Briefings On Hospital Safety, January 2017
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January 31, 2017
Prevent elopement in healthcare facilities
Who are those most likely to try to escape, and what are some of the ways you can prevent it?
In long-term care facilities, one of the greatest risks to elderly residents is their ability to leave the facility unseen and put themselves in harm’s way. Called elopement, this is often associated with wandering, an act whereby the person is disoriented or disengaged in his or her environment and goes about seeking someone or something or just wanders randomly.
The critical first 48 hours
Elizabeth Gould, MSW, is the director of state programs at the Alzheimer’s Association in Chicago. Gould reports that people who wander persistently are the source of 80% of elopement cases. Additionally, she notes that 45% of these incidents occur within the first 48 hours of admission to the residence.
For those in the role of protecting residents—including administrators, staff, and security at long-term care facilities—Gould stresses it is important to understand why a person wanders, so the necessary safeguards can be anticipated.
For the elderly, especially those with cognitive issues, wandering may serve as a form of communication for both physical and psychological needs. Wandering may indicate something as elemental as needing to use the bathroom or wanting a glass of water, or it may be a reaction to something in the environment that is irritating to the resident. Other factors behind wandering include medical or emotional conditions or the desire for physical stimulation, such as wanting to feel the warmth of the sun.
By understanding someone’s needs, says Gould, security and others may be able to anticipate what is necessary before the wandering or elopement takes place. Staff should be especially aware of these issues when a resident first enters a facility, because a new environment often triggers a desire to return home.
Have a “lost person” plan
Gould says all staff involved with residents should be trained on the risks of wandering and the approaches for prevention. In its Dementia Care Practice Recommendations, the Alzheimer’s Association outlines several effective staff approaches, such as developing a care plan based on a resident assessment that allows mobility but takes into consideration wandering patterns; working with residents to develop a feeling of safety and familiarity with staff; alerting staff about those who have a tendency to wander and under what conditions it may occur; and providing additional staff assistance as new residents adjust to the environment.
Facilities also should have a “lost person” plan in place that can be activated in the event of an elopement, says Gould. The plan begins with regular accounting for residents, such as at mealtimes and shift changes. Another component is developing a sign-in/sign-out policy for family and visitors who take residents out of the facility.
If an elopement does occur, having recent photos of residents and their former address is important so police can look for and follow up on exiting seniors. Management, family, law enforcement, and state agencies as required should be notified when someone elopes from the residence and police should be provided with a description of what the person was wearing. Within and around the facility, staff should carry out an organized search, keeping in mind that the person, especially if he or she has dementia, may not respond to his or her name.
For some facilities, using electronic devices to track patients with memory or wandering issues provides an extra layer of prevention and protection. Al Arzola, the facilities director at the 250-resident TLC Care Center in Henderson, Nevada, says he uses a cut band system from Accutech for the 20 residents of the facility’s Alzheimer’s unit.
Residents in that part of the building wear wristbands with transmitters. The bands can set off different sounding alarms depending on the situation, he says. If someone is playing with the band, one alarm will sound, while a much louder, persistent one sounds if the band is cut. A softer alarm is triggered if a resident loiters in one spot for an extended period, and there is yet another alarm if someone exits through the unit’s doorway.
Arzola says that for staff one of the biggest learning curves is recognizing the different alarms and responding accordingly. For those wearing the bands, the transition has been quite easy.
Other precautions for reducing elopement
In addition to the alarm system, Arzola says TLC has taken other precautions to reduce elopement, such as having windows that only partially open and closing facility doors at 8 p.m. each evening so anyone leaving the building has to go through the front doors. All staff, from nurses and aides to housekeeping personnel, are also trained on the signs of wandering and elopement, he says. Arzola notes that making sure the right residents are assigned to the proper units also helps with security procedures.
If a facility is going to use an electronic monitoring system, Arzola says there needs to be a review of the facility to see how easily it can be fitted for the system and if it continues to meet local and state regulations for fire and patient safety.
Even if a facility has an electronic monitoring system or uses wrist, bed, or chair alarms for individual patients, Gould says it may be beneficial to enroll the patients in the Alzheimer’s Association’s Safe Return program—a nationwide program that helps identify, locate, and return dementia patients to their homes.
Editor’s note: Portions of this story originally appeared in Facility Care, a publication of Thompson Information Services.
Prevent infant abductions using WiFi
New technologies can help prevent newborns with systems that hospitals may already have in place
Electronic infant protection is a widely adopted technology to protect newborn infants from the threat of abduction and mother/infant mismatches. At this stage, the majority of hospitals offering maternal childcare services are using this advanced radio frequency identification (RFID) smart tag technology to provide individual protection to infants.
A body of best practice also has arisen, based on more than a decade of experience in using infant protection solutions. While rare, abduction attempts continue to occur at a rate of a few per year. Increasingly they are successfully thwarted; however, each time an event occurs there is something to be learned. Since these incidents often are widely reported, the collective knowledge gained can be used to better counter this hard-to-predict threat.
A new generation of technology has the potential to raise the bar even further. A shift is taking place from an older generation of systems that use proprietary RF protocols to those that leverage the existing WiFi network to locate and track infants all over the hospital.
The ability to see the infant anywhere covered by WiFi—right down to the parking garage—dramatically expands the range of possibilities for deploying and using infant protection solutions.
The current strategy is to build a perimeter around one part of the hospital—usually the OB unit—and turn it into a mini fortress. All exits are protected to prevent an egress, and infants are continually monitored while inside the zone.
However, beyond this area there is no visibility at all, since covering the whole hospital with proprietary infrastructure is prohibitively expensive. If a would-be abductor makes it through a monitored exit with an infant, or if the infant is kidnapped while receiving care outside of the safe area, there is no way to locate them.
Because of this, the security response is essentially blind. Typically, nurses on the unit go to the exit where the alarm occurred, and if the infant is not quickly located, then all exits from the hospital must be secured. The hospital is effectively placed in lockdown while a comprehensive search is undertaken with few clues as to which direction the abductor might have gone.
With a WiFi-based solution, the current location of the infant can be monitored in real time based on signals received from the hospital’s standard WiFi access points. With this kind of information available, the nursing staff’s first action can be to go to any computer and find out where the infant is now, not rush to an exit to find the infant is already gone. Similarly, it is possible to imagine the security control center acting as quarterback for the incident response, tracking the abductor’s movements through real-time Wi-Fi location and complementary video surveillance, remotely locking doors in the abductor’s path of travel and directing security personnel to the area of the hospital where the abductor is heading.
Taking it a step further, the whole design approach to infant protection can be altered to make not just the OB unit the protected area, but the entire hospital. Since the location of infants is continually monitored, it is possible to generate alerts not only when infants pass through an exit, but when they are detected in restricted parts of the hospital. Standard workflow routes can be designated so that staff members can transport infants to other areas for treatment without hindrance, but if the infant is ever taken outside these areas an alarm is immediately generated.
Many hospitals likely will continue to secure exits from the OB unit, but it is also now feasible to monitor exits in other parts of the hospital to stop an abductor. In addition, the access control system can respond in real time, funneling the abductor in a certain direction by progressively locking exits until the abductor has only one choice, leading to where the security team is waiting.
It is not yet clear what practices will emerge with this new technology, and the security of infants will continue to rest ultimately on comprehensive procedures and on educated, motivated, and prepared hospital staff. What is certain is that the net result will be better protection for infants through continual visibility on their whereabouts.
Editor’s note: Portions of this story originally appeared in Facility Care, a publication of Thompson Information Services.
Emergency planning: Preparing for a winter storm
As the first flakes of winter start to fly, here’s your plan to keep your facility open and operational.
Editor’s note: This is the second of a series of articles addressing common planning concerns when it comes to certain types of emergencies that can strike a hospital facility.
Take a look out the window. If you’re in most parts of the U.S., you might see a blanket of white out there. If the snow hasn’t started falling yet, it’s a safe bet that it will be soon.
Most areas, and hospital facilities, are ready for the typical snowstorm. But are you ready for a truly bad snowstorm that can leave a region crippled for days, or even weeks at a time?
All you have to do is ask folks in places like Buffalo, New York, which was hit with 7 feet of snow in just one storm in November 2014. The monster storm also blanketed most of the Central U.S. and New England over a six-day period with amounts reaching record levels in many places. In many cities such as Boston and New York, services ground to a halt and citizens found themselves stranded.
Of course, a hospital can’t just shut down; it needs to remain open and ready to take in patients at any time. This is also a requirement. The Joint Commission already requires you to have a plan in place to prepare for “all hazards,” and similar new emergency preparedness requirements were recently adopted by the Department of Health and Human Services. These are meant to prevent the disruption of hospital services on a mass scale, such as that experienced during disasters such as Hurricane Katrina in New Orleans, and in New York City during Hurricane Sandy.
Given that a winter storm is a statistical certainty to occur during the colder winter months, what are some things you can do to help prepare your facility to ride out the storm? Allow us to help you form a plan. Also check out FEMA’s new resource that gives you a sample tabletop exercise that you can use to help your staff plan. See p. 4 for an example that you can tailor to your own needs.
Prepare to turn your hospital into a hotel. In September 2015, Pope Francis visited Philadelphia as part of his first-ever U.S. visit. With more than 3 million people estimated to visit the city, security was so tight in the downtown Philadelphia area that the Secret Service closed off a three-square-mile area that became known as “the box” to emergency planners. Essentially, traffic in and out of the downtown area was stopped for a week. As was seen in recent winters in places such as Atlanta and other less-prepared areas of the South—a good snowstorm can do the same thing. But neither Pope nor snow can stop a hospital from operating. So take a lesson from the folks in Philly who still had to get their staff into work. Instead of closing, facilities canceled visitations and elective surgeries, and made plans to “hotel” entire shifts of workers at the hospital to make sure they would be able to get to work.
“We were told to plan like this is a major snowstorm, but we had to take this one to extremes,” says Bernie Dyer, director of safety and emergency management for the University of Pennsylvania Health System, Philadelphia.
In a typical snowstorm, Dyer says his hospital might have 200 staff sleeping over, but in this case the hospital had to plan for 1,000 employees being housed and fed. A monster snowstorm might not keep your staff hunkered down for a week, but maybe you should have it in your plans to turn a conference room into a supply closet, or use the building under renovation or another seldom-used on-campus building as a temporary hotel for some of your staff sleeping over. Prepare to rent shower trailers if you don’t have enough bathrooms, and bring in catering for meals, while making sure there are table games, televisions, and quiet spaces staff can decompress in.
Prepare for the power to go out. It would seem an obvious piece of advice that hospitals should have a plan in place to keep power going, and in fact, it is a regulatory requirement that facilities have backup generators as well as emergency fuel on board and available in case of a blackout. You may well have a plan, but is it the best it can be? Ask hospitals in New York City—in the wake of Hurricane Sandy, and the many hospital blackouts that were caused when storm water flooded basements, government agencies such as FEMA started issuing new guidelines designed to help hospital engineers design backups for their backup systems. If they don’t have it in their library, tell your maintenance crew to download FEMA’s 170-page book, Emergency Power Systems for Critical Facilities: A Best Practices Approach to Improving Reliability. Known as FEMA P-1019 in the industry, the book was completed in September 2014 and last updated in February 2015. Check out and download the entire publication at goo.gl/CbcLgZ.
Consider the following tips extremely important. These are simple things that could mean the difference between a minor disruption in your services and a full-scale evacuation/desperate search to find a hospital that can take your critical patients during an emergency:
- Can your generator be hooked up quickly? Some hospitals prefer to set their systems up so that a “quick connect” temporary generator (that can be trucked in) with a pre-installed connection can be quickly set up and connected. It doesn’t require constant testing and maintenance, and maintenance requirement can be given to outside vendors. For that matter, can vehicles get to the connection? Make sure there is a paved, plowed vehicle access road that can handle a large truck with a huge load (at least 10,000 pounds).
- Can you trust your vendors? You need to establish vendor contracts ahead of time. During a blizzard, demand for fuel (and snowplows) will be high and it may be difficult or impossible for trucks to get to you to restock or refuel your site. Some hospitals have begun to form collaborations with fuel stations in their areas that would allow them to take over the inventory in the event of an emergency. Some even bought their own tanker trucks to store fuel stocks during storms.
- Where do you keep your emergency fuel? Gone are the days when it was considered smart practice to store emergency fuel in underground tanks or in basements. During Sandy, and many other disasters such as the 2011 tornado in Joplin, Missouri, emergency fuel stocks were rendered impossible to access or contaminated by floodwater or debris. New buildings, such as the brand-new Spaulding Rehabilitation Hospital in Boston, are being designed with what is called “upside-down” construction, where the main primary electrical services are located in the rooftop and powered by a fuel pump that is secured in a flood-proof vault with a 150,000-gallon tank and reserve fuel stored on site. At the very least, secure your fuel stores in concrete bunkers and make certain there is a way to get to them.
Maintain your grounds. You may have the most foolproof, ready-to-go action plan ever. But that’s all lost if a worker or visitor gets killed by a large tree limb that falls on a car during a heavy snowstorm. You need to make sure to assess the outside of your facility to determine the damage that could occur from your surroundings during a blizzard. Are your drains clear? Is your facility near a river that could be susceptible to ice dams? If so, if you’re in a ?ood plain, do you have a plan to sandbag around low-lying areas?
“We are always thinking about how [secure] is our roof structure, and whether we are sure drains and capabilities to get rid of water is okay,” says Steven Shay, safety coordinator for Winchester (Massachusetts) Hospital. Shay learned this lesson the hard way when his own vehicle was struck by falling limbs in the parking lot during a heavy snowstorm. Pay close attention to making sure dead limbs on trees are removed every year, especially in areas such as walkways or parking lots where a windy storm could easily send a branch falling onto a car or person.
Reduce slips and falls. This is one of those perennial warnings that seem to be overused, and preventing slips on slippery floors seems to be common sense, yet injuries caused by slips, trips, and falls continue to rank among the biggest hazards for healthcare workers, according to OSHA. To prevent injuries to your workers and visitors, you need to have a robust plan in place to battle slippery and icy surfaces, both indoors and outdoors.
Start with your parking lots, and make sure you have a reliable contractor—and several backups on call—for when the big snow hits. If your primary contractor is busy, or can’t make it, you have to make sure the lots and the sidewalks are treated.
Your maintenance department needs to then concentrate on the entrances, routinely sanding and salting high-traffic areas that are prone to icing over (make sure you have backup staff, just in case). Then work your way indoors and take care of the hallways near your entrances, as they are likely to become slippery with melted snow and water and present a slipping hazard.
Heavy duty rubber mats in these high-traffic areas are a must in the winter months, and you also need to make sure they are properly anchored to the floor to make sure they don’t inadvertently become a tripping hazard. Lastly, remind all staff about the importance of proper footwear. Sturdy, closed-toe shoes with rubber soles are almost always the best way to go in healthcare, and in winter when the floors can be slick, they can save a person from slipping and injuring themselves.
Expert Q&A: Proper PPE in Healthcare
Hospital infection control experts give you tips on how to improve compliance and staff awareness
Editor’s note: This Q&A was taken from the October 2016 webinar, PPE in Healthcare: How to Improve Culture, Consistency, and Compliance. The speakers are Marjorie Quint-Bouzid, MPA, RN, NEA-BC, who currently serves as vice president of nursing at Parkland Hospital and Health System in Dallas and Kevin Bussiere, RN-CIC, infection prevention occupational health manager at Fort Washington (Maryland) Medical Center. To listen to the full program on demand, check out the HCPro Marketplace at http://hcmarketplace.com/ppe-in-healthcare-improve-culture-consistency-compliance.
Q: How do you know that your PPE staff training program is successful?
Marjorie Quint-Bouzid: At the end of your training program, your employees should know what PPE is necessary based on the potential exposure that they're going to have in your specific work environment. So not to be able to tell you generally, oh, PPE means gown and gloves and mask. They need to be able to tie it back to what are the potential infectious risks in your organization and then what are the ways that we protect ourselves and our patients and what PPE do we select.
A key thing that we always tend to forget is a training program should involve how to check if the PPE is damaged or not working properly. Prior to the Ebola outbreak, I would never recall ever hearing anyone talk about PPE not working or reminding us to make sure it works. So I recall vividly putting on an N-95 respirator mask and never doing a fit test or never doing a quick check to make sure it’s fit properly because I was fit tested and they said, ‘Oh, this is the size mask that you wear.’ But I never took that final step until I was informed by another organization with a very good stellar PPE training program that it is a part. It’s the final step in making sure that you've donned properly, to do that test with the respirator. So don’t forget that piece as well.
Q: Should visiting children be required to wear PPE?
MQB: PPE for children rarely fits well. So why do we allow children to come in and visit? Well, they should be allowed to see, if it’s important, if it’s life threatening, if their family member is going to die and pass, or even if they just need some contact but should they be at the door and just wave and say hi? Do they really need to be in the room for an hour and a half? We need to really look at that. How many of us have designed gowns and masks for children? How about gowns and masks for the large healthcare worker or the very short healthcare worker? We've seen those being just as badly worn as the children’s PPE.
Q: What are some reasons for noncompliance?
MQB: I personally don’t believe people go to work daily to be noncompliant. Noncompliance sometimes is just embedded in some of our structural processes. And it’s interesting. Nothing in our industry happens void of something else. It’s generally in tandem with noncompliance of other measures. Arguably rampant noncompliance in any organization is coupled in that organization with low employee engagement scores, low patient satisfaction scores, and overall, poor compliance with hand hygiene. Their approach to noncompliance must be rooted in a renewed focus on worker safety being fundamental to patient safety.
The reason why culture sometimes can be difficult, as I said before, it’s just difficult to remove and it requires a significant amount of up-front investment in resources and costs. It’s like turning the Titanic. It’s possible but requires a lot of work.
A study by OSHA was designed that actually showed that 70% of the 1,000 that responded found that PPE was too uncomfortable or too hot. So that's really the equipment, the design of the PPE that's contributing to why people tend to be noncompliant. As Kevin alluded to earlier, one size does not fit all. During the Ebola crisis, we actually realized that several of our frontline emergency department healthcare workers were well over 6 feet, not just 6. One was 6’ 5” and over 300 pounds. Nothing we had in stock at the time fit. So we had, as an organization, this person would have wanted to become complaint with PPE selection but really the organization did not have the appropriate tools for that person to be successful.
Some other organizational factors are forcing functions. We look at trying to fit, at least I refer to it as forcing a square peg into a round hole. Our PPE availability of the equipment and supply, actually sometimes we put too many of the wrong type of PPE on a cart. The employee has to go through and try to select. So one of the things that we did in our Ebola was to create an Ebola cart and make sure only the things that were appropriate to be selected were on that versus given an extended choice.
Can you recall some examples of healthcare workers who have not worn proper PPE and put others in danger?
Kevin Bussiere: In Tilton, New Hampshire, the director of nurses became ill with terminal cancer. She was a patient in her own hospital. The MD didn't think she needed isolation, and so canceled the nurse’s order for airborne and wasn't challenged. Everyone who worked there came to see her and after she died, everyone started converting on their annual TB screens. An outbreak investigation when they did everyone in the hospital showed 64% of the hospital had converted to exposed TB and everybody in the hospital was on prophylactics. That was a fun place to work, let me tell you.
In Virginia Beach, a respiratory therapist refused to come in for his annual TB screening and just kept postponing it and they didn't take him off the schedule. There was no policy saying take him off the schedule. They didn't have any bite in their policy or the program. He continued for a year and a half not being screened for TB. He finally came in and was screened. He was positive for TB and it led to 6,000 exposed patients between the hospital and another part-time job that he had over that long of a period of time. So the health department was not very happy.
Last but not least was in Chesapeake where the nurse was sick but she was one of these troopers that always showed up to work on time, good, bad, or indifferent. Even though she seemed to have this chronic problem, nobody challenged her and she ended up having TB and exposed 4,000 patients and healthcare workers over a two- to three-year period. So airborne doesn’t always seem to be the most disastrous or worrisome of the isolations, but it can certainly have a bigger impact over time.
Q: How do I correct leaders and doctors if I see them not using the correct PPE?
KB: For me, it’s easy, I walk up and I [simply say]: “I don't understand why you're not wearing the PPE correctly.” Let them fill in the blank. It’s, “Well, I’m just going to ... ” and I just stand there and look at them, you know? “Well, it’s not really needed” or then why do we have them on isolation if it’s not really needed. And the simple asking of a question without judgment because that's the part where they want to become defensive, simply ask, “I don't understand why you're not wearing the gown? Is that okay?” And they're like, “Well, no, it’s not but I really ... ” “Well, then maybe you should be wearing the gown.”
MQB: I agree with my colleague. Part of doing those crucial confrontations, I guess, is to really have a skill of putting a person at ease, not making them defensive. And it’s kind of hard to argue with a question. So I like the tactic of making it a question, understanding and saying, you know, please help me understand why you're not doing the behavior that you know is the right thing to do. And it allows for dialogue as well.
Q: Why is PPE important?
MQB: Simply, PPE is a defense against bloodborne pathogens. We used to call it universal protection. It’s now standard precautions. PPE is used as a barrier to prevent bloodborne pathogens from infecting you. It also enhances effective hand hygiene use. Alcohol rubs and soap and water can decontaminate your hands, but gloves help in preventing the initial contamination. It’s a barrier against transmission-based pathogens. Once we know how it’s transmitted: contact, droplet, airborne, etc., a mask, gown, gloves, shields and goggles, etc., prevent transmission from the different vectors and have a pretty consistent approach.
And lastly it’s a stopgap measure against emerging pathogens. Each emerging pathogen or a new superbug has its own vector or combinations of vectors. Reinventing and redesigning the use of PPE can prevent emerging pathogens. Now we could go on forever and ever and a day on the Ebola outbreak that just came