Briefings On Hospital Safety Online, February 2017
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February 27, 2017
Emergency preparedness planning: Biological and chemical response
Editor’s note: This is the third of a series of stories that will address common planning concerns when it comes to certain types of emergencies that can strike a hospital facility.
For the most part, hospitals are ready for just about anything. When a disaster strikes, patients need to know that their local hospital is open and ready, and that they can expect the best care.
But a hospital also needs to protect itself—in most cases, when a disaster strikes, it stays outside the confines of a hospital’s doors, and at least theoretically, the hospital is a safe zone that is outside the confines of what is going on out there to make people hurt or sick.
There are a few types of emergencies, however, where the effects of the emergency can be brought right into the hospital, and if not prepared for, it can make hospital staff part of the problem.
Take a biological or chemical incident, for instance. These incidents tend to occur in situations that seem relatively commonplace, until the secondary situation makes people realize it’s not. When one or two people get sick, hospitals can handle it, but when those people are followed by another 200 that may have been exposed to an unknown illness, it may be too late—many of those people may already be sitting in your waiting room.
On May 12, 2016, when an Amtrak train derailed on the major Washington-New York rail corridor running through Philadelphia, at least seven hospitals in the greater Philly area had only minutes to get ready to receive hundreds of patients, from busloads of “walking wounded” to critically injured patients coming in via ambulance.
Officials didn’t not know at first if it was a terrorist attack or if the crash involved hazardous materials that could affect the safety of the hospital.
“I needed to know about bomb residue, chemicals, or radiation,” says Herbert Cushing, MD, FACP, chief medical officer of Temple University Hospital. “We were about 40 minutes in and I couldn’t let [staff] keep treating people if there was an issue. We were able to get information from the scene about whether or not there were [weapons of mass destruction] involved.”
These unknowns that can occur before patients even walk in the front door are the reason emergency preparedness officials and accreditation experts expect hospitals to have a plan in place and practice ahead of time. So take a lesson, and learn about some of the things you can do to prepare.
Prepare for what can happen in your neighborhood. Ideally, you already have a good idea of the hazards that lurk around your hospital, and that drives much of your emergency planning. In emergency planning circles, this is called conducting a Hazard Vulnerability Analysis (HVA), the base document that hospitals should develop to help guide their emergency response plans. It’s a document that is required by The Joint Commission as part of its Emergency Management standards (EM.01.01.01, EP 2), and CMS requires it as part of its increasingly stringent survey standards requiring an “all hazards” approach to emergency planning.
By design, the HVA is a flexible document; it should be reviewed annually and revised as needed, used as a planning document for your drills, and improved as you discover weaknesses (or strengths) in your facility’s response plans.
In this document, start with a clear assessment of the hazards that are present in your community. Is there, for instance, a research facility for hazardous diseases, or a huge chemical plant in the middle of town that could cause a large-scale evacuation or contamination in the event of an explosion (ask the folks in West, Texas about that one)? Does a rail line with frequent freight trains rolling through go through the center of town? Are you the only major facility for miles around? These are all factors that could make you the first and only place where victims of a biological or chemical incident look for help.
Know where the money is. It’s been said many times that you need to have a plan in place, and you need to drill to practice those plans; we won’t overemphasize the point. But many hospitals still say one of the reasons they don’t do it enough is because of a lack of money or resources for knowing where to start.
That’s no longer an excuse. If you do the homework, you’ll discover that there are lots of places—private and public—where you can find funding to help you out.
“There is a lot of money that’s going toward that coalition development, coalition exercises, coalition training,” says Christopher Sonne, CHEC, assistant director of the Emergency Management Solutions Program at HSS, Inc., in Denver. It is the company that provides emergency management training, facilitation, and subject matter expertise for hospitals and healthcare providers throughout the United States. “Depending on what regions of the country you’re from, what state, what city, what municipality or healthcare coalition, you may have different capabilities that you’re looking to pursue, to foster with your community partners.”
Consider the following resources as a starting point:
- Public Health Emergency Preparedness (PHEP) Cooperative Agreements—A CDC-backed program, since 2002 it has provided nearly $9 billion to public health departments across the nation to upgrade their ability to effectively respond to a range of public health threats, including infectious diseases, natural disasters, and biological, chemical, nuclear, and radiological events.
- Hospital Preparedness Program—A program from the U.S. Department of Health and Human Services (HHS) that has granted more than $4 billion to help “improve surge capacity and enhance community and hospital preparedness for public health emergencies.”
- Homeland Security Exercise and Evaluation Program (HSEEP)—This won’t necessarily pay for your drill, but it will help you get the biggest bang for your buck. Designed by the Homeland Security Department in 2002, HSEEP provides a set of guiding principles for exercise programs, as well as a common approach to exercise program management, design and development, conduct, evaluation, and improvement planning. Check it out for lots of ideas on how to plan and execute your exercises.
If you can share money, that’s even better. A lot of public agencies—your police and fire departments, for example—are also looking for this grant money to help them prepare. If your hospital can partner with them and become part of their own exercises, you could benefit from that.
Train your staff to be a SWAT team. If someone walked into your hospital with symptoms of Ebola or acute radiation poisoning—or if several did, would your ER staff know what to do?
After the Philadelphia train crash, a number of hospitals in the area created SWAT teams of staff members who are specially trained to respond immediately.
“It’s been nothing but training and they are very motivated,” says John Ward, director of safety and materials management for Einstein Healthcare Network in Philadelphia.
Einstein formed what it calls an SIDRT (Special Infectious Disease Response Team) that would be first on the scene as soon as the symptoms are identified. The team consists of seven ER physicians, 22 critical care nurses, four respiratory therapy assistants, and a radiological team that would swing into action with their specialized skills. A response plan has been mapped out that involves blocking off certain areas of the hospital, designating certain rooms as off limits, and pre-stocked carts that can be wheeled into place at a moment’s notice.
Get ready to lock everyone out. That being said, you’ll need to be ready to cut off the source of contamination coming into your facility, and that may mean keeping everyone outside until the problem can be contained. That goes against everything a hospital stands for. But you may be dealing with mass hysteria, media coverage, concerned family members, and keeping your staff healthy. And your security staff will be the ones front and center handling the lockdown and the anxious crowd.
Figure out your protocols now: You may have lockdown procedures in place, but when is the last time you went over them and practiced them? And at what point do you shut all the doors and let no one else inside? Do you have the proper facility locks and barricades in place? Are there protocols in place to limit facility access to only a few entrance points so that you can control the movement of people who are potentially infectious through your doors?
Buy and stock plenty of PPE. The moment that you get scores of patients with smallpox lesions or evidence of radiation poisoning is not the time to realize that you don’t have enough respirators available for your entire team; nor is it the time to discover that the only full-body suits your hospital owns are in a closet or trailer somewhere off-site. By now, you should have purchased at least the very least you will need to deal with the very intricate PPE your staff will need to wear when dealing with very infectious organisms, especially since the Ebola outbreak of 2014 taught healthcare workers what can happen. Many hospitals also have begun stocking the equipment in easy-to-access cabinets outside patient safety rooms.
Make sure everyone knows how to use it. Just because you have equipment available doesn’t always mean staff know how to use it. One of the biggest revelations to come out of the Ebola outbreak of 2014 was how little nurses and other staff members responsible for patient care knew about donning full-body suits and other PPE such as respirators. The result was new training programs and funding from the CDC and other agencies to help get hospitals ready.
It’s also why you need to drill. A realistic drill with local emergency officials can make for lots of teachable moments. There’s nothing quite as encouraging as watching your local fire chief give an impromptu lesson to your ER staff during a HazMat disaster simulation when he realizes that not everyone knows how to operate the decontamination tent. Should they know how to do this? Yes? Will you need to test them on it later? Of course. But letting educational needs unveil themselves during a drill is when it should happen; it saves you effort, and it’s also a great time to create permanent relationships with your local emergency response officials.
Drilling can be a fun way to practice. A well-planned drill can be a great way to test your staff’s response to a patient surge that would inevitably occur after a biological or chemical incident—and The Joint Commission requires it.
At Longmont (Colorado) United Hospital, a drill was planned on Halloween 2014 that simulated a zombie invasion, which coincidentally, was a perfect simulation of a surge of patients.
The ER staff was tested with more than 50 “zombie” patients with a disease called Zombthrax to descend upon the hospital looking for treatment.
“We had people here who did moulage, and they looked great,” says Mary M. Pancheri, CHEP, HEM, manager of safety, security, and emergency preparedness at Longmont. “Everyone had a great learning experience. We flowed them into the hospital units and everyone had to deal with them.”
Triage protocols went into place, and decontamination tents were set up in the parking lot of the hospital, just like it would happen if there was a real life chemical or biohazard emergency. Extra help was called in from the public health department and first responders in the community. High school students from the local EMS explorers unit were used as victims and also helped out with the triage process. The best part? The prophylactic “pills” that were handed out to everyone who was potentially contaminated were really M&Ms® candies.
CDC: Hand hygiene helps stop infections
High compliance rates linked to lower incidences, while CDC pledges $67 million to help hospitals
This may not come as a surprise to many people in the healthcare industry, but when workers wash their hands more often, it often makes for a healthier environment.
Now, it seems the CDC has proof. A recent study conducted by the agency, and published in the September 2016 issue of the Emerging Infectious Diseases journal, found that increasing hand hygiene compliance from high to very high could have a positive effect on healthcare-associated infections (HAI).
During the 17-month period of the study, the research team at the University of North Carolina Health Care Center made 140,000 unique hand hygiene observations as the health system increased its compliance from 82.6% to 95.9%.
Researchers say they “noted a significant increase in overall hand hygiene compliance rate and a significantly decreased overall HAI rate, supported by 197 fewer infections and an estimated 22 fewer deaths,” according to an article published by Healthcare Facilities Management magazine.
The study’s findings come at a time when the CDC also is pledging to spend $67 million nationwide to help state health departments battle antibiotic resistance and other patient safety threats, including HAIs, which have become a major problem in U.S. hospitals.
The new funding for antibiotic resistance will help support the founding of seven new regional laboratories with specialized capabilities for rapid detection and identification of emerging antibiotic-resistant threats.
According to a CDC release, the funds, which became available in August 2016, will be distributed to all 50 state health departments, six local health departments in Chicago, the District of Columbia, Houston, Los Angeles County, New York City, Philadelphia, and Puerto Rico.
The money also will expand state capability to track infections in healthcare settings, protect patients through targeted prevention, and increase coordination across medical care. In addition, the money will help conduct foodborne disease tracking, investigation and prevention, including increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, plus continued support for the National Antimicrobial Resistance Monitoring System.
The CDC also will provide support teams in nine health departments for rapid response activities designed to quickly identify and respond to the threat of antibiotic-resistant gonorrhea in the U.S.
Hospitals have been trying all sorts of tactics to try to get workers—especially busy nurses and physicians on the go—to do a better job of washing their hands after seeing patients or after personal tasks during the day. It becomes easy to forget sometimes, and over time many hundreds of missed hand washing “opportunities,” as they are referred to, can add up to a much bigger chance that your facility will fall victim to a deadly infection such as MRSA or C. difficile. Nationally, the hand washing compliance rate is only about 45%.
See the sidebar below for advice from healthcare safety experts on how you can improve hand hygiene in your facility.
Many hospitals use what are termed “secret shoppers,” usually infection preventionists or other experts who come in to casually watch employees during the course of a day to track hand washing compliance rates.
The problem with this tactic, some experts say, is that those being watched usually can figure it out pretty quickly and adjust their habits accordingly. What’s more, observers can only watch so many people and can’t get an accurate count of how many “opportunities” are seized over a longer period of time. For this reason, compliance rates in these facilities still only range around the 80% mark.
Sidebar: Experts tell you how to get them to wash their hands and maintain better hand hygiene
It turns out that the WHO might know more about effective hand washing techniques than the CDC, according to a new report.
The report, published last April 6 in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA), found that a six-step hand washing technique developed by the WHO is more effective at killing bacteria than the CDC’s three-step method.
Jacqui Reilly, PhD, professor of infection prevention and control at Glasgow Caledonian University in Scotland, was one of the lead authors comparing the WHO’s and the CDC’s hand washing methods. She told HealthLeaders Media in April 2016 that the WHO’s method washes 67% of the bacterial load from a person’s hand, while the CDC’s method only washes off 35%. The trade-off is that the WHO method takes 42.5 seconds to do properly, while the CDC method only takes 35 seconds. Reilly and her team compared the bacterial load on the hands of 42 physicians and 78 nurses after taking care of patients. Researchers documented how much bacteria were left over after each participant had washed their hands, either using the CDC or the WHO method.
“Hand hygiene is the most important intervention we can all do to prevent disease and infection,” said Reilly.
The need for good hand washing hygiene in healthcare is not new, but the struggle to get healthcare workers to not only do it, but do it right, is constant.
And necessary. According to WHO officials, many healthcare-associated infections (HAI) are preventable through good hand hygiene. Hand washing is a cheap and effective method of preventing the spread of antibiotic resistant diseases, which are expected to annually kill 10 million people worldwide by 2050.
However, the type of hand washing method is a secondary concern compared to a bigger issue; getting healthcare workers to wash their hands at all. In a different study published in the April issue of the American Journal of Infection Control (AJIC), researchers secretly chronicled 330 hand hygiene observations at 15 different facilities. The AJIC researchers found that a frighteningly low 37% of the staff observed washed their hands.
What is the proper way to wash your hands?
Reilly says her study found that the WHO’s six-step hand washing technique is better at cleaning one’s hands than the CDC’s three-step process. The WHO’s method states that after applying soap or sanitizer to one’s hands:
- Rub your palms together.
- Rub each palm front to back over the back of the other hand, interlacing fingers.
- Twist your palms with fingers interlaced, and rub between fingers.
- Interlock your fingers (thumbs should be on opposite sides) and twist again, this time with the backs of fingers against palms.
- Clasp your left thumb in your right hand and move thumb in circular motion—then switch thumbs.
- Press your right fingers together and rub them in a circular motion on your left palm, then switch.
“The uptake of this six-step technique, or any other hand hygiene technique, is not measured at the international level, although many countries do measure hand hygiene compliance in healthcare settings,” Reilly said. She continued to say that some countries, such as the U.S., have promoted a simpler process historically which only involves three steps:
- Apply the sanitizer to one palm.
- Rub both palms together.
- Rub product over your hands until dry.
Reilly says that the WHO endorses several multi-modal campaigns focusing on improving hand hygiene compliance by healthcare workers. She recommends that those who want to learn more about maintaining hand hygiene compliance visit the WHO guidelines and guidance on the measure.
Experts offer advice
Some healthcare experts say that while healthcare workers sometimes fall out of the practice of washing their hands, they’ll return to proper measures if prompted.
“The excuse of being too busy is not acceptable,” says Linda Gylland, QLS, MLS (ASCP), lab safety officer at Sanford Health in Fargo, North Dakota. “The excuse of ‘I will wear gloves anyway so don’t need to wash my hands,’ is also unacceptable. Hand washing is to be done before and after gloving. The excuse of ‘it’s hard on my hands’ is also unacceptable. There are great lotions available and options for hand sanitizers that actually lubricate your hands and feel good.”
While her facility’s goal for hand hygiene compliance is 95%, she says they’ve only managed to achieve 75% overall compliance.
“Our laboratories typically are very good with hand washing since we all wear gloves most of the time and know we are required to wash hands before and after glove removal and when leaving the lab,” she says. “We know the pathogens we are working with and do not care to take them home with us.”
Dan Scungio, MT (ASCP), SLS, the laboratory safety officer for the Sentara Healthcare system in Virginia, says that people often don’t understand the consequences of poor hand hygiene. He also places some of the blame on a lack of enforcement in healthcare facilities.
“I think it’s a difficult area for compliance for a lot of reasons, one [being] we don’t always make it easy for people to comply,” he says. “We don’t always educate staff and physicians and others in the facility the way we need to about the importance of hand hygiene. It’s something we hear about in everyday life, we hear about it in commercials, we hear about it at home, school, wherever. But there’s no special emphasis placed on it in the healthcare setting, and there really should be. Hospital-acquired infections can be pretty deadly.”
Hand hygiene is a high priority for Sentara Healthcare, he says, with a goal of achieving 100% compliance organizationwide. He notes that they’ve had some success toward that goal, with two of their hospitals becoming the first in the world to receive the DNV’s Managing Infectious Risks certification.
“It was known nationally that hand hygiene compliance in healthcare facilities was not great,” he says. “So we wanted to establish a program here and have been talking about it ever since. It’s not fallen off the radar screen here.”
Scungio notes that some departments struggle more with hand washing compliance than others. Emergency departments are one of the biggest offenders due to the extra pressures they face.
“In the emergency department where they live in a world of chaos and sometimes because of that world they do things to cut corners,” he says. “And they’re looking at it as, ‘I’m doing this for the patient.’ But don’t realize they may be harming the patient. That’s not particular to the emergency department but it does happen a lot there.”
Education and awareness
Scungio says that for any facility trying to improve its hand hygiene compliance, the first step is always education and awareness. Unless staff and visitors understand why hand hygiene is important and why the facility is going at lengths to enforce it, subsequent steps won’t work.
Facilities should do more with storytelling about hand hygiene cases, he says. There are a lot of true stories out there about HAIs, ones that have caused patient deaths and harm, adds Scungio. By giving staff members some of these stories and explaining how they happened and how they could’ve been prevented, it can make hand hygiene become a higher priority.
“Another thing we can do is to inform the public about our intent,” he says. “We actually have posters that say, ‘If you see your healthcare worker not washing their hands before they come to work with you, you make sure to tell them to wash their hands.’ ”
Gylland says Sanford’s hand hygiene posters are signed by their staff members and placed where the public can see them, to further drive home the importance of hand washing. Her facility also sends out e-newsletters with hand washing updates as well as compliance progress reports for each department.
“[I’d recommend] trying the secret shopper method for a month, keep the hand sanitizers in visual locations, reward departments who have successful compliance with donuts or fruit,” Gylland says. “If the budget does not allow that, even a ‘Congratulations on Hand Hygiene Compliance’ sticker to wear with your name badge shows the healthcare system is proud of you.”
Make compliance simple and everyone’s job
Scungio says one of the best ways of getting people to follow any type of regulation is to make it easier for them to do. He points to how the placement of hand soap and sanitizer dispensers has a huge effect on if people will use them. If they aren’t in a place where it’s obvious and easy for people to access, they simply won’t use them.
“If you want people to ‘wash-in’ and ‘wash-out’ out of every patient room, you better be darn sure you have soap both outside the door and before you leave the room,” he says. “Just having it on one side of the door, in my view, doesn’t send the message that we want them to do it both times. Maybe that’s overdoing it, some people might think that’s overdoing it. But I’m a lab safety officer, I want people to comply with using personal protective equipment. But if I don’t have face shields in the department, people aren’t going to go get them if they’re not handy. You’ve got to make it easy for people to comply with the things you want them to do.”
Sentara also has put more emphasis on making all departments culpable for their hand hygiene compliance and responsible for monitoring other departments, says Scungio. Sentara has been doing departmental hand hygiene audits for the past five years, he says. While hand hygiene is still the main purview of the infection control department, the other departments are required to do hand hygiene audits of each other to make sure they stay involved in the process.
Don’t be afraid to speak out
Deborah Thompson, MD, MSPH, medical director of patient safety for Presbyterian Healthcare Services and lead author behind the AJIC study on lack of hand washing in healthcare, told HealthLeaders Media that only following hand washing guidelines two-thirds of the time is not enough to effectively prevent infection.
“Because we live in those environments all day long, and we don’t get sick ourselves, there’s a little bit of a disconnect and not a conscious one,” she said.
Leaders can tackle this problem by discussing hand hygiene with staff and encouraging people to speak up whenever they see someone not washing their hands, said Thompson. Staff should also get into the habit of saying thank you whenever someone points out that they didn’t wash their hands. It normalizes the exchange from a punitive or accusatory one to a helpful and friendly prompt.
Scungio says when it comes to hand hygiene, the biggest offenders tend to be physicians. Encouraging a culture where staff and patients feel comfortable bringing up hand hygiene compliance with physicians would have a major impact on reducing infection rates.
“There’s a lot of people—and hospitals can be guilty of this too—[who] are afraid to talk to physicians about certain issues for a number of reasons,” he says. “Though number one [reason is] we don’t want to lose our physicians; we want to keep them happy. But at the same time we need to be able to talk to them like everybody else about importance of hand hygiene.”
Q&A: The experts explain GHS compliance
Editor’s note: This Q&A was taken from the HCPro webinar, OSHA's Revised Hazard Communication Standard: Strategies for Training Staff and Implementing the GHS. Healthcare safety experts Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance, LLC, in Eau Claire, Wisconsin, and Paul Penn, president of EnMagine, Inc., emergency environmental health and safety management in Diamond Springs, California, provide their professional insight into implementing OSHA’s Globally Harmonized System of Classification and Labeling of Chemicals. To listen to the full program on demand, check out the HCPro Marketplace at www.hcmarketplace.com.
Q: Do facilities need to keep their MSDS (now SDS) on file for 30 years?
McFarlane: People who are using online systems have been relying on online systems to archive their MSDS. The OSHA standard has not changed. We still need to archive MSDS and now the SDS for 30 years plus the time of employment. I believe that in this electronic age we do not necessarily need to keep hard copies anymore. Why not scan them into a flash drive; have them in some computer file that can be readily accessed?
The whole purpose of saving MSDS and now SDS is that long-term health effects are the issue. In the old days, we used to use formaldehyde with abandon. We used it in the laboratory, we used it to clean dialysis equipment, and we did not really, really recognize the long-term carcinogenic effect of formaldehyde. We used to use benzene as a solvent until we realized that it caused bone marrow cancer. Again, if I come to you as my employer in 30 years because now I have cancer, and I am trying to link it back to a chemical that I used when I was in your employment, the 30-year saving of the material safety data sheets<