Briefings on Hospital Safety, September 2017
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August 31, 2017
Even localized crime can pose an emergency threat to healthcare centers
While an all-hazards risk assessment is required for the annual review of your emergency preparedness plan under the new Conditions of Participation (CoP), be aware that new hazards can pop up at a moment’s notice—and you can use them to review your readiness.
Take, for example, a recent warning by an Ohio sheriff who told residents of his county to be ready for a rough July 4 holiday weekend because of what he said were criminal gangs looking to target the area with possible violence and extra-lethal drugs.
The warning seemed to startle other law enforcement officials in the area. When it came up in the daily safety huddle held by a local health system, managers there used it as an opportunity to review the system’s emergency planning.
Hospital heeds warning
Pike County Sheriff Charles Reader issued the alert on Facebook the Monday before the long holiday weekend. Members of the criminal gangs MS-13 or Konvicted Family could make their way into the region, about an hour’s drive south of Columbus, with plans to wreak havoc, the sheriff said.
“Possibly planning on ‘taking out’ believed snitches and spread ‘HOTSHOTS’ of heavily laced Heroin into the area that could cause an extremely large amount of overdoses in Pike County and surrounding counties,” Reader wrote in an alert reported by The Columbus Dispatch and other local media. “This is according to very limited intelligence deputies have gathered in recent drug-related investigations across the area in the past weeks.”
When news of the sheriff’s warning broke, leaders within Chillicothe, Ohio–based Adena Health System convened a special planning meeting to ensure that its facilities in and around Pike County would be prepared in case an influx in opioid overdoses, or any other incident, did materialize, says Jason Gilham, BA, Adena’s communications manager.
“We operate a daily patient safety huddle every single morning at 9:30 a.m., which brings together … one representative from across the health system in, I think, about 18 different departments, from surgical, our emergency department, communications security, housekeeping, all across the board,” Gilham says.
Law enforcement contacts are key
The sheriff’s warning came up during the 15-minute huddle that Monday, and the group decided to schedule a follow-up meeting Tuesday with key players to discuss the matter in greater detail.
“That gave our security team a chance to touch base again with the local law enforcement, whether that be in Ross County and in Pike County, with a little bit more detail, just to kind of get a greater feel for where they stood and the latest information,” Gilham says. (Chillicothe is in Ross County, which shares a border with Pike County.)
The hospital leaders revisited the system’s emergency response plans and asked whether workers could use a refresher on what to do, for instance, in the event of a lockdown, Gilham says. They also decided to add an off-duty officer for the July 4 weekend at Adena Pike Medical Center, the system’s 25-bed critical access hospital in Waverly, Ohio, which is the Pike County seat.
Furthermore, the system’s pharmacy department checked with all Adena facilities in the area to ensure that each had a sufficient supply of the opioid overdose–reversing drug Narcan® (naloxone).
“It was just kind of bringing everybody up to speed and having that comfort level going into the weekend,” Gilham says.
Threat did not materialize
The Ohio Attorney General’s Office distanced itself from Reader’s warning. “We are not involved with this,” spokeswoman Jill Del Greco said, according to the Dayton Daily News.
The alert was greeted with skepticism from other law enforcement in the area, too. Scioto County Sheriff Marty V. Donini said there was “absolutely” no credible evidence that the gangs listed in the warning were present in the county he oversees, which lies just south of Pike County.
“The public is urged to be responsible and to refrain from circulating ‘unverified’ facts,” Donini said in a press release, as reported by Columbus, Ohio–based NBC4. “[T]o do so simply fuels hysteria and pandemonium within our community.”
Donini said he had investigated the matter and consulted the Southern Ohio Drug Task Force after several Scioto County residents voiced concerns about social media posts and news reports.
Reader shot back with another Facebook post, arguing that Donini’s office was not involved in executing the search warrants and conducting the interviews that led to the alert being issued.
“Scioto County would NOT have the information that we obtained in aggressively attacking the drug epidemic in Pike County,” Reader wrote. “I’m sure they stay busy enough in Scioto County.”
Opioid-related trips to the ED have risen dramatically over the past decade in Ohio, according to data from the Agency for Healthcare Research and Quality (AHRQ). While rates of opioid-related ED visits have approximately doubled nationwide since 2007, they have nearly quadrupled in Ohio, where rates have held consistently above the national average, according to AHRQ’s Healthcare Cost and Utilization Project (www.hcup-us.ahrq.gov/).
Deputies in Pike County have been cracking down on heroin dealers recently, with one recent raid garnering nearly $10,000 and 42 grams of fentanyl-laced heroin, as Cincinnati-based Fox19 reported.
Reader would later say that the information about the possible criminal activity had been gathered after executing search warrants and conducting interviews, and noted that at least one person arrested during those investigations was confirmed as a gang member.
Fortunately, the preparations by Adena proved to be just an exercise in readiness. No spike in drug overdoses or other gang-related activity was reported during the weekend.
OSHA: Legal questions delay implementation of electronic reporting of injury data
Less than one week before its scheduled compliance date, OSHA officials delayed a new electronic recordkeeping rule that’s being challenged in more than one federal courtroom.
The U.S. Department of Labor (DOL) announced that the new compliance date would be December 1, giving OSHA five months more to review “questions of law and policy” pertaining to the rule finalized last year.
The rule would require about 466,000 employers nationwide to electronically file their Form 300A summaries of workplace injuries and illnesses with OSHA. It has been controversial in large part because employers dislike the idea that OSHA plans to publish some of their injury and illness data online.
Employers have also opposed the rule’s prohibition of incentive and testing programs associated with injury reporting, Bloomberg BNA reported. Workers’ groups contend that ending such programs will protect employees from being ostracized by their employers for voicing safety concerns. With clearer protections for whistleblowers, the rule requires that employers make clear to staff that anyone has the right to alert OSHA to problems without fear of retaliation.
The rule did not change the types of information to be filed with OSHA each year, but it did change how employers were supposed to file the data. Employers would be required to use a secure web-based application to submit the data electronically. That would allow OSHA to capture the information such that it could report the safety records of each employer publicly and in a searchable format.
While OSHA promised that the information would be “scrubbed” of personally identifiable details about workers, there were concerns that healthcare providers, who also face responsibility for preventing data breaches of protected health information (PHI), could face problems.
“The rule presents a number of challenges for all employers, but I believe that healthcare employers carry an even heavier burden than employers in other industries,” said Valerie Butera, an attorney in the employment, labor, and workforce management practice area of the Washington, D.C., law firm Epstein Becker Green, last year.
“No computer system is infallible, and this step opens the doors to an inadvertent disclosure of private employee information,” Butera added. “The heightened threat to healthcare employers is the very real possibility that patients’ protected health information could be breached as well.”
Although the new online system was not ready for the original July 1 compliance date, the online Injury Tracking Application was made accessible on August 1, OSHA announced. The system offers three ways to submit data: entering information into an online form, uploading a CSV file, or automatic data transfer using an application programming interface.
Maintain blanket warmers and educate staff on policies to avoid RFIs
Schedule regular maintenance of blanket warmers, update related policies, and ensure that nurses or other staff are documenting temperature checks and keeping those logs up to date. Educate staff on the policies as well as the appropriate storage related to warmers on patient floors.
Hospital compliance officers have reported blanket warmers as a regular target of Joint Commission surveyors over the last two years, and a check of CMS inspection reports shows repeated citations related to this equipment, which can pose a fire hazard and injure patients or staff if improperly used.
CMS reports highlight common problems
Hospitals nationwide have been subject to CMS citations centered on blanket warmers. A hospital in Oklahoma was cited under deficiency tags for patient safety and executive responsibilities for quality assurance and performance improvement for not adhering to hospital policy, which called for blanket warmers to be “inspected annually by Clinical Engineering to verify proper temperature settings and performance” and stated that “temperature will not be set higher than 130°F.” The last inspection documented for the blanket warmer in question was two years old, and CMS inspectors found that, while the temperature setting was at 150°F, the temperature reading was 210°F. In addition, “the hospital did not keep a temperature log for the blanket warmer.”
A hospital in Arizona was cited under a maintenance deficiency after a survey found problems with several pieces of equipment in an operating room, including a blanket warmer for which no preventive maintenance documentation could be found.
A hospital in Maryland was cited under infection control after a blanket warmer was found in the soiled linen storage.
A hospital in New York was cited under physical plant maintenance after CMS surveyors found three “recliner chairs and two blanket warmers were stored on and obstructing the corridor next to the exit door of the unit.”
Risk assessment advised
While The Joint Commission does not have a standard specifically addressing blanket warmers, in an FAQ it states that under Environment of Care standard EC.02.01.01 on managing safety risks, hospitals are encouraged to perform a risk assessment when setting a policy regarding temperature settings, and staff should be well versed in that policy.
Hospital accreditation officers who have recently gone through survey also point to EC.02.04.03, element of performance (EP) 3, which calls for inspecting, testing, and maintaining non-high-risk equipment.
The Joint Commission FAQ also notes that the equipment should be maintained according to manufacturer’s instructions or a schedule established as part of an alternative equipment maintenance program.
Do not set temperatures too high
When considering temperature settings, again review manufacturer’s instructions as part of your risk assessment. ECRI Institute, a Plymouth Meeting, Pennsylvania–based Patient Safety Organization that often works with The Joint Commission, recommends a maximum setting of 130°F to decrease the risk of burning a patient or staffer.
Also, caution staff members about overstuffing blanket warmers. Hospitals are required under EC.02.03.01 to manage fire risks, including under EP 1, which minimizes combustion products. Fires have resulted when blanket warmers are overloaded, hindering air circulation, fire safety experts have said.
Editor’s note: This article originally appeared in Environment of Care Leader.
Fire doors keep flames contained but smoke still problem in Texas hospital fire
Just after lunch on a Wednesday, four days into the new year, someone decided to set the University of Texas Medical Branch’s (UTMB) John Sealy Hospital in Galveston, Texas, on fire.
The 12-story hospital, built in 1975, is in a complex of interconnected UTMB Health buildings. John Sealy is L-shaped, with a shaft of elevators sitting in the center core area that connects wings A–B on one side and wings C–D on the other.
Built before fire codes required patient care facilities to be fully equipped with fire suppression systems, the building is being retrofitted with fire sprinklers one wing at a time, one floor at a time, says Jack Tarpley,UTMB Health’s associate vice president for environmental health and safety.
Alarm triggers automatic responses
The fire alarm system activated at 1:20 p.m. January 4, signaling smoke and heat in a waiting area on the second floor. Designed to provide families a quiet place to wait while patients were in surgery, the open area is off the elevator core. At the time of the fire, however, the area was unused because the wing it served was closed for renovations, including the addition of sprinklers, Tarpley recalls.
The second-floor wing on the other side of the elevator core housed John Sealy’s burn unit. On the first floor below the waiting area was the hospital entrance and lobby, which connects to other buildings, including a central food court. The floor above the fire was labor and delivery. The fire alarm activated on the central alarm panel, on the floor where the heat and smoke were detected, and on the floors above and below, says Tarpley.
Throughout the second floor, fire doors had closed automatically, sealing each wing from the flames. With the alarm’s activation, the elevator cars, as designed, recalled to the first floor. However, the smoke from the furniture-fueled fire infiltrated the elevator shaft.
First on the scene was the hospital’s fire marshal of the day, who also is an off-duty Galveston firefighter. The hospital employs the off-duty firefighters to take advantage of their expertise and to ensure that local firefighters are familiar with the hospital as well, Tarpley says. The marshal had entered the lobby, checked the alarm panel as he passed through to a stairwell, and was on the second floor within a minute or so of the alarm’s activation.
Incident command setup
As required under the hospital’s fire plan, UTMB police as well as staff from environmental services, property services, safety, facilities crew, and other first responders met within minutes at the main fire panel. Tarpley, whose office is in another building, says he arrived just as Galveston firefighters did.
The hospital’s fire marshal began coordinating his fellow firefighters and directing them to the fire as other staff throughout the building reacted according to the fire plan—all fire doors were closed and staff prepared to shelter and defend in place, as they are trained every quarter to do, Tarpley says.
Tarpley, meanwhile, was working with on-scene commanders and alerting hospital executives to what was happening. “It’s hard to fathom how literally in minutes, how fast everything happens,” he recalls.
As firefighters began laying fire water lines from connections in the stairwells into the second floor to breach the fire area, the smell of smoke began infiltrating other floors, going through the stairwells as well as the elevator shaft.
While the fire was contained, the smoke smell began to intensify and some staff members “felt like they needed to be outside the building,” Tarpley says, noting that drills train staff to use their own judgment.
The continued sound of the fire alarm and the smell of smoke quickly evoked the concern of patients as well. Indeed, it was someone visiting a patient who first alerted David Marshall, a UTMB vice president and the medical center’s chief nursing officer, to the fire. Less than 10 minutes after the initial alarm, Marshall says he received a text from a coworker, whose daughter had given birth the day before and was still in the labor and delivery unit on the floor above the fire. Almost at the same time, Marshall received a text from the hospital’s chief operating officer, and they, along with other staff, headed over to John Sealy to help with patients.
A nurse for 34 years, Marshall says he has gone through decades of fire drills and training, including how to evacuate patients. But that training always involved a horizontal evacuation—taking patients from one wing to another or from one building through a passageway to another building. “Never vertically,” Marshall notes.
That was about to change.
Smoke prompts evacuation order
On the second floor and the floor directly above the fire, smoke was becoming heavier but was still moderate. Patients were evacuated immediately from the second floor burn unit.
Marshall said he navigated firefighters and hoses as he made his way up the stairwell to the third-floor labor and delivery unit to offer assistance. Several women were in labor, including one who had been given an epidural and could not move on her own.
Out of “an abundance of caution,” a decision was made to evacuate the entire building along with a connected annex building. Overhead communication was used to send out the order, and staff went into action to help ambulatory patients down the stairs.
Fortunately, patients were not on every floor. Unfortunately, the patients John Sealy housed were in some cases quite vulnerable. Besides the burn unit and labor and delivery, the hospital housed high-risk obstetric patients on the 10th floor, pediatric ICUs on the ninth floor, mother-baby units on the seventh and eighth floors, intermediate nursery and newborns on the sixth floor, dialysis on the fifth floor, and a cardiac catheterization unit on the fourth floor. One surgical team was in the middle of a catheterization when the alarm sounded, says Marshall. The team finished and evacuated the patient on his mattress.
Meanwhile, Marshall and others had to figure out how to move the woman in labor who had received an epidural. She was carefully strapped to an evacuation sled and guided down the stairwell by Marshall and others.
On the way down, they met a physician and a patient care technician carrying an adolescent patient with cognitive problems. The patient, who was being cared for in the ninth floor unit, was having difficulty dealing with the noise and stress of the evacuation and could not manage to walk down the stairs. So his doctor and the technician locked arms to form a chair; they made it as far down as the third floor before faltering under the weight, says Marshall.
To allow the evacuation of the woman on the sled, the pediatric team stopped on the third floor—giving them a chance to rest and to call the patient’s mother, who calmed the teen enough to finish being carried down, relates Marshall. It took six people to get the woman in labor down the stairs, but she was safely evacuated, along with her husband who followed behind the team, he says. The staff worked to keep the distraught mother-to-be and her husband informed as to what was happening and where they were going.
All hands on deck
Outside the building, teams were waiting with stretchers to transport non-ambulatory patients to care units in other buildings. Several babies and other children were taken to the Shriners Hospital for Children about a block away.
By 2:00 p.m., about 110 patients had been evacuated from the building, where firefighters worked to finally knock down the flames in the waiting area.
There were no injuries and no deaths as a result of the fire or evacuation. “It was scary for everybody,” notes Tarpley. Yet while staff were “very attentive, they weren’t panicked.”
“It was great to see all hands on deck,” he observes.
“The message I’ve been giving is, ‘We did an incredible job,’ ” says Marshall. Everyone seemed to be working intuitively, responding to their training from previous drills.
Still, the work was just beginning. The recovery process was ahead, including figuring out just what happened and how to prevent it from happening again. Part of this would involve dealing with some sobering news—the state fire marshal ruled the fire was due to arson.
Residual smoke and humidity complicate cleanup after fire in aging building
In many respects, everything at the University of Texas Medical Branch (UTMB)’s John Sealy Hospital in Galveston went according to plan on January 4—or as much as anything could for a day interrupted by a fire and the evacuation of more than 100 patients from a 12-story building.
There were no injuries or fatalities that day. The fire doors contained the flames, staff safely shepherded patients down stairs and outside as trained, and firefighters quickly doused the inferno on the second floor of the building, which had been constructed before fire codes required automatic fire suppression systems.
Even as congratulations of a job well done went out, fire inspectors began the work of determining what caused the blaze, and hospital officials and facilities staff launched into the next task at hand—disaster recovery and evaluation of lessons learned.
The Joint Commission requires a hospital to have an emergency operations plan (EOP) that includes not only how it will care for patients during an emergency, but how it will communicate to patients, staff, and others during the emergency; how it will recover from the event; and an evaluation of the effectiveness of its EOP.
Recovery begins once outside building
At UTMB, the Galveston campus rallied to assist when the fire broke out. Most immediately, evacuated patients had to be accounted for, evaluated, and settled into other care units, notes David Marshall, a UTMB vice president and the medical center’s chief nursing officer, who helped evacuate labor and delivery patients from the third floor, which was directly over the fire.
Patients who could be discharged were, while others were taken to intermediate patient care areas in other buildings on campus, he says. Babies evacuated from the sixth floor nursery and neonatal ICU were taken to Jenny Sealy Hospital nearby and to the Shriners Hospital for Children a block over. (An unused ICU was eventually converted to a temporary neonatal ICU.)
“Communication is critical in any event like that—the command center was up and running and trying to get information out campuswide,” says Marshall.
Within a day or so, the hospital had a simple webpage online dedicated to information on the fire and recovery. The site included a recap of events, which buildings were open, which buildings were closed or had limited access because they were attached to John Sealy, which parking garages were open, and whom staff should contact for more information.
There were also instructions for staff to access UTMB Health’s intranet system for more information, as well as reassurances and directions on how staff would get paid if they were instructed not to report for work. Over the next few weeks, the website was updated as buildings and floors reopened.
New building, new fire training
With patients redeployed to other treatment areas, the fire plan faced a new challenge, notes Jack Tarpley, UTMB Health’s associate vice president for environmental health and safety. The staff from John Sealy now working in other buildings needed to know about fire protection and evacuation in their new work areas.
“We had to do an expedited training program,” Tarpley says, including setting up education sessions on how the fire alarms worked in the new buildings and conducting fire drills.
At the same time, Tarpley and other officials were evaluating what happened and why, and assessing the fire response.
Two weeks after the fire, hospital officials posted a short request on the hospital recovery webpage for feedback from the UTMB community “while the events of the fire on January 4 are still fresh.” Although the feedback could be anonymous, officials encouraged staff to provide a name and contact information for follow-up information.
Media reports immediately after the fire noted that the blaze was difficult for firefighters because it was fueled by furniture and other combustibles in the area. While fire inspectors were still working on their report on the direct cause of the fire, the immediate evaluation was clear: Fire doors work.
“It was truly amazing to see it,” says Tarpley.
Blaze destroys waiting area
Tarpley describes the second-floor waiting area outside the center elevator core, which sits where the two legs of the L-shaped building meet, as a charred, melted mass after the fire. But the areas on the outside of the fire doors that kept the flames from spreading to either wing were untouched.
“It really does work,” he says of the fire barrier system.
The fire was contained. Smoke, however, went throughout the building.
The Texas fire marshal’s report stated that black smoke was present throughout the second-floor compartment when Galveston firefighters arrived. Patients on that floor were evacuated, Tarpley says. Then, without a fire suppression system to automatically knock down the flames, firefighters were forced to open the fire doors to attack the blaze, allowing the smoke into the immediate area. With the fire located directly next to the elevator core, smoke also infiltrated the elevator shaft and began permeating floors throughout the building, Tarpley adds.
Fire hoses were run from connections in the stairwells and, by necessity, the hoses propped open doors on the second floor, notes Marshall. That meant that as the stairwells were accessed by patients and staff to evacuate the building, the smoke spread even more. Fortunately, the heaviest smoke was on the second and third floors, with only light smoke and the smell of smoke elsewhere, says Tarpley.