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Briefings on Hospital Safety, August 2017


July 28, 2017

When a suspicious package prompts an ER lockdown

How prepping for Ebola helped empower a Maryland hospital to handle hazmat scare

When two men opened a piece of mail at home in Frederick, Maryland, in May, they found a mysterious substance lurking inside. One man soon developed a small burn on his forearm. Both began suffering respiratory symptoms. So the two decided to seek medical treatment about a mile down the road at Frederick Memorial Hospital. And they brought the suspicious package with them. 

Once hospital staff realized the patients had brought a potentially hazardous material into the ED, they initiated a multi-agency emergency response, calling upon police, firefighters, public health officials, and others to contain a situation that seemed poised to rapidly deteriorate into chaos. The hospital evacuated its ED and relied on a segregated HVAC system to minimize the threat of cross-contamination. A hazmat team established a decontamination tent on-site, and ambulances carrying incoming patients were diverted to other hospitals.

Phil Giuliano, director of public safety and security for Frederick Memorial, says medical staff believed they were dealing with an unknown white powder delivered in an envelope to the two patients from an unknown source. The big fear was that the contents of the envelope, which were mailed to a residence on Military Road, might have something to do with the U.S. Army installation across the street. 

While single-family homes line the south side of Military Road, a barbed-wire fence along the north marks the outer boundary of Fort Detrick, a garrison that serves not only as the top employer in the county but also as a hub for biodefense research. It was the heart of the U.S. biological weapons program (until the program was discontinued in 1969), and today it facilitates an array of military agencies and private research groups within the National Interagency Biodefense Campus. This is not the sort of place where mysterious white powders are given the benefit of the doubt.

Hospital staff and law enforcement worried that one of the men might work in one of the laboratories at the installation, Giuliano says. A spokesperson for Fort Detrick confirmed, however, that the men were neither service members nor civilian employees of the military. Initial testing revealed that the suspicious package did not contain a biological or viral agent, Giuliano says; a second round confirmed the result, suggesting that the substance was instead a common household chemical. A third round is expected to tell investigators precisely what that chemical was.

While the three-hour hazmat scare proved far less dire than it could have—the patients’ condition never worsened, and the nurse who worked with them never showed symptoms—the incident offered real-world practice to the various local, state, and federal officials involved in this sort of emergency response.

“Honestly, I think it went as smooth and as seamless as it could,” says Lt. Clark Pennington, commander of the Frederick Police Department (FPD) Criminal Investigation Division. “This is something we plan and we train for.”

That being said, there are always areas for potential improvement, which is why FPD committed to joining with the hospital and other local agencies for an after-action review of the response, Pennington says.

At this point, it seems the overarching lesson is that emergency responders need each other, and they need to build strong bonds in anticipation of emergencies large and small, Giuliano says.

“When events like this take place, I think it’s a reminder for hospital staff, hospital leaders, and community members as a whole how important it is to have strong relationships, to maintain strong relationships with those other partners you have in your county, in your jurisdiction, in your area of operations,” Giuliano says.

That level of refined collaboration requires that agencies have confidence not only in their own members but in each other as well, says Michael G. McLane Jr., MBA, BSN, RN, assistant vice president of support services and behavioral health for Frederick Memorial.

“You don’t get that trust just by saying, ‘Well, I trust you,’ ” McLane says. It takes extensive collaboration, meeting, pre-planning, training together, frequent communication, and more.

Prepped for Ebola

The ED team at Frederick Memorial didn’t have an emergency response guide labeled “How to handle envelopes of unknown white powder.” But they did have detailed plans on how to respond to a different type of emergency: suspected cases of Ebola.

As the deadly Ebola virus ravaged West Africa in mid-2014, the CDC launched an initiative to prepare U.S. hospital systems to respond quickly to patients with symptoms. A man in Texas who had recently traveled to Liberia died after his Ebola symptoms were first diagnosed as sinusitis, then two nurses who cared for him also contracted the virus, spurring fears that U.S. facilities might be underprepared to spot and deal with the highly contagious infection, according to a report published by the CDC last year.

Since certain hospitals faced a higher likelihood than others of having a patient with Ebola show up in the ED entryway, the CDC and the HHS Office of the Assistant Secretary for Preparedness and Response rolled out an approach with three tiers: frontline healthcare facilities (which would quickly identify and isolate patients with possible infections), Ebola assessment hospitals (which would receive patients with possible infections and coordinate laboratory testing for the virus), and Ebola treatment centers (which would care for patients with confirmed cases as long as needed).

Frederick Memorial was designated an Ebola-assessment hospital, one of only five in Maryland, Giuliano says. That means his team has spent the past few years developing and practicing plans around how clinical staff would safely care for patients with Ebola symptoms while minimizing the threat to fellow patients and staff. These plans came in handy when hospital staff were faced with the threat of the suspicious envelope.

“It provided good guidance up front for us and the right steps to take in getting the right partners in place quickly,” Giuliano says.

Since there was concern that the nurse who initially cared for the two men might also have been exposed to hazardous material, she was treated alongside the patients and underwent a decontamination shower.

“There was no break in her care,” Giuliano says, “and it was done in tandem prophylactically just to make sure that, if there was any opportunity for any exposure, she received the same treatment.”

Praise for training

Credit for the smooth response to May’s hazmat scare should be assigned to the extensive and collaborative practice undertaken by hospital staff and other agencies, Giuliano says. He advises other healthcare safety professionals to similarly prioritize training, even for unlikely scenarios, because the lessons learned focusing on one particular issue can come in handy responding to a number of real-world situations. At least one staff member who was working through an active-assailant training program, for instance, said the practice on how to keep clearheaded in the event of an attack made it easier for that person to keep everyone in the hospital calm as the hazmat incident was unfolding.

“Train and educate every opportunity you have. The plans are only as good as the exercises that you put behind them,” Giuliano says. “There are always going to be gaps in any plan that you’ve created, and to close those gaps, they have to be living documents.”

Giuliano adds that repeatedly putting a plan into practice is the best way to ensure your team knows how to respond in high-stress situations.

“A policy, again, is only as good as the understanding of the individual who is trying to utilize it, and that understanding has to come from a basis of knowledge that is already in place,” he says. “So I think emergency managers have a responsibility to be educators as one of their top priorities, because a hospital [requires] an all-hazards approach. There are so many things that can walk through those doors. There are so many things that can impact a hospital system. Without having an all-hazards approach that’s understood at a line-staff level, you’ve really lost an opportunity.”

In the wake of any emergency response—even a false alarm or pre-planned exercise—a thorough after-action assessment is indispensable.

“If you’re not looking for those opportunities on how to enhance the program after an event like this, or a smaller event, then you’re missing the mark,” Giuliano says. “We’re always ironing out wrinkles. With an event like this, it’s an opportunity to take pause.”

Emergency preparedness rule

Under the new CMS Emergency Preparedness Rule implemented last fall, Frederick Memorial and other hospitals must conduct two annual exercises by November 16, 2017. When a real-world incident prompts a hospital to activate its Emergency Operations Plan, however, that can count as an exercise, as The Joint Commission acknowledges in element of performance 1 under EM.03.01.03.

Giuliano says the May hazmat scare was one of four separate real responses, all within a 10-month time span, that could count toward the CMS/Joint Commission requirement. These are in addition to two pre-planned exercises. Although the hospital does not plan to use the real responses as substitutes for any exercises, the team keeps documentation of each response anyway—digital and hard copies—for regulators to review, Giuliano says.

“I like having a separate binder for each event that’s categorized the same way, completed with an after-action report that follows the six subcategories [of the Emergency Preparedness Rule] so that it’s apples-to-apples and you can do comparisons on the event,” Giuliano says.

Most inspectors have really wanted to see those hard copies, he adds, so keep them printed out and stored in a logical order.


Surveilling injuries: Why OHSN wants you to share your injury data

Network expanded this year to include needlesticks and bodily fluid exposure

For nearly four years, the Occupational Health and Safety Network (OHSN) has been collecting traumatic injury data from hospitals on a voluntary basis. The initiative, which is part of an effort to identify persistent hazards and injury trends in healthcare settings, has in recent months grown both in its size and scope. And organizers are looking to sustain that steady acceleration.

When the network first launched in 2013, it dealt exclusively with three injury categories: slips, trips, and falls; workplace violence; and patient handling. Earlier this year, the network added two more modules: one for needlestick injury data and the other for incidents involving exposure to blood or bodily fluid. The team launched a recruitment campaign, and within a month, more than 50 additional hospitals asked to sign up, says Ahmed Gomaa, MD, ScD, MSPH, project officer for OHSN. As of mid-May, there were 170 hospitals enrolled across 28 states.

Why do hospitals put forth the effort to send their injury data to a subset of the U.S. Department of Health and Human Services without being required to do so? Perhaps because they see value in what they get back: information that is both actionable and timely.

“The difference between our surveillance and other surveillance is that we give the data to the hospital one week after they submit it to us, instead of waiting two or three years to get a generated report,” Gomaa says. “So they get the data right away.”

What’s more, OHSN ensures that the data it collects is standardized, making it much easier to measure changes over time—which is essential to testing whether a new solution is having any effect on the problem.

“We make it simple. We get the data in a standard way. You get it back in tables and graphs,” Gomaa says. “Anybody can understand and comprehend it in one minute and show it to the worker or supervisor or whoever, administrator or certification agency like [The] Joint Commission, or regulatory agency like OSHA.”

For each injury or illness, the data track the date, location, and impact of the incident, including the number of days affected employees spent away from work as a result of the mishap, among other data points. The OHSN team then processes the data and delivers reports to the hospital staff in about a week, with accompanying visuals. Since the data are recorded with standardized locations and job categories, the regular reports help to identify which areas and job titles are at greatest risk. That way, hospitals can craft solutions to improve safety, then measure whether those solutions are working.

“In our system, you submit the data every month. You get it after one week. Everybody speaks the same language. They can look at the historical data over time, and they can see trends, and they can see visual data. They don’t have to learn how to do analyses,” Gomaa says.


In mining, what sets an ore apart from a mere mineral is the fact that it can be extracted for a profit. Analogously, what sets a valuable data set apart from others is its utility—surveillance statistics are only as valuable as they are timely and actionable. So those running OHSN have built their entire operation with this in mind, seeking to provide data that are sufficiently granular to enable participants to test safety interventions on the local level.

“If you look at your data and find that you have a problem with violence against nurses, for example, the natural question after that is, ‘So what can I do about it?’ ” Gomaa says. The answer—actually, a number of possible answers—can be found on the OHSN website, where there are a number of proposed interventions listed by injury type.

Worried about blood and body fluid exposures? Review the four documents outlining universal precautions, engineering controls, PPE, and more. Looking to stop sharps injuries? There are eight resources on the topic. More links to workplace violence prevention strategies, safe patient handling refreshers, and advice on making slips, trips, and falls less likely are there as well, readily available for participants to review, adopt changes, then check their results.

Jennifer Beining, MSN, JD, RN, COHN-S, NE-BC, system manager of clinical services at Ohio Health Associate Health & Wellness, whose team has been using the OHSN system for about two years, says it has helped shift the conversation. Healthcare workers should not simply accept the risk of injury as part of their line of work, she said.

“I think in nursing the mindset is that there are some things that come with the job, and we spend so much time focusing on what’s right for the patient, we don’t necessarily take care of ourselves. That’s a culture that needs to change,” Beining said in a video testimonial for OHSN’s service, adding that the data-tracking system helps to reinforce best practices that can often be abandoned for the sake of convenience.

“There are a lot of tools out there that can be used to prevent our healthcare workers from lifting; however, we just aren’t using them,” Beining said. “With the Occupational Health and Safety Network, we can show the areas that we have been using the devices have lower rates of safe-patient-handling injuries. And that helps us spread that out to other areas and also convince the staff and the leaders that this is the right thing to do.”

Integrated and free of charge

When researchers with the CDC’s NIOSH devised the OHSN system, they did so because there was clearly demand for a standardized injury surveillance system—demand that has persisted after the system’s launch.

“An annual survey of OHSN users shows overwhelming support for a system that helps mitigate high-risk aspects of the healthcare industry and guides prevention efforts,” NIOSH Director John Howard, MD, said in a statement. “A commitment to a culture of safety that emphasizes continuous monitoring and improvement benefits not only the worker, but the employer as well.”

There’s a major incentive, Gomaa says, for hospitals to promote employee safety because promoting healthy workers helps to promote healthy patients and healthy hospital environments. But identifying an area in high demand is only half the equation. If a mineral is too difficult to extract affordably, then it’s not “ore,” which is why OHSN’s services are offered free of charge and designed to align with existing data-collection activity.

Participants who already collect incident reports and send them off to OSHA want to maximize the information they already have, Gomaa says.

“They don’t want to be passive partners sending data and receiving reports three to four years later when they don’t have to share the analysis and everything else,” he says. “They want to be active participants, and they want it to be easy, and they want it not to do double-entry.”

Importantly, the data OHSN collects is viewable only by the organizations that submit the information and those who prepare the reports. Information released to outside parties is done in aggregate, Gomaa says.

“We are not a regulatory agency. We are a public health agency,” he notes. 

Gomaa’s team prioritized the five current modules because they address the most common, most serious, and most preventable injuries in the hospital setting. The team has identified other areas worth surveilling, but there is no timeline on when (or whether) the scope of the project will expand again.

“We would like to have a lot of other modules,” Gomaa says, “but I think that we are limited by the budget and time.”

Even if OHSN’s recently expanded scope remains constant, however, there is plenty of room for growth in membership. While 170 hospitals have enrolled thus far, there are more than 5,500 registered hospitals nationwide, according to the AHA.


Keeping service animals out of healthcare settings is rarely legal

How to apply the law correctly and consistently when excluding animals from your facility

When anyone brings an animal into a healthcare setting, it is reasonable to wonder whether the animal’s presence might pose a sanitation risk. Fleas, ticks, mites, and more could threaten to undermine the facility’s infection control efforts. Since some of these animals will be service animals, however, medical and support staffers should be cautious to avoid violating the rights of patients and visitors with disabilities.

Generally speaking, government bodies, businesses, and nonprofit organizations that serve the public are required by the Americans with Disabilities Act (ADA) to permit service animals in their facilities. The law supersedes any and all breed-specific bans and prohibits covered entities from requesting documentation to prove that the animal is a service animal. But there are limited circumstances in which covered entities can exclude such animals, according to the Disability Rights Section of the U.S. Department of Justice (DOJ) Civil Rights Division.

“For example, in a hospital it would be inappropriate to exclude a service animal from areas such as patient rooms, clinics, cafeterias, or examination rooms,” the DOJ explained in a summary of the ADA’s provisions. “However, it may be appropriate to exclude a service animal from operating rooms or burn units where the animal’s presence may compromise a sterile environment.”

Balancing the need to keep medical settings safe and clean against the rights of patients with disabilities to bring service animals with them is not always easy. Applying the law correctly and consistently requires a significant amount of pre-work and communication, both within the organization and with the public.

Do your homework

Some patients and visitors will assert that their “companion animal,” “emotional support animal,” or “comfort creature” qualifies for ADA protections, but that is not the case—unless those animals also meet the definition of a service animal.

“Because we’re dealing with very clear regulations, people’s rights, compliance with those rights, we have to understand what is and what is not a service animal,” says Frank Ruelas, facility compliance professional at St. Joseph’s Hospital and Medical Center/Dignity Health in Phoenix, Arizona.

Definition. The DOJ states that a service animal is defined as a dog that has been “individually trained to do work or perform tasks for people with disabilities.” (A separate provision acknowledges that a miniature horse can similarly be individually trained as a service animal.) In order to qualify, a dog must be trained to take some specific action to help the individual with a disability.

“For example, a person with diabetes may have a dog that is trained to alert him when his blood sugar reaches high or low levels. A person with depression may have a dog that is trained to remind her to take her medication. Or, a person who has epilepsy may have a dog that is trained to detect the onset of a seizure and then help the person remain safe during the seizure,” the DOJ states.

Questions. Since some disability-related tasks are less obvious than others and the law does not require any special certification, registration, vest, or badge to prove that a dog has been trained, healthcare workers must proceed with caution if they wish to ask about a person’s service animal.

“There’s basically only two questions that they can ask,” Ruelas says: (1) whether the dog is a service animal required because of a disability, and (2) what work or task the dog has been trained to perform. These two inquiries come from the DOJ, which specifies that staff are “not allowed to request any documentation for the dog, require that the dog demonstrate its task, or inquire about the nature of the person’s disability.” The ADA does not require that a service animal be trained professionally.

Clearly, on the one hand, if patients say their dog is not a service animal, then they admit the ADA does not apply. In that case, healthcare workers would have maximum leeway to exclude the animal. If, on the other hand, the person says their dog is a service animal that has received individualized training to perform a task related to a disability, then staff should proceed as if the assertion were a proven fact—there are other factors still that could justify excluding the service animal.

It’s worth noting that state laws may impose a more generous definition of a service animal. While this would not affect enforcement of the ADA, it could impact other disability rights laws in effect where your facility operates, so do your homework.

Communicate with your team

Knowing what the law says is a prerequisite to applying it correctly. Communicating the law to your staff is key to applying it consistently.

“The overriding factor that I always am emphasizing to folks is they need to do whatever they need to do to be consistent,” Ruelas says. Perhaps that means developing a standard operating procedure or a flow chart. How will your organization handle disruptive service animals? Put it in writing.

“If you’re going to really look at the question of service animals, how you are going to address service animals in your facility, look for folks that have done so successfully—or even more importantly, unsuccessfully—that are similar to your setting and see what has worked and what has not worked for them,” Ruelas says. This topic is a prime area for collaboration with other facilities, even those outside your immediate network, he adds.

“Here’s the thing: We’re talking about an area of information-sharing that’s far from anything that could be considered proprietary,” Ruelas says.

When can an animal that qualifies as a service animal be excluded from a healthcare setting? There are several scenarios identified by the DOJ:

Is the animal housebroken? If a service animal is unable to control its bladder and bowel movements, then there is sufficient basis under the ADA to exclude it from a facility. Even if you can lawfully exclude an animal, however, remember that you should continue to offer services to its handler.

Is the handler controlling the animal? The patient or visitor who brings a service animal into a healthcare setting must keep it under control at all times. The animal must wear a harness or leash in public, unless wearing one would inhibit the animal’s work, according to the DOJ.

Handlers are not permitted to let their dogs wander away, but there are certain scenarios that healthcare workers should keep in mind to avoid assuming that an animal is wandering or otherwise out of control. A veteran suffering from post-traumatic stress disorder, for instance, could have a service animal that is trained to enter unfamiliar spaces and confirm that there are no threats present. In this case, the animal would be off-leash while inspecting a room for its handler, and it could still be considered under control.

Is the animal being overly disruptive? A bark here and there would be insufficient under the ADA to exclude a service animal. But repeated barking in quiet places without provocation could be grounds for exclusion.

Is the animal undermining what you’re offering the public? This is arguably the most subjective category identified by the DOJ, which explains that the ADA does not require you to change your policies, practices, or procedures if doing so would “fundamentally alter” the nature of your operation.

“In most settings, the presence of a service animal will not result in a fundamental alteration. However, there are some exceptions,” the DOJ explains. “For example, at a boarding school, service animals could be restricted from a specific area of a dormitory reserved specifically for students with allergies to dog dander.”

If allergy sufferers and service animals must share space, then the facility should accommodate them both to the best of its ability, assigning them to different areas within a room or different rooms within a building, the DOJ notes. A patient’s allergies (or fear of dogs) would be an inadequate basis to exclude the animal.

As an example of a scenario in which facilities do not have to accommodate a service animal, Ruelas says he has had people insist upon bringing a dog into the operating room, which could compromise operating room sanitation. So he has refused this request, while still permitting the animal in patient rooms.

Keep the patient in mind

You and your team should know when it’s appropriate to ask someone to remove animals from your facilities. You should be prepared to do so politely and firmly. But you should also approach each situation with the patient in mind, Ruelas says. Step back and view your facility and staff from the perspective of a patient or visitor with a disability. Build your policies and procedures with that point of view in mind.

“I like to actually walk in the shoes of the patient that might have a service animal. When that person comes through, whom are they going to first interact with?” Ruelas says, noting that it could be staff at a registration or information desk. “Those are going to be your key touch points who need to be educated on whatever process you come up with. It’s nice if everyone knows, but certainly start with those critical touch points first and then develop it beyond that, after you’ve established a good foundation.”

Expect pushback, remain empathetic, and be prepared to calmly explain the law and your local policies, Ruelas says. It is common for someone who has had to defend an animal’s presence repeatedly in the past to become defensive when faced even with fair questions, so take steps to avoid escalating the situation unnecessarily. Respectfully ask the questions you are permitted to ask and make a determination, then calmly explain the rules and process. Being able to educate the handler could help defuse the immediate situation or, at the very least, clearly communicate the rationale behind your actions if the individual complains about you to regulators or media outlets.

Follow up as patients and visitors leave. If you ask your staff to notify you when someone with a service animal is about to depart from your facility, you can initiate a brief conversation with patients at the exit, Ruelas says. Ask them about their experience, and about how you can better meet their needs in the future or make the process smoother. If they don’t notice anything that could or should change, count this as a success.

Ruelas cautions that all the above factors should be discussed with whomever at your facility is responsible for signing off on legal language. That likely means pulling those staff members into the conversation sooner rather than later.

“Before you start down the path of self-development and self-education, find out whom you’re going to have to answer to, whom you’re going to have to justify and provide information to so that you can get their buy-in,” Ruelas says. “If legal says, ‘Well, that’s all well and fine, Frank, but I need to hear this from an ADA expert,’ then you need to go down that path.”


Proper device cleaning requires manufacturer guidance, internal process

Press manufacturers and vendors for details on the proper cleaning products and solutions to use on their equipment. Then make sure that employees responsible for cle

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