July 2010 Vol. 8, No. 7
California hospital hit with
major fine for ATD violation
A $100,000-plus fine serves as a warning
for other California hospitals
Continuing Education | Learning Objectives
as Cal/OSHA, fined Alta Bates Summit Medical Center
in Oakland $101,485 for violating numerous state health
and safety standards that contributed to a hospital employee and an Oakland police officer developing bacterial
meningitis.
Cal/OSHA also fined the Oakland police and fire
departments for failing to limit emergency workers’
After reading this article, you will be able to:
exposure to
➤➤ Explain why Alta Bates Summit Medical Center was
the contagious
disease.
fined by Cal/OSHA
➤➤ Define the requirements of California’s aerosol
transmissible disease standard
➤➤ Predict the implications for other hospitals in the
Along with a
respiratory therapist at the hospi-
“This is a textbook case
of why the ATD standard
was developed and why it
is so important that it be
implemented.”
tal, an Oakland
country
—Len Welsh
police officer was also exposed to the patient with bacteA California hospital was hit with a fine in April for
violations of the state’s aerosol transmissible disease
(ATD) standard—the only one currently on the books
rial meningitis in December. Both required hospitalization, although they survived the illness.
On May 18, the hospital officially submitted an appeal to retract the fine, according to a spokesperson at
in the United States.
The Department of Industrial Relations’ (DIR) Division of Occupational Safety and Health, better known
the DIR.
Clearly, hospitals in California need to embrace the
new regulations or risk the fallout from enforcement,
IN THIS ISSUE
p. 4 CDC and Premier partner for
better surveillance of CLABSI
The CDC and Premier recently collaborated
on a research initiative that aims to establish
better technology for tracking CLABSIs.
p. 6 Can universal gloving replace contact precautions?
One recently published study indicates that a universal gloving policy
returned better compliance with the policy and hand hygiene—not to
mention better skin health.
p. 8 An iPhone app that tracks hand hygiene
A new app developed by computer scientists at the University of Iowa
allows quick and easy data collection to track hand washing compliance.
p. 10 IC considerations for EC standards
Greeley consultant and safety expert Steven MacArthur discussed how IC
fits in with Environment of Care compliance at the 4th Annual Hospital
Safety Center Symposium.
says Steven MacArthur, safety consultant at The
Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
“The advice to hospitals is to refrain from dragging
their feet when it comes to the evolution of regulatory
standards,” MacArthur says.
Implications for other states
In addition to serving notice to other California hospitals, the Alta Bates case has implications for hospitals
across the country because federal OSHA is considering
an infectious disease standard.
The federal agency isn’t just focusing on ATDs for its
new regulations, but is instead considering a standard
> continued on p. 2
Briefings on Infection Control
Page 2
ATD violation
July 2010
< continued from p. 1
that would apply to all possible routes of infectious dis-
an exposure, DIR Director John C. Duncan said in a
ease transmission—contact, droplet, and airborne trans-
news release.
mission routes.
On December 3, 2009, Alta Bates received a patient
Federal OSHA put out a request for information (RFI)
with bacterial meningitis, Cal/OSHA said. An ambulance
on an infectious disease standard, with responses due in
transported the patient with the assistance of a fire de-
August, says Deborah Gold, MPH, CIH, a senior safe-
partment paramedic. The ambulance went to the pa-
ty engineer at Cal/OSHA in Oakland. Such a regulation
tient’s home, where personnel from the Oakland police
could protect 16.5 million healthcare and social service
and fire departments had previously arrived. Employees
workers from transmissible infectious diseases, according
of all three responders at the scene were exposed to the
to an RFI fact sheet.
disease, according to the news release.
“This is a textbook case of why the ATD standard was
What happened in California
Cal/OSHA cited Alta Bates for 10 violations of its ATD
standard in connection with the life-threatening exposure
to bacterial meningitis.
developed and why it is so important that it be implemented,” Cal/OSHA Chief Len Welsh said in the news
release.
“This case is also a wake-up call for other medical facili-
The ATD standard, which took effect in August
ties and first responders to make sure their ATD program,
2009, was designed to protect workers from just such
procedures, and employee training meet the requirement
of the standard and will be effective in preventing situ-
Editorial Advisory Board
Briefings on Infection Control
Group Publisher: Emily Sheahan
Associate Editor: Evan Sweeney,
[email protected]
ations like this, which are completely preventable and
should never happen,” Welsh said.
Cal/OSHA said Alta Bates did not notify the state
agency until December 15 that a respiratory therapist,
Libby Chinnes, RN, BSN, CIC
Infection Control Consultant
IC Solutions, LLC
Mount Pleasant, SC
Mary Ann Hollman, MD
Regional Medical Director
SSM Corporate Health Services
Hazelwood, MO
Mark Elberfeld, BS, MHHA
Project Director
Granary Associates
Philadelphia, PA
Renée Patterson, CSP
Resident Safety Specialist
Extendicare Health Services, Inc.
Milwaukee, WI
Chris Farnum, DO, FACOI
Infectious Disease Director
Ingham Regional Medical Center
Lansing, MI
Terri Rebmann, RN, PhD, CIC
Associate Director of Curricular Affairs
and Assistant Professor
Saint Louis University School
of Public Health
St. Louis, MO
Wayne Hansen, PE, REA, CEM
Healthcare Engineering Consultant
Hansen Cornel Consulting Group
Huntington Beach, CA
Laura Harrington, RN
Consultant
The Greeley Company
Marblehead, MA
Robert J. Sharbaugh, PhD, CIC
Consultant
Risk Tech
Charleston, SC
Carol Shenold, RN, CIC
Infection Control Nurse
Deaconess Hospital
Oklahoma City, OK
who directly treated the patient, was being treated for
bacterial meningitis in the ICU of another hospital. The
respiratory therapist spent 11 days in the hospital but recovered from the illness.
The violations
Cal/OSHA cited the hospital for failure to:
➤➤ Implement an ATD program
➤➤ Provide post-exposure information to employees
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Briefings on Infection Control
July 2010
Page 3
➤➤ Properly fit test employees for respirators
the ATD standard, bacterial meningitis was “the poster
➤➤ Provide medical treatment to the exposed employee
child” for which prompt exposure investigation, evaluation, and follow-up was necessary. It is the kind of disease
The hospital also received two willful citations for:
➤➤ Not reporting the meningitis case to the local health
authorities and to other employees in a timely way
that is very serious, has a high case fatality rate, and for
which prophylaxis are available for treatment and should
be started early in the course of the disease.
➤➤ Failure to contact an exposure analysis of employees
exposed to bacterial meningitis for a week after the
What went wrong?
Alta Bates should have reported the initial case of
exposure
bacterial meningitis as soon as it had a positive sample
Cal/OSHA said it issues willful citations when evidence
shows that the employer knew hazards existed that could
lead to physical harm or a fatality and took no action
of spinal fluid from the patient indicating a suspected
case, Gold says.
That happened on a Friday morning, but the hospi-
to correct the hazards and comply with the appropriate
tal did not report the case to the health department until
regulations.
Monday afternoon, she says. After receiving the report,
the local health department notified people who may
What the standard requires
The ATD standard requires all employers involved
have been exposed to the disease.
The Oakland police officer, who got sick on Wednesday,
in the transportation and treatment of a patient ex-
would have been notified and health professionals could
posed to bacterial meningitis to wear personal protective
have intervened earlier, although it’s not known whether
equipment.
the infection could have been prevented, Gold says.
The hospital or diagnosing physician is required to
The hospital also did not conduct a sufficient exposure
report the case to the local health authority, to its ex-
investigation of its own employees, she says. That inves-
posed employees, and to other employers of exposed
tigation was not conducted until a week after the expo-
employees, and initiate appropriate medical treatment,
sure and after the respiratory therapist became ill.
Cal/OSHA said.
The hospital was also required by the standard to com-
The state agency’s investigation revealed a failure
municate with other employers—such as the fire de-
to comply with those requirements, it said in a press
partment, police, and ambulance company—to notify
release.
emergency responders of their potential exposure to
Gold says Cal/OSHA officials hope hospitals will learn
from the errors made by Alta Bates.
“What we hope is that hospitals will review their
the disease and recommend a physician evaluation if
necessary.
“The standard was intended to provide a safety net-
procedures for reporting these reportable diseases to
work … they missed a number of definite opportunities
their local health department, which California law
along the way,” Gold says.
has required for years,” she says. “And we hope they
Cal/OSHA is now working with the California Depart-
review their procedures for investigating these expo-
ment of Public Health and the California branch of APIC
sures to employees. We’re just grateful none of the
to get the word out about the standard, which is based in
people died.”
large part on the CDC guidelines.
The standard grew out of concerns over SARS, mul-
“Certainly this was a bad situation,” Gold says. “We’d
tidrug-resistant tuberculosis, and the threat of pandemic
like everybody who can learn from it to learn from it. We
flu, Gold says, and when California officials were drafting
want to try and prevent this from happening again.” n
© 2010 HCPro, Inc.
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Briefings on Infection Control
Page 4
July 2010
CDC and Premier partner to develop CLABSI surveillance
New technology aims to provide much-needed streamlined data collection
Continuing Education | Learning Objectives
line–associated bloodstream infections (CLABSI). “Infection preventionists have a challenging job that is critical
After reading this article, you will be able to:
to patient safety,” Susan DeVore, Premier president and
➤➤ Define the research project conducted by the CDC
CEO, said in a press release. “By automating the surveillance process to help them better predict and act upon
and Premier
➤➤ Identify ways an automated surveillance system will
adverse events as quickly as possible, we hope to deliver the tools they need to become even better advocates
help IPs
➤➤ List reasons why the project focuses on central line–­
for infection prevention strategies that improve patient
outcomes.”
associated bloodstream infections
Ultimately, the project will also incorporate a reportTime and again, IPs voice their displeasure and frustration with spending more time at their desk disseminat-
ing system into the CDC’s National Healthcare Safety
Network (NHSN).
ing data on healthcare-­associated infections (HAI) within
“The collaboration we have with Premier is focused
their facility than actually doing what their job requires:
on evaluating the utility of using electronic data sources
preventing infections.
to electronically capture the key data elements to reliably
Further, the economic climate has left many IPs without adequate staffing to conduct surveillance and insuf-
identify patients with central line–associated bloodstream
infections,” says Scott Fridkin, MD, deputy surveil-
ficient technology
lance branch chief in the Division of Healthcare Quality
to easily track in-
Promotion, National Center for Emerging and ­Zoonotic
fections. A 2009
Infectious Diseases at the CDC. “The ultimate goal is to
survey of IPs, pub-
incorporate these electronic data sources to improve the
lished by APIC,
work flow of infection preventionists to do their job and/
indicated that one-
or minimize the amount of data collection burden they
minimize the amount of
quarter of respon-
need to get a reliable and useful healthcare-­associated
data collection burden
dents have reduced
infection data.”
they need.”
surveillance activi-
“The ultimate goal is
to incorporate these
electronic data sources to
improve the work flow of
infection preventionists
to do their job and/or
—Scott Fridkin, MD
ties to detect, track,
and manage HAIs.
Project initiatives
For the next two years, analysts at the Chicago Pre-
Only one in five respondents had electronic data-­mining
vention Epicenter at Stroger (Cook County) Hospital will
systems that allowed them to quickly gather statistics
analyze data from roughly 15 different facilities provided
and intervene with prevention techniques.
by Premier and the CDC, according to Fridkin.
Additionally, some states require reporting of HAIs,
Stroger has already developed an algorithm for
but the process can be cumbersome, taking away time
­CLABSI data that has been tested in a small number of
from more productive activities.
academic facilities. The CDC plans to test that algorithm
In May, however, the CDC announced its partnership
with larger, more geographically diverse facilities to fine-
with the Premier healthcare alliance for a joint research
tune the method and demonstrate its effectiveness on
initiative that will test and develop new surveillance
large-scale surveillance, and then incorporate it into the
technology specifically for tracking and reporting central
NHSN system.
© 2010 HCPro, Inc.
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Briefings on Infection Control
July 2010
Once the algorithms are confirmed and validated, they
Page 5
“But we don’t want to stop at CLABSI,” Fridkin says.
will be publicly available. The CDC plans to encourage
“We want to explore this with catheter-associated [urinary
vendors to adopt the algorithms to generate streamlined
tract infections], surgical site infections, and pneumonia,
measurements throughout hospitals across the country.
but we can’t do it all parallel.”
“It limits the variability between human beings on
interpreting surveillance definitions by following the al-
Combining electronic medical records
gorithms,” Fridkin says. “Using the electronic systems
The project also aims to benefit facilities switching
will end up with less variability between institutions,
over to electronic medical records (EMR). Information
which will help all institutions operate on a level play-
from patient EMRs can be populated into a program for
ing field.”
broader and more simplified data mining.
Streamlined data collection technology will ultimately
“It helps establish some standards for processing of se-
ensure less variability of HAI measurements throughout
lect medical record information, predominantly microbi-
medical facilities, and it will decrease the data collection
ology records, in conjunction with admission, discharge,
burden on IPs, giving them more time to identify prob-
and transfer records, which combined can populate this
lems or risks related to IC and implement better preven-
algorithm,” Fridkin says.
As facilities switch over to electronic records, Fridkin
tion measures.
“What we’re hoping is that by doing this relatively
believes the results of this project will allow them to es-
large-scale project, it bridges the experience of an infec-
tablish guidelines for setting up a system that will not
tion preventionist with the advances in IT,” Fridkin says.
only make patient records more manageable, but will
“We will demonstrate this sort of data capture and use of
­also assist in infection prevention efforts in the future.
this data is efficient, effective, and useful to the IP.”
“As they transfer over and develop health record sys-
Eventually, it will also bolster the CDC’s NHSN sys-
tems, having this sort of a project firmly established will
tem since the clients of the algorithm will also be NHSN
help [facilities] set their standards and make determina-
users. Data will be transferred to NHSN, which will pro-
tions for how they should set up their electronic medical
vide more data for the CDC to make recommendations
records,” Fridkin says. n
or guidelines.
“This is the direction the National Healthcare Safety
Network is committed to: minimizing the data collection
Illustration by
David Harbaugh
burden, high validity of useful and interpretable data,
and capitalizing on advances in health IT,” Fridkin says.
Why CLABSI?
According to Fridkin, Premier and the CDC decided to
focus specifically on CLABSI for a few reasons:
➤➤ CLABSI is one of the highest-profiled infection classes
from a surveillance perspective and is most ­often associated with negative outcomes
➤➤ The partners felt CLABSI had the highest rate for success with algorithmic detection
➤➤ Preliminary work had already been done through the
CDC and the Prevention Epicenter
© 2010 HCPro, Inc.
“I’m with infection control, and my name
is Staphylococcus aureus.”
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Briefings on Infection Control
Page 6
July 2010
Study: Universal gloving could be viable alternative for
contact precautions
Results show improved compliance rates and better skin health among healthcare workers
Continuing Education | Learning Objectives
Gonzalo Bearman, MD, MPH, lead author of the
study and associate hospital epidemiologist at Virginia
After reading this article, you will be able to:
➤➤ Explain the difference between universal gloving and
standard contact precautions
➤➤ Justify increased compliance rates with universal gloving
➤➤ Recognize the limitations of this study
Commonwealth.
Infection rates stayed the same or decreased with
universal gloving. Bloodstream and urinary tract infections decreased, while ventilator-associated pneumonia increased only slightly. Additionally, hand cultures
of healthcare workers showed fewer positive MRSA cul-
Every IP knows that when a patient is on standard
contact precautions, the healthcare worker caring for
tures during phase two of the study.
“Research shows in outbreak situations, heightened
that patient should be wearing the appropriate person-
infection prevention—which includes hand hygiene, the
al protective equipment (PPE), including gloves, a gown,
use of gloves, and the use of gowns—is probably what is
and a mask.
preferred,” Bearman says. “However, using those mea-
The problem with contact precautions is ensuring that
staff members are complying with proper PPE protocol.
A study published in the May Infection Control and Hos-
sures for standard care in endemic settings may not be
necessary; it may be too aggressive. So what we’re saying
is that maybe a less restrictive option—just issuing uni-
pital Epidemiology found that a universal gloving policy
versal gloves—appears to work for the control of multi-
could be equally as effective as placing patients under
drug-resistant organisms and should be considered.”
contact precautions for an MDRO infection.
The 12-month prospective study in an 18-bed sur-
Improved compliance rates
gical ICU at Virginia Commonwealth University Medi-
One of the major positive results from the study was
cal Center in Richmond included two phases. The first
the increased compliance with the universal glove policy
phase (first six months) measured the rate of compli-
and hand hygiene (see table on the following page).
ance with contact precautions, and the second phase
(second six months) measured the rate of compliance
with universal gloving. Results showed that policy com-
Bearman believes that compliance with the policy increased because it was well received by staff members.
A survey given to healthcare workers at the conclusion
pliance was higher in phase two (78%) than phase one
of the study indicated that the majority of workers wel-
(67%), and hand hygiene compliance was higher in
comed the idea of universal gloving and believed it was
phase two before patient care (40% vs. 35%) and after
not too cumbersome, says Bearman. Only 15% said they
patient care (63% vs. 51%).
thought that universal gloving was impractical.
“Throughout the entire study, both the first and sec-
“Generally, healthcare workers don’t like having to
ond phases, we did active surveillance cultures twice a
put on gowns and gloves to go see patients,” ­Bearman
week on all patients to see if they were carrying MRSA
says. “It’s much easier to don gloves than put on the
or VRE, and we also did concurrent or real-time sur-
gown for patient care. So I think that twist on isola-
veillance for hospital-acquired infections like we do
tion precautions was well received by the healthcare
here with the hospital infection prevention unit,” says
workers.”
© 2010 HCPro, Inc.
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Briefings on Infection Control
July 2010
Improved skin health
Page 7
“Whether you can actually generalize that to other units
The study also indicated improved skin health among
is a bit of a stretch. However, I will say the mechanisms
healthcare workers at Virginia Commonwealth, ­largely
of disease transmission, whether it’s medical intensive
due to the fact that staff used emollient-impregnated
care or surgical intensive care, are going to be largely the
gloves. The gloves themselves were not a new product,
same, although the patient populations might be a little
but the fact that staff members wore them so consistent-
bit different.
“As such, since the mechanisms of disease cross-trans-
ly led to an improvement in skin health.
This may have contributed to increased hand hygiene
mission are the same, it’s reasonable to think that this
compliance rates as well, since healthcare workers most
may work in a nonsurgical ICU, whether it’s medicine,
often complain that dry, irritated skin deters them from
neurosurgery, pediatrics, cardiothoracic, etc.”
Bearman also notes that during the study’s 12-month
washing their hands.
“It’s believed that if you wear the gloves long enough
duration, there were no outbreaks of infectious disease.
and intensely enough or frequently enough, then they do
During possible outbreaks, universal gloving alone may
have a benefit on the health of the skin—in other words,
not be as effective.
decreased redness or dermatitis or flakiness,” Bearman
However, this method could be particularly helpful
says. “A lot of times I’m seeing patients and I constantly
for smaller facilities such as ambulatory surgery centers,
have to put cream on my hands because the alcohol rubs
clinics, or physician offices that may not have the space
are so caustic.”
for isolation rooms or single-occupancy rooms.
“If there aren’t enough single-occupancy rooms, it
Is it a viable option?
may be helpful to do universal gloving for multiple or
Unfortunately, probably not enough information can
dual-occupancy rooms,” Bearman says. “The important
be gleaned from the study to make general recommen-
thing, however, is clearly the gloves need to be changed
dations, but it’s possible to see the potential translation of
between patients, and hand hygiene must occur before
this study to other units or hospitals, depending on the
and after patient care, even in between patients in the
risks that are present, Bearman says. “I think the results
same room. If there is a breakdown in that, there is go-
of the study are certainly unique to this unit,” he adds.
ing to be a breakdown in the effectiveness.” n
Compliance and infection rates with universal gloving
Below are the data from the published study comparing phase one (standard contact precautions) and phase two
(­universal gloving).
Phase 1 (September 2007
Phase 2 (March 2008
through March 2008)
through September 2008)
Policy compliance
67%
78%
Hand hygiene compliance (before patient care)
35%
40%
Hand hygiene compliance (after patient care)
51%
63%
Bloodstream infections
3.7 per 1,000 patient days
2.6 per 1,000 patient days
Urinary tract infections
8.9 per 1,000 patient days
7.8 per 1,000 patient days
Ventilator-associated pneumonia
1.0 per 1,000 patient days
1.1 per 1,000 patient days
29%
13%
Hand cultures that were positive for MRSA
Source: Infection Control and Hospital Epidemiology, May 2010.
© 2010 HCPro, Inc.
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Briefings on Infection Control
Page 8
July 2010
iPhone app attempts to streamline hand hygiene tracking
New technology could replace the traditional pencil and paper method
Continuing Education | Learning Objectives
Additionally, one of The Joint Commission’s National Patient Safety Goals (NPSG.07.01.01) specifically re-
After reading this article, you will be able to:
quires medical facilities to comply with guidelines from
➤➤ Explain how the iScrub makes hand hygiene compli-
the CDC and the WHO.
ance tracking easier
Therefore, most facilities are already collecting hand
➤➤ List the WHO’s “5 Moments for Hand Hygiene”
hygiene compliance data, but this new app could trans-
➤➤ Explain how the next version of iScrub could improve
late to less time collecting data and more time actually
data collection
If you have an iPhone™ or an iPod touch™, you’ve
probably already downloaded a number of applica-
improving compliance rates.
How it works
The idea originated at UI when medical professors
tions that make everyday tasks—such as opening the
at the UI Roy J. and Lucille A. Carver College of Medi-
trunk of your car or turning off your lights—as simple as
cine teamed with developers in the Computational Ep-
touching a screen.
idemiology group in the UI Department of ­Computer
But for those of you with iPhones in the medical set-
Science. Chris Hlady, a doctoral student in computer
ting, a newly released app will streamline hand hygiene
science, built the first version of iScrub (iScrub Lite)
compliance tracking, one of the more time-intensive du-
and has gained traction with the product as two more
ties of a hospital IP.
The appropriately named “iScrub” app, developed at
the University of Iowa (UI), aims to replace the traditional method of pencil and paper tracking, providing
more accurate data and a less time-consuming collection process.
The iScrub app was released on May 5 in collaboration with the CDC, and coinciding with the World Health
Organization’s (WHO) “5 Moments for Hand Hygiene”
campaign.
Two versions of the iScrub app
Currently, there are two versions of iScrub, but only one
is available to the public, while the other is still undergoing
pilot testing.
iScrub Lite 1.5
➤➤ Currently available in the Apple iTunes™ App Store
for free
➤➤ Compatible with iPhone™ and iPod touch™
“The long-term goal of our research is to understand hand hygiene behavior and use the feedback to
help improve rates. This app can help standardize and
streamline how observations are recorded,” Philip
­Polgreen, MD, one of the application’s developers and
an assistant professor of internal medicine at the UI Roy
J. and Lucille A. Carver College of Medicine, said in a
press release.
The CDC Guideline for Hand Hygiene in Healthcare
Settings recommends that medical facilities periodically
➤➤ Ability to track and input specific hand hygiene
measures
➤➤ Raw data can be sent via e-mail
iScrub Pro
➤➤ Currently being pilot-tested at the University of Iowa
➤➤ Same data input features as iScrub Lite 1.5
➤➤ Compatible with iPhone™ and iPod touch™
➤➤ Data can be sent to an interactive website, which stores
information and creates charts and graphs for staff
consumption
monitor hand hygiene adherence among staff members.
© 2010 HCPro, Inc.
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Briefings on Infection Control
July 2010
doctoral students, Donald Curtis and Jason Fries, have
expanded the platform to iScrub Pro, currently in pilot
deployment.
Page 9
A streamlined approach
In addition to making the cumbersome process of
hand hygiene data collection more efficient, the iScrub
“I think hospitals have been tracking this compliance
app also allows a streamlined approach to hand hygiene
for a while,” Curtis says. “I think it was the idea that we
compliance. Although most hospitals constantly track
have been given this device and we have a way for re-
compliance, the methods used to monitor adherence can
placing clipboards and pencils and transcription, so why
vary significantly from facility to facility. The iScrub app
not do it?”
ensures that each hospital uses the same measures and
The plus side is that medical facilities won’t need to
purchase hundreds of mobile devices to effectively use
the app.
definitions.
Grants from the CDC and the National Institutes of
Health went toward the development of this project,
“The idea is you have a couple of these devices in the
which gave developers access to a standardized process.
hospital and they are used to track the hand hygiene,”
“I think it also helps for hospitals to have an app
Curtis says. “It’s designed so you don’t have to buy one
that is more globally available,” Curtis says. “One as-
for everyone.”
pect we are trying to take with iScrub is how do we
Staff members assigned to track hand hygiene can in-
help standardize hand hygiene monitoring, and we’ve
put data according to the WHO’s “5 Moments for Hand
worked closely with the CDC and the WHO to de-
Hygiene”:
sign iScrub to encapsulate everything that hospitals
➤➤ Before touching a patient
need to record when they are doing hand hygiene
➤➤ Before clean/aseptic procedures
observations.”
➤➤ After body fluid exposure/risk
➤➤ After touching a patient
The next steps
➤➤ After touching patient surroundings
Currently, iScrub Lite 1.5 is available to download for
free at the iTunes™ App Store, but the team and UI are
Observers can also separate data into job titles of their
choosing to track compliance among specific subsets of
already working on the upgraded iScrub Pro model.
The Pro model allows users to send data to a website
staff members such as nurses, physicians, or physical
rather than an e-mail address. That website puts the in-
therapists. Additionally, there is room to indicate wheth-
formation in a database and generates charts based on
er a patient was on contact, droplet, or airborne precau-
the data. “It’s kind of a next step,” Curtis says. “Here we
tions and whether the healthcare worker used gloves, a
have the whole input device, which is iScrub Lite, and
mask, and a gown.
then there is what do you do with that data. That’s part
Data and observations are then e-mailed to an address and can be transferred onto a spreadsheet for
documentation.
“I think everybody that has used it is really excited,
not just about what’s been done, but about the future
of using devices like this,” Curtis says. “I guess the most
of what we are working on in the Pro version.”
Currently, iScrub Pro is undergoing a pilot study on
units at the University of Iowa Hospitals and Clinics. Interested facilities can also apply to be a part of the pilot
program at the iScrub website.
“I guess the next step for us is to start expanding from
positive feedback is actually about feedback and how
there,” Curtis says. “It’s about evolving the product and
quickly using a device like this allows the data to get
getting people to use it and getting feedback on the prod-
fed back into the system. People get immediate feedback
uct and then hopefully seeing if that product can become
from what they are tracking.”
more mature.” n
© 2010 HCPro, Inc.
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Briefings on Infection Control
Page 10
July 2010
Standard of the month
Identifying IC risks within Environment of Care standards
General duty clauses allow flexibility but require risk assessments
Continuing Education | Learning Objectives
Under EC.02.06.01, surveyors paid close attention to
the following elements of performance (EP), all of which
After reading this article, you will be able to:
involve some degree of IC input:
➤➤ Explain how Environment of Care standards incorporate
➤➤ EP 13: Maintenance of ventilation, temperature, and
IC requirements
humidity levels
➤➤ Identify 2009 top-cited safety standards by The Joint
Commission
➤➤ EP 20: Areas used by patients are clean and free of
­offensive odors
➤➤ List items that can be stored underneath the sink
➤➤ EP 26: The hospital keeps furnishings and equipment
safe and in good repair
As an IP, it’s your job to ensure that your facility is in
compliance with some of the major Joint Commission
EC.02.01.01, on the other hand, is really a ­general
IC standards. But your responsibilities don’t stop there.
­duty clause, MacArthur said. “The expectation of this
Many of the Environment of Care standards subtly (and
is that we take action to minimize or eliminate, to the
sometimes not so subtly) incorporate IC requirements,
extent possible, identified safety risks in the physical
usually in a general sense.
This was the primary focus of consultant Steven
“If we look at some of the
frequently cited standards
from 2009, there is a
lot of infection control
crossover.”
—Steven MacArthur
­MacArthur’s presentation, “Tying
Environment of
Care into Infection Control,” at
HCPro’s 4th Annual Hospital Safe-
ty Center Symposium in Las Vegas on May 7. MacArthur
When to do a risk assessment
Save the in-depth documented risk assessment for particularly contentious issues in which either the solution is
unclear or compliance is lacking, recommended Steven
­MacArthur during his presentation at the 4th ­Annual
Hospital Safety Center Symposium in Las Vegas on May 7.
­MacArthur is a safety consultant at The Greeley Company,
a division of HCPro, Inc., in Marblehead, MA.
“How you choose to manage risks is focused basically
is a safety consultant at The Greeley Company, a division
on your identification of what safe means to you, what se-
of HCPro, Inc., in Marblehead, MA.
cure means to you,” MacArthur said. “You know your staff
“If we look at some of the frequently cited standards
from 2009, there is a lot of infection control crossover,”
MacArthur said.
and you know your building, so that allows you to customize strategies for compliance.”
Your risk assessment should include the following
elements:
Frequently cited standards
Specifically, MacArthur cited EC.02.06.01, which requires a safe and clean environment, and EC.02.01.01,
which requires the facility to maintain a safe and secure environment. Those two standards, along with
IC.02.02.01, were part of the 2009 Joint Commission
➤➤ A review of other available literature (Web searches
included)
➤➤ A reflection of your own experience
➤➤ Your decision
➤➤ Documentation
➤➤ Committee minutes
➤➤ Annual evaluation
top 25 most frequently cited survey findings.
© 2010 HCPro, Inc.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on Infection Control
July 2010
Page 11
­environment,” he explained. “Elimination, that’s gener-
“So we’re standing a little bit closer to a require-
ally easy for us to demonstrate to a surveyor. That we’ve
ment for improvement than we did in the past,” noted
minimized to the extent possible, that can be a little bit
­MacArthur.
more challenging.”
The major difference between a survey in 2009 or
2010 and a survey in 2008 is the way this standard is
Focusing on reprocessing
Device reprocessing remains a major focus for Joint
Commission surveyors, including proper processes, doc-
scored.
Prior to 2009, a C element of performance required
umentation, and storage. MacArthur cited the following
three instances of noncompliance. Now surveyors only
EPs specifically under IC.02.02.01:
need to find two.
➤➤ EP 1: Cleaning and disinfecting medical equipment,
devices, and supplies
What exactly are we able
to store under a sink?
➤➤ EP 2: Sterilizing medical equipment, devices, and
supplies
➤➤ EP 3: Disposing of medical equipment, devices, and
A common issue that arises under Environment of Care
compliance is determining what can be stored underneath
sinks. Since The Joint Commission doesn’t have an official
stance on the issue, the answer really depends on how you
build your policy.
“Basically, this is another instance where we have to determine what represents appropriate storage under a sink,”
supplies
➤➤ EP 4: Storing medical equipment, devices, and supplies
“So clearly, how we manage this device class, if you
will, in the physical environment is undergoing a lot of
scrutiny,” MacArthur said.
> continued on p. 12
said Steven MacArthur during his presentation at the
4th Annual Hospital Safety Center Symposium in Las Vegas
on May 7. MacArthur is a safety consultant at The Greeley
Company, a division of HCPro, Inc., in Marblehead, MA.
Navigating the sticky issues
around mandatory flu shots
“Some folks have gone to the extent of they forbid it
completely; they lock under the sink,” he said. “When you
In the past year, seasonal and H1N1 influenza has
talk about elimination versus minimization of risks to the
prompted many healthcare facilities and some govern-
extent possible, if you lock those so no one can store any-
mental organizations to consider and/or institute manda-
thing underneath it, you’ve eliminated that risk.”
tory influenza immunization for employees. The reaction,
Some facilities will only allow storage of cleaning equip-
both pro and con, from employees, healthcare worker as-
ment or supplies, but it’s important to discuss this issue
sociations and unions, and healthcare professional societies
with your safety committee, document the minutes, and
has been unmistakably vocal, as issues of patient safety and
include those minutes in your annual evaluation. This shows
workers’ rights clash.
a surveyor that you have assessed the risk and made a decision based on that assessment.
“Housekeeping supplies can be as narrow and as broad
a category as you want,” MacArthur said. “The way I look
at it, I wouldn’t store anything under a sink that I wouldn’t
want to get wet: paper towels, toilet paper. You could make
a case to them that it’s housekeeping supplies, but do you
really want to store stuff like that under your sink?”
© 2010 HCPro, Inc.
Join HCPro Wednesday, July 14, at 1 p.m. (Eastern) for
a 90-minute audio conference to provide you with the
medical and legal perspectives for developing a mandatory influenza immunization policy.
For more info on schedule, speakers, and
content, go to OSHA Healthcare Advisor
at www.oshahealthcareadvisor.com or call customer service
at 800/650-8511.
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Page 12
Briefings on Infection Control
Standard of the month
< continued from p. 11
MacArthur emphasized the need for a risk assessment
July 2010
“If you were to go and look in the Federal Register or
in order to show that device reprocessing has been thor-
any of the national standards, there is nothing that will
oughly evaluated. Although policies are good to have, a
say, ‘No, you can’t have cardboard boxes in the patient
risk assessment shows critical thinking and action.
care environment,’ or, ‘No, you can’t store stuff on the
“Basically, we have to say what we do and do what
we say,” MacArthur said. “If we can complete that cycle,
floor,’ ” MacArthur said.
“Now I think we can agree in some instances we are
talking about best practice versus less best practice, but
we will be in compliance.”
there is nothing that prohibits it. So it’s up to the organi-
The FAQ and general duty clauses
zation to decide what is and what isn’t appropriate man-
MacArthur recommended that safety officers and IPs
bookmark The Joint Commission’s FAQ page.
agement of infection risks.”
Ultimately, you know your facility better than any-
“They have updated a lot of concepts through that
one else, MacArthur said. So it’s important to careful-
venue,” he said. “In case folks weren’t aware of this, once
ly look at your processes and determine what fits best
an FAQ is posted, that becomes pretty much enforceable
within your facility. Don’t adopt a surveyor’s suggestion
as a standard or an element of performance.”
unless you truly believe it fits into the dynamic of your
These FAQs are especially helpful when it comes to
compliance with general duty clauses, which essentially
ensure that the medical facility is a safe environment.
For example, items such as management of card-
hospital.
“Basically, it’s up to us to determine what the black
and white of compliance means within our four walls,”
MacArthur explained. “Elimination of a risk is simple
board boxes or storing equipment on the floor are not
to demonstrate, although not at all easy to achieve,
standards-based requirements. Although state require-
as you know. And minimization is in the eye of the
ments may be more specific, national standards are very
­beholder.” n
vague.
However, these responsibilities often fall under the
Editor’s note: You can access the entire 4th Annual Hos-
general duty clause, which is usually based on surveyor
pital Safety Center Symposium on demand by visiting www.­
preference.
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