources.

For example, if other hospitals in the same locale

Pooled assets < p. 1



don’t fall under the mutual aid agreement, they mustbe approached as first resources if possible.

In concert with the mutual aid plan, St. Vincentbought several pieces of equipment that are availableto others in the agreement. One item is an 8 ft x 10 fttrailer that doubles as a first aid station for incidentsand as a mobile command post. The trailer includesair conditioning, a generator, portable radios, cellphones, and a fax machine.

A pickup truck can haul the trailer to needed loca-tions. The total cost, including a pickup, will be$50,000 at most, Huser says.

Air lines work wellA big improvement at LICH occurred with added res-piratory protection in the decontamination area. Staffmembers can use 20 new positive pressure, medicalair hose hookups, which plug right into their hoods.

LICH has conducted emergency drills using the pos-itive pressure air hoses and no one fumbled overthem, Woods says. Nonetheless, the hospital plans toinstall spools on the ceiling that will collect the airlines, much like you’d see with garden hose reels.

St. Vincent’s Manhattan offered every employee fittesting for respirators. More than 2,000 workers cameforward. “I was fit testing people who worked in thebusiness office or volunteers who worked in the giftshop,” Wojcicki says. Even the president of the healthsystem signed up.

An outside consulting company came in first to train58 fit-testers, who then went out to do the actual fit-ting of the employees.

Editor’s note: Next month we will look at how St. Vin-cent’s Manhattan rewrote its disaster plans from theincident commander’s perspective.

As your disaster plans evolve, look at these hints

Here are some other emergency management tipsto think about:

• Even if you already use an incident commandsystem (ICS), it may make sense to develop aseparate ICS for bioterrorism incidents. That’sbecause bioterrorism requires far different ef-forts compared to a more “traditional” emergen-cy, such as a flood in the building, says TuckerWoods, MD, assistant director of the emergencydepartment at Long Island College Hospital inBrooklyn, NY.

• Hospitals should involve themselves in all region-al emergency drills. “We participate now with anydrill in Arlington County,” says Carl Bahnlein,executive vice president and chief operating offi-cer at Virginia Hospital Center in Arlington, VA.

• Along that thought, hospitals should also drill

for primary and secondary incidents. For exam-ple, if you drill for a smallpox attack at a mall,also include the potential that a follow-up attackwill occur against responders, such as hospitalworkers, Bahnlein says.

• Nonclinical workers need to understand howrelated patient treatment during a contaminationincident will affect the building. For example,the engineering department must know howquickly it can convert the emergency room tonegative pressure, Woods says.

• Include in your disaster plans provisions on whereto set up a family liaison center for relatives of vic-tims, and if you’re near a military site, plan for aseparate liaison center for those officials, Bahnleinsays. The military will want to know many detailsabout their injured personnel and arrange for rec-ord transfers if necessary, he adds.



Q&A session focuses on JCAHO and disaster plans

At this summer’s annual conference of the AmericanSociety of Healthcare Engineering (ASHE) in Nash-ville, TN, a panel of experts fielded an array of queriesfrom attendees. Here are some of those questions andanswers, which we paraphrased. See the box on p. 7for more about the panel’s members.

Q: A surveyor cited us for not having “break-away” grab bars in the psychiatric unit. Our state health department doesn’t require thebreakaway design. What should we do? Also,what is the Joint Commission on Accredita-tion of Healthcare Organizations’ (JCAHO) view on showerheads that don’t prevent hangings?

Dean Samet: The JCAHO doesn’t specify that youinstall breakaway items. Show your surveyors thatyou performed a risk assessment and explain yourhospital’s experience with any hangings, or lack ofthem. Though the JCAHO doesn’t mandate suicide-safe showerheads, if you choose to use them, checkwith a plumbing vendor who might know where tobuy them.

Douglas Erickson: Be warned that some surveyorsalso look at P-trap on pipes under the sink as a fur-ther suicide risk.

Q: Will anyone, such as the JCAHO, the NationalFire Protection Association (NFPA), or the gov-ernment, require the Hospital Emergency Inci-dent Command System (HEICS)?

Samet: The JCAHO doesn’t require HEICS or eventhe incident command system model. Rather, it wantsyou to use the guidelines in environment of care(EC) standard EC.1.4 as the basis for your plan.

Q: Has HEICS been accepted nationally?

Susan McLaughlin: No agency or group requires itnationally, though it is among the only emergency re-sponse models that specifically handles hospital re-sponse plans. There is a less-detailed incident commandsystem explanation in NFPA 99.

Q: Will future codes require hospitals to putchillers on emergency power to keep patientrooms at 75 degrees during hot days?

William Koffel: It’s hard to predict. NFPA 99, HealthCare Facilities, allows hospitals to already do this,but it doesn’t require the measure.

Erickson: There’s no movement to mandate emer-gency hookups for chillers, but it may be prudentfor hospitals accustomed to hot spells to at leastconsider the option in terms of the following:

• How long the building could operate without airconditioning

• Whether emergency generators could handle theextra work of also running chillers

Q: Is the JCAHO enforcing fuel capacity require-ments from NFPA 110, Emergency and StandbyPower Systems? My state requires 72 hours, butNFPA 110 says 96 hours.

Samet: The JCAHO expects you to comply with themore stringent capacity requirement.

Q: Will a tabletop community drill replace oneof the required emergency drills, or must youperform three drills?

Samet: The JCAHO requires two emergency drillseach year. If you can get local or regional respon-ders to join you in a drill, that takes care of the re-quirement for community participation in at leastone drill. This also holds true if the hospital takespart in a community-wide exercise. Tabletop drillsonly count as community drills if full-fledged exer-cises aren’t possible in terms of scheduling or costs.

McLaughlin: Either way, the tabletop drill doesn’tcount as your required influx drill.

Q: What’s the appropriate level of respiratoryprotection for employees in a patient decontam-ination area?

al Safety and Health Administration discusses re-quirements for in-house teams that handle largerspills in its hazardous waste operations and emer-gency response standard.

Q: When conducting emergency generator test-ing, should you notify staff members ahead oftime?

Samet: It probably makes sense to, especially forstaff members who oversee computerized or criticalcare equipment.

Erickson: There’s no NFPA requirements to conductunannounced generator testing, so why not let peo-ple know in case the transfer switch doesn’t workproperly?



McLaughlin: If the employees face an unknownhazardous agent, they must use level B protection—in other words, using either a positive pressure, full-face piece, self-contained breathing apparatus, or apositive pressure, supplied air respirator with escapecylinder. Once they know what the agent is, theycan go with level C protection (full-face or half-mask, air purifying respirators).

Q: After you complete a hazard vulnerabilityanalysis, how do you address the four phases ofmitigation, preparedness, response, and recov-ery? Do you need to look at these four steps foreach identified risk in the analysis?

McLaughlin: There aren’t specific requirements onhow to handle this situation. While it might be use-ful for some hospitals to use all four phases for eachidentified risk, it’s not necessary. You can discussthe four steps by explaining the hospital’s activitiesin each phase, for example, by bulleted lists. Youcan also take any intent statements in your emer-gency plan and show how these intents bridge tothe four phases.

Q: Must hospitals build an anteroom for eachisolation room in the building?

Erickson: The American Institute of Architects (AIA)deleted this requirement a few years ago from itsGuidelines for Design and Construction of Hospitaland Health Care Facilities, though some states, suchas California, still mandate it. The AIA eliminated theprovision because it found these anterooms becameprime space for storage, which was not the intent.Without the anterooms, employees must be carefulto keep the door to an isolation room closed at alltimes. Any negative or positive air pressure withinthe room must immediately correct itself if someoneopens the door.

Q: What type of education do workers need forhandling hazardous spills, such as from mer-cury or infected blood?

McLaughlin: It’s up to the hospital to decide this.The JCAHO says employees who work with hazard-ous materials need to know about relevant emergencyprocedures and cleanup strategies. The Occupation-

Straight from the sources . . .

Here are some of the members of the panel thatconvened during the American Society for Health-care Engineering’s (ASHE) conference:

• Douglas Erickson, FASHE, codes and stan-dards consultant for ASHE

• William Koffel, president of Koffel AssociatesInc. in Ellicott City, MD

• Susan McLaughlin, MBA, CHSP, MT(ASCP),SC, president of SBM Consulting Ltd., in Bar-rington, IL

• Dean Samet, CHSP, associate director of stan-dards for the Joint Commission on Accredita-tion of Healthcare Organizations

Questions? Comments? Ideas?

Contact Senior Managing Editor Scott Wallask

Telephone: 781/639-1872,

Ext. 3119

E-mail:[email protected]



Advice to keep up with the new patient safety goalsJCAHO notes that clinical alarms goal goes beyond ventilators

In making its new patient safety recommendations,the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) strayed from its usual stanceof letting a hospital decide how to meet the intent ofa given requirement.

For example, the new recommendation for infusionpumps is very specific about not allowing free-flowsettings. Another pair of recommendations that affectthe environment of care require preventive mainte-nance and appropriate sound levels for clinicalalarms.

These details may make it difficult for hospitals tocomply by the required deadline of January 1, 2003(unless the recommendation doesn’t apply to theservices the facility offers).

It will be an all-or-nothing proposition when survey-ors score the recommendations—you’ll get a specialType I recommendation if you don’t meet all of them,says Robert Marder, MD, practice director of qualityand patient safety at The Greeley Company in Marble-head, MA. Greeley, a division of HCPro, is the sistercompany of BHS’ publisher.

With that in mind, let’s look at a few practical waysto meet the goals.

Go broad with clinical alarmsIn our last issue, we reported that the clinical alarmsrecommendations applied to ventilators.

However, since then the JCAHO further explainedthat this goal includes a full range of alarm systemstied into physiologic monitoring or variations in med-ical equipment measurements, such as cardiac moni-tor alarms and abduction devices.

These alarms are in many units, including postpar-tum, surgical, and geriatrics, says Susan Huerta, RN,director of nursing systems at Rush Presbyterian-St.Luke’s Medical Center in Chicago.

Huerta and Marder spoke during a Greeley audio-

conference about the patient safety goals in August.

The JCAHO offers two recommendations for clinicalalarms:

1. Schedule regular preventive maintenance and test-ing of the alarms

2. Ensure that alarms use the appropriate settingsand that staff members can hear them

Can you hear me now?Keeping the alarms audible in a hospital is a formi-dable task, Huerta says.

“If you think of layouts, older buildings may nothave the acoustics to [carry sound] down a corridor,”she says. “This is a very easy thing for a surveyor tocheck.” Surveyors will also watch employees’ reac-tions to alarms going off.

Some easy steps to take include instructing staffmembers to always check the alarms when theyattach the related items to a patient, and insistingthat employees check patients when they hear analarm.

Illustration by Dave Harbaugh

“Yes, I said try and forecast our equipment failures, but based on our historical records.”



Tight lips hurt youUnderreporting of free-flow problems—a commonevent in hospitals—led to the recommendation oninfusion pumps, Huerta says.

Both mechanical and human errors lead to unpro-tected free-flow. A health care worker changing apatient gown could accidentally remove infusion tub-ing, which then stops free-flow protection, she says.Programming errors from more sophisticated infu-sion pumps can also result in free-flow problems,Marder says.

In a frequently asked questions (FAQ) section of itsWeb site, the JCAHO seems leery of add-on devicesthat provide free-flow protection for older infusion

pumps that lack this built-in feature, Huerta says.

“You’ll want to check with [the JCAHO] if youthink you’ll add on a device to prevent free-flow,”she adds.

Editor’s note: To read the JCAHO’s FAQs about itspatient safety goals, go to www.jcaho.org, scrolldown to “Latest from the JCAHO,” and hit the linkfor the patient safety FAQs.

Also, to purchase a tape of the audioconference men-tioned above, How to Comply with the JCAHO’s New2003 Patient Safety Goals, go to www.hcmarketplace.com, click on the accreditation tab, and scrolldown to “Audio.”

We want to help you, not hurt you, JCAHO says

Nagging areas of survey compliance—such as sur-veyors checking refrigerator temperatures—may phaseout in the future, according to the Joint Commissionon Accreditation of Healthcare Organizations(JCAHO).

Instead of getting your knuckles cracked by theaccreditor, you may receive more help complyingwith environment of care standards, mainly throughInternet assistance, the JCAHO said during its annu-al conference in Chicago in August.

“You will see a shift away from survey preparationto systems improvement,” said Russell Massaro,MD, FACPE, the JCAHO’s executive vice presidentof accreditation operations. “We want to focus moreon operational improvements rather than surveyscores.”

Safety committees will see a significantly differentsurvey process in 2004, including more fairness insurveyor evaluations. Part of the problem is thatthese days, surveyors don’t have time for in-depthprobing, Massaro said. “I was a surveyor for sevenyears and you tend to go on autopilot,” he said.

“You move to what is known and comfortable andjust focus on refrigerator temperatures, cigarettebutts, and dust bunnies, and leave wondering whatthe survey process is all about.”

A major thrust entails hospitals working on fixingtheir own problems using a Web-based self-assess-ment tool. This tool will tie in with the JCAHO’s movetoward reducing paperwork through electronic ap-plications that you can update as needed, as well ascommunicating via a password-protected intranet.

The self-assessment program will guide youthrough all the standards by asking you questionsin various areas. You will feed it responses such as “always,” “usually,” and “sometimes.” The com-puter will tally up a compliance rating, and thenyou’ll write a correction plan and e-mail it to theJCAHO.

In turn, the Joint Commission will help you tweakyour plan as needed and eventually approve it. Thisprocess will not affect your survey score. Hospitalswill receive the self-assessment tool by about thefourth quarter of 2003.



Bits & briefs

Surgical scrubbing alternative shinesSurgeons who prefer rubbing on hand gels insteadof scrubbing may have a point.

One minute of nonantiseptic handwashing, fol-lowed by use of an alcoholic, antiseptic gel or sol-ution, was just as effective in preventing surgicalsite infections as the more traditional hand scrub-bing with antiseptic soap, according to a study pub-lished in the August 14 Journal of the AmericanMedical Association.

Better yet, surgical teams better tolerated the alco-holic rubs and proved more likely to comply withhandwashing policies, the Journal reports.

Researchers made their conclusions after studyinginfection rates from more than 4,000 surgeries in2000 and 2001.

SUD deadline passes for hospitalsAs of August 14, hospitals that reprocess single-usedevices (SUDs) had to meet all of the regulatory re-quirements of a device manufacturer under Foodand Drug Administration (FDA) laws.

According to the FDA, these requirements includethe following:

• Establishment registration and device listing

• Premarket clearance or approval

• Labeling

• Corrections and removals

• Medical device tracking

• Medical device reporting

• Quality system regulation

Visit the FDA’s reuse Web site at www.fda.gov/cdrh/reuse/index.shtml for additional information aboutSUD reprocessing.

UV lights take on needlesticksA Scotland hospital hopes to prevent further needle-stick injuries by installing ultraviolet (UV) lights inone of its men’s bathrooms.

The lights, believe it or not, make veins invisible tothe eye, and the Aberdeen Royal Infirmary hopesthis move will prevent addicts from using the bath-rooms to inject themselves with drugs, according toThe Mirror newspaper.

Officials at the hospital fear that unsuspecting staffmembers or patients might accidentally stab them-selves with a discarded syringe left in the publicbathroom.

If the UV lights prove effective, the infirmary mayinstall the system in all of its bathrooms. Some rail-road station restrooms already feature the lights be-cause the bathrooms are common spot for addicts toinject drugs, The Mirror reports.

‘I’ll just take these records, thanks’In a strange tale, a temp worker for the medicalrecords department at Easton (PA) Hospital walkedout with patient files, and then ended up discardingthem on a street in nearby Allentown.

The worker violated hospital policy by removingthe confidential records, the hospital told The Morn-ing Call. It plans to install security cameras in therecords department because of the incident inAugust.

The temp worker told police she took the records so she could sort them at home and then returnthem, The Morning Call reports.

The next morning, the woman said she got into anargument with the person driving her to work, soshe got out of the car in Allentown and accidentallydropped the records.

However, the spot of the argument was near theoffices of The Morning Call, and an employee of thenewspaper says the woman tossed—not dropped—



the records onto the street. Either way, the womanleft the area in a huff and went home.

Authorities charged the woman—whom the hospitaldismissed from the job—with theft and tampering ofrecords.

Workers at the newspaper picked up the recordsand reported the problem to the hospital.

Pollution prevention template on the WebIf creating a useful pollution prevention plan miffsyou, or you just want to see how another grouphandles this effort, Maine Hospitals for a HealthyEnvironment has a good online toolkit.

You can read guidance on how to initiate a pollu-tion prevention program at your hospital (includinga checklist to get started), as well as use a templatepolicy with highlighted notes to help you under-stand the steps involved.

Go to www.themha.org/pages/resource_pages/kit.htm to see these resources.

Draft ergonomics guidelines released for nursing homesAlthough nursing homes are a bit beyond our scopehere at BHS, some of you may still want to knowabout draft ergonomics guidelines for that setting.

The voluntary guidelines, released for public com-ment by the Occupational Safety and Health Adminis-tration (OSHA), aim to provide practical solutions forreducing ergonomic-related injuries in nursing homes.

Hospitals may find the information useful, thoughOSHA cautions everyone that work settings differentfrom nursing homes will likely need tailored ergonom-ic programs.

Either way, the guidelines do not create a new stan-dard, and inspectors will not cite nursing homes ifthey don’t observe them.

You can send comments on the draft to OSHA bySeptember 30. Go to www.osha.gov/ergonomics/guidelines.html to read the proposal and for moredetails about submitting comments.

Tougher latex glove rules for 2003

Hospitals can expect a new law early next yearthat should help health care workers discern be-tween powdered and powder-free latex gloves.

The Food and Drug Administration (FDA) con-tinues to work on the final rule, which grewfrom a 1999 proposal to increase the regulationof latex gloves as medical devices.

The requirements of the proposal, which maychange with the final rule, require glove man-ufacturers to follow established testing, or anequivalent, to measure powder on latex gloves,says Joseph Sheehan, the head of regulatorystaff at the FDA’s Center for Devices and Radio-logical Health.

Aside from allergies caused by direct skin con-tact with natural rubber latex gloves, workerscan also develop symptoms when they changegloves because latex proteins attach to the lubri-cant powder in some types.

The proposal under review includes the follow-ing recommendations:

• Designate medical gloves as Class II medicaldevices, which would toughen safety stan-dards for gloves

• Regulate medical gloves into four categories:powdered surgeons’ gloves, powder-free sur-geons’ gloves, powdered patient examinationgloves, and powder-free patient examinationgloves

• Set powder limits for powdered and powder-free gloves

• Require labeling of gloves to indicate powdercontent and FDA recommendations on pow-der limits

• Require expiration dating for these gloves

The new requirements would give health careworkers a choice in gloves, Sheehan says, add-ing that some people prefer the comfort of pow-dered gloves.



That doesn’t stop OSHA from referring people to theANSI requirements, which almost implies their use.But in the end, OSHA only states that you have toprovide equipment to quickly flush the eyes or bodywhen they come in contact with corrosive material.

Z358.1 requires “tepid” water for eyewash stationsand showers, but even it doesn’t mandate a temper-ature range, nor is there an accepted industry limit,says Cristine Fargo. She’s a technical project coor-dinator at the International Safety Equipment Associ-ation, a trade group that developed the standard forANSI.

This ambiguity in Z358.1 allows a hospital to de-cide what an acceptable temperature is based onthe given circumstances.

However, for the sake of providing some direction,a recommended range for tepid water is from 60 to95 degrees Fahrenheit, Fargo says.

Earlier this year, the Occupational Safety and HealthAdministration (OSHA) issued an interpretation letterabout water temperatures that centered around itsmedical services and first aid standard (1910.151, which,by the way, is the 10th most cited standard in gener-al medical and surgical hospitals).

The point to take from the letter is that OSHA doesnot regulate the water temperatures in your emer-gency showers and eyewash stations.

Though OSHA references provisions from the Ameri-can National Standards Institute (ANSI), the agency willnot cite a hospital if it doesn’t observe ANSI’s show-er and eyewash standard, known as Z358.1-1998.OSHA never adopted the standard as part of its own requirements.

“It is the employer’s responsibility to assess the particu-lar conditions related to the eyewash/shower unit, suchas water temperature,” the interpretation letter says.

Tip of the month

When it comes to shower/eyewash temperatures, you decide

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

Kenneth S. Weinberg, PhDPresidentSafdoc Systems, LLCStoughton, MA

Steven Weinstein, MT(ASCP) MPH, CIC, HEMEnvironmental, Health & Safety SpecialistAbbott Laboratories, MediSense ProductsBedford, MA

Pier-George Zanoni, PE, CSP, CIHEngineering Manager/Safety OfficerMemorial Healthcare CenterOwosso, MI

Briefings on Hospital Safety (ISSN 1076-5972) is published monthly by Opus Communications, Inc., a division of HCPro, 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $259/year or$466/two years; back issues are available at $25 each. • Periodicals postage paid at Marblehead, MA 01945. Postmaster: Send address changes to Briefings on Hospital Safety, P.O. Box 1168,Marblehead, MA 01945. • Copyright 2002 Opus Communications, Inc., a division of HCPro. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publicationmay be reproduced, in any form or by any means, outside the subscriber’s facility, without prior written consent of Opus Communications 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 781/639-2982. For renewal or subscription information,call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available toselected 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 thoseof 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.

Casestudies:ncidentstest a facility’ssafety efforts

Case studies:Two incidents

test a facility’ssafety efforts

A supplement to Opus Communications publications

Along with your regular issue, we’re happy to present a pair of case studies from real-life incidents at St. Vincent Hospitals & Health Services,a 700–bed facility in Indianapolis.

You’ll learn how post-incident critiques showed flaws in emergency plan-ning and fire drill training at the hospital, as well as what safety officialsdid to improve things.

We extend special thanks to Thomas Huser, MS, CHSP, manager of healthand safety at St. Vincent, who authored these pieces.

Case studies: Incidents test a facility’s safety efforts2

Case study one: Fiery crash

Most hospitals create elaborate disaster plans that lookgood on paper and that staff members execute well dur-ing semiannual drills. But many facilities lack the oppor-tunity to truly test disaster readiness to see whether thepaper plans work as well as believed.

We faced such an incident, though, and discoveredvery quickly that what looks good on paper does notalways translate into a useful plan when placed intopractice. This article covers what we experienced inhopes that others may learn from our mistakes.

First, a little backgroundIn the spring of 1994, several members of our disastercommittee attended a conference inFlorida where the primary topic wasthe response to Hurricane Andrew.With the information fresh on theminds of the attendees, we deter-mined our current system of incidentmanagement was no longer appro-priate for the needs of our facility.

The co-chairs of the committee de-cided that the hospital needed toscrap its plans and create new ones based on the inci-dent command system (ICS). As a recent graduate ofthe National Fire Academy incident command course atthe time, I headed up the subcommittee working on thenew plan.

Throughout 1994, we revised all of our disaster plans sothat they reflected the ICS method of incident manage-ment. Among the changes, we removed the chief exec-utive officer and the on-call administrator from the leadpositions and replaced them with the “disaster coordi-nator” position.

Constant coverage was the goalWe trained numerous employees to fill this role so thata disaster coordinator could be on-site 24 hours a day.As such, we wouldn’t need to wait for a return call totop administrators to start a disaster response.

We also established a command center and put the pri-mary disaster plan equipment on a cart for mobility.We developed a color-coded flow sheet to act both as

a guide and a record of actions taken during a disasterplan activation. We put clipboards with position descrip-tions, forms, and identification vests on the cart, too.

The hospital made a video to allow for frequent re-view of the disaster command center, as well as theflow sheet and the support roles. We ran drills andmade modifications. We were ready—or so we thought.

A surprise strikesOn July 30, 1999, at 11:05 a.m., a man drove his carthrough the entrance to the hospital and into the mainconcourse. He then turned right and drove about 50 ft,where he left the vehicle and set it on fire. He had dous-

ed the car with gasoline earlier.Media reports indicated the sus-pect might have been upset at thehospital for some reason.

Within moments of the fire alarmsounding, members of the securitydepartment, facilities services, andenvironmental services—all ofwhom made up the fire responseteam—came to the scene. A sprin-

kler controlled the fire, allowing the team to help re-move people from the concourse.

The telecommunications office called the fire departmentto verify the station’s receipt of the alarm. Respondingfire units, believing the call to be a false alarm becauseJuly 30 was a very hot day, failed to put on their pro-tective gear.

Who’s talking? No oneThe first engine should have established radio contactwith our security department, but the engine’s radiodid not work, so no one made an initial contact.

As firefighters arrived, they saw smoke coming fromthe concourse and reported an ongoing fire. They alsoquickly discovered that the fire hydrants they connect-ed to had low water pressure.

Internally, the hospital responded rapidly as word spreadof the incident. Personnel assisted seven victims, includ-ing the driver. One of the responders was the disaster

Rumors of evacuationsbegan as staff members

operated without acentral commander.

Case studies: Incidents test a facility’s safety efforts 3

coordinator assigned to that shift. However, she helpedtriage and treat patients, so she never activated the dis-aster plan.

Soon after, several employees tried to step into the com-mand void, none of whom had training as disaster co-ordinators. They issued conflicting orders to hospitalstaff members.

The doors didn’t stay closedBarriers contained the smoke to the concourse and themain lobby. Unfortunately, as personnel opened firedoors to the area to assist or just to look in, they allow-ed smoke to migrate to other areas of the facility, caus-ing more alarms to go off.

Rumors of evacuations began as staff members operat-ed without a central commander. The hospital notifiedme of the incident and I returned there just as seniorleaders organized a post-incident meeting.

After speaking with the fire investigator and attending themeeting, it became evident that our “model plan” failedand that we needed a critique to sort through the events.

We conducted our review the following week and in-vited the following people:

• From the Washington Township Fire Department—the on-duty battalion chief, fire marshal, anddeputy chief continued on p. 4

The following is a summary of St. Vincent Hospital’scritique findings:

What went right:

• The fire system activated properly and containedthe smoke

• One sprinkler contained the fire

• Fire response team personnel responded withmore than 14 fire extinguishers

• Other staff members evacuated from the imme-diate area and went to a central location fortriage and transport

Opportunities for improvement:

• No one called the telecommunications office tonotify it of the actual fire

• Hospital employees initially notified the fire de-partment of the alarm, not the fire alarm moni-toring company

• The hospital lacked radio contact with the re-sponding fire department units

• The disaster coordinator became involved intriage and failed to activate the disaster plan

• Numerous unqualified employees issued conflict-ing orders

• Sightseers undermined the smoke barriers by con-tinually opening the fire doors

• Unauthorized personnel entered the area of thecrash, which was a crime scene

• There was low fire hydrant water pressure

• Staff members could not use their “Spectra-link”telephones outside of the building and had diffi-culties with the disaster radio system

• The fire department did not receive confirmationof the actual fire

• Confusion arose about who had responsibility totransport patients

• No unified command was established for allresponding agencies

—Thomas Huser, MS, CHSP

Looking for ways to improve


gency plan to establish a clear line of authority duringan incident.

Hospital leaders also attended educational sessions ondisaster plans. At the time, we had experienced recentchanges in several senior positions and the new officialswere not familiar with their roles during a disaster.

They should support the disaster coordinator, who holdsauthority during a disaster plan activation. This educa-

tion now takes place on a regu-lar basis as leadership changesoccur.

Controlling accessUnauthorized personnel enteringthe area during the fire createdtwo problems.

First, they opened the fire doors,which allowed smoke to enterportions of the building that oth-erwise would have remainedunaffected by the incident.

Second, their presence potentiallycontaminated the crime scene.

ACTION: Subsequently, security modified the dis-

• From the hospital—the vice presidents of clinicaland nonclinical support services, director of facili-ty services, manager of security services, securityteam leader, director of emergency services (whochairs the disaster committee), fire alarm techni-cian, director of nursing administration (the on-duty disaster coordinator at the time), and me

The critique revealed that several things went accord-ing to plan. However, we also learned we had a greatdeal of room for improvement(see the box on p. 3 for moredetails).

How things changedFollowing the critique, St.Vincent took a series of steps toimprove the disaster plan.

ACTION: Among the firstmoves, a training blitz tookplace to remind associates ofthe need to contact the tele-communications office via the“code phone” to verify thereason for an alarm.

We did this in our internalprint and electronic newsletters, as well as duringannual fire safety inservices.

ACTION: Because of our experience with thealarm monitoring company, we formally proposedamending the 2003 Life Safety Code to require anyhealth care facility to call its local fire departmentto verify receipt of an alarm.

We expect this proposal to go before the full mem-bership of the National Fire Protection Associationfor a vote at its November 2003 meeting.

ACTION: Further, we incorporated the phrase, “Doyou need to activate the disaster plan?” into all ofour disaster training. Since the incident under dis-cussion began as a fire, no one considered acti-vating the disaster plan. We reinforced to all disastercoordinators the need to implement the emer-

Case study one continued from p. 3

Security modified the disaster plan to restrict access

to fire and crime areas.

Questions? Comments? Ideas?

Contact Senior Managing Editor Scott Wallask

Telephone: 781/639-1872,

Ext. 3119

E-mail:[email protected]

In conclusion . . .

Take a hard look at your disaster plans. Do notbe afraid to work with someone familiar withdisaster planning and response from outside yourhospital for an impartial perspective. It is betterto find fault with your plans before an emergen-cy than to find out that they fall short duringan actual incident.

It is also very important to have a timely post-incident critique of all agencies involved. We haveexperienced two incidents since the fire andwe used the critiques to build upon our exist-ing plans.

—Thomas Huser, MS, CHSP


aster plan to restrict access to fire and crime areas.

ACTION: We also got in touch with the local utilitycompany and asked it to raise the water pressureon the grid that affects the fire hydrants on the eastside of our facility. The office denied our request;officials there said the pressure is adequate for ourneeds and if needed in an emergency, they couldincrease it.

The city just bought the water company, and we’ve filedanother request about the water pressure. We current-ly await a response.

Upgrading communicationStaff members responding to the fire tried to use “Spectra-link” telephones. These phones feature a cordless sys-tem that operates similar to cellular phones. The phoneshave a limited range and must be close to a “cell” tooperate.

ACTION: To remedy the limited range of the system,we installed additional cells on outside light poles.

This allows the telephones to better operate inexternal areas. We also reviewed the radio systemand changed the location of the antenna to allowfor a greater range of operation.

Problems at the hospital and at the fire department ledto a lack of information for the station and its respond-ing units.

The failure of hospital personnel to contact telecommu-nications impeded that office’s ability to notify the firedepartment of the events taking place.

The fire department kept hospital radios in the first re-sponding units, but fire crews didn’t maintain them. Also,communication didn’t occur between the respondersand hospital security officers.

ACTION: We installed new radios in some of theincoming trucks (engines, aerials, rescues, and am-bulances) and the battalion chief’s vehicle. We putthe equipment on a preventive maintenance scheduleto ensure that it functions appropriately.

ACTION: After much discussion, we agreed that

firefighters should transport patients sufferingfrom traumatic injuries.

They possess the training and equipment to movethe patients in a manner that prevents furtherinjuries.

Building stronger leadershipThe lack of a unified command at the scene occurredfor a couple of reasons:

1. The failure of the hospital to activate its internalcommand system

2. The sheriff and fire departments’ failure to recog-nize the severity of the situation

ACTION: The two departments changed their stan-dard operating guidelines to request that the mobilecommand post comes to any incident involving amultiple agency response.

All of those injured fully recovered, and the driver ofthe vehicle that crashed into the building received 20years in prison for his actions. He faces deportationupon his release.


Case study two: Fire alarm frenzy

Two medical office buildings directly attach to our mainhospital. One of the buildings is four stories with a two-story underground garage, and the other is nine stories.

The hospital owns the attached buildings, and variousdepartments—including clinical, safety, and administra-tion—occupy the majority of one of the buildings.

However, since an independent management firm oper-ates these attached buildings, the hospital—includingfrom the safety and emergency preparedness commit-tees—took a hands-off approach to them.

Teams used to conduct fire drills on a suite-by-suitebasis since the hospital did not occupy 100% of thebuildings. Many of the tenants, including me, had noidea what the fire alarm sounded like.

The hospital also left it to the management company toprepare for emergency response in the buildings. Genericplans for the hospital-based occupants existed; howev-er, all other tenants took their direction from the man-agement firm for planning and response programs.

What’s that noise?On February 16, 2000, at 9:13 a.m., I heard something Ihadn’t heard previously in my two years in the build-ing: A gong rang three times followed by the

announcement, “prepare to evacuate.”

This continued as I located the building manager andinquired about the announcement. He stated that thefire alarm went off and that he was uncertain of thefire’s location. Reports of the smell of smoke filtered intothe building management office as security and facilityservices personnel responded from the hospital.

Several employees searched for the origin of the smoke.The fire department soon arrived and also looked forthe source. A short time later, we learned that water wasrunning down the stairs in the northwest stair tower.We traced the waterfall to a sprinkler in the ninth floormechanical room.

A wastebasket had caught fire and the flames spread toa desk, which in turn activated the sprinkler. For thesafety of the tenants, we evacuated the entire building.Several hundred people either went into an adjoiningparking garage or into the hospital cafeteria.

Mixed messages cause problemsIt soon became apparent that we needed a chain ofcommand. As occupants evacuated, a hospital officialtook it upon himself to announce that everyone couldreturn to the building.

Confusion reigned as the firefighters, who had on-scenecommand of the building, ran head-on into the peoplereturning. Disorder also followed in the hospital becausethere was no way to communicate with the peoplewho evacuated there.

More problems occurred because some tenants in thebuilding under alarm refused to leave until threatenedwith arrest. Also, patients arrived for appointments andcould not enter the building, and other people couldn’tleave as the only exit from the parking garage was viathe front of the building, which fire trucks blocked.

After the fire department ensured that the fire was com-pletely out and that carbon monoxide levels were safe,it allowed tenants to return to their offices. Within onehour, someone called an ambulance for a “sick person.”Soon, more calls went out for the same symptoms, in-cluding nausea, headaches, and continued on p. 8

Illustration by Dave Harbaugh

“Congratulations, you’ve been chosen to write our comprehensive emergency procedures manual.

Help yourself to the oxygen.”


The fire alarm announcement confused people, andno one made additional announcements after the ini-tial alarm.

Communication lacked between building staff mem-bers and responding hospital personnel.

Building staff members didn’t receive training in fire response.

Hospital departments were not prepared for theinflux of people who evacuated the adjoining building.

Personnel in the hospital were unaware of the fire in the adjoining building.

Responders and staff members couldn’t communicatewith people outside of the buildings.

Tenants were not familiar with the building’s fire planand fire alarm system.

Building tenants couldn’t hear the fire alarm or pub-lic address announcements.

No clear chain of command ever went into effect.

We reprogrammed the alarm system for three an-nouncements: notification of initial alarm activation,building evacuation, and the all-clear.

We installed a radio in the fire control room thatoperates on the hospital’s maintenance and securityfrequencies.

We trained all building workers on fire extinguishers,hazardous materials awareness, bloodborne pathogens,and CPR.

In the event of future evacuations, the hospital willactivate the disaster plan to minimize disruptions.

Operators will announce over the public address system events in the attached buildings that affect the hospital.

We put together a response bag that contains a bull-horn, orange vest, paper and pens, duct tape, barriertape, and clipboard to aid in communication.

We held meetings with representatives from eachsuite to review the disaster plans; we also hold annual fire drills for the entire building.

After conducting tests, we installed additionalaudio/visual alert devices throughout the building.

Building management and hospital leaders met todevelop a command plan, which places the seniorbuilding official in command of any incidents withinthe attached buildings.

After alarm mixup, critique yields worthy points

As with many post-incident reviews, we discovered numerous opportunities for improvement. Listed below areour findings and the actions we took to reduce risk to the tenants and emergency responders in future events:

Findings Corrective actions

Source: Thomas Huser, MS, CHSP. Reprinted with permission.


upset stomachs.

As the reports of ill people grew, a meeting convenedwith the fire marshal, building manager, and me.

We determined it was best to close the building for therest of the day. This time, we announced the evacuation inperson to the occupants of each suite and informed themthat they had 30 minutes to leave the building for the day.

The next morning, officials took air samples throughoutthe building. Once this testing determined that the build-ing was safe, we allowed tenants to resume their busi-ness. We called a post-incident critique and found areas

we could improve (see the chart on p. 7).

Causes and cooperationFire officials determined that the fire was an accidentcaused by improperly discarded smoking materials oroily rags. No one suffered injuries and the building sus-tained no permanent damage.

Since then, annual fire drills continue, as does the co-operation established between the hospital and the build-ing management. We also upgraded the alarm system.

Yes, these buildings are off-site; however, they are stillvery much a part of the hospital in terms of fire plans.

Case study two continued from p. 6

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briefings on hospital safety - on meeting the joint commission’s new patient ... the emergency...

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