Resilient design and security strategies are two of the hottest topics on the minds of those responsible for the planning the design of healthcare facilities, according to the annual Hospital Construction Survey conducted by Health Facilities Management, the magazine for the American Society for Healthcare Engineering (ASHE).
Of the 274 facilities professionals from hospitals across the country who completed the survey, 89% of respondents said that when designing and building new spaces they now consider resiliency. The magazine described resiliency as "a design style that resists a variety of natural or human-induced disasters and aids in quick recovery."
Power outages have been the most common events experienced over the past three years by facilities participating in the survey, with 66% of respondents putting this on their list. After that, the most common events were winter storms (47%), hurricanes (19%), and flooding (19%). Meanwhile, the respondents most often identified power outages, fires, and winter storms as priorities in building for resiliency.
“Resilience is a topic that has increased in prevalence, particularly in the face of recent events, both natural and man-made,” Joseph Sprague, FAIA, FACHA, FHFI, an associate member director of the ASHE board of directors, told the magazine. “Globally, natural disasters have increased by 400 percent in the past two decades. We have also seen an increase in epidemics, including contagious diseases, diabetes and the opioid crisis. Each of these has directly and uniquely [affected] hospital design.”
“Questions have been raised," Chad Beebe, AIA, FASHE, deputy executive director for advocacy for ASHA, told the magazine. "But, most importantly, this environment has led to awareness and the development of procedures in case of such events."
Asked about design and architecture features used in their facilities to "prevent damage from violence and civil unrest," respondents said they tried solutions such as bollards in front of entrance points; installing breakproof glass, cameras, and metal detectors; and installing fencing, caging, and walls "around the roof to prevent unauthorized access to roof-mounted air handlers, intakes, and other areas of ventilation."
While the researchers found no change in the overall annual antibiotic prescribing rate, or the prescribing rate of any one drug in particular, they did observe variation in rates of antibiotics prescribed based on the season.
A study published in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA), has concluded that antibiotics continue to be prescribed at "alarming rates" in outpatient settings. Researchers found this increase in prescriptions occurred even though there has been a recent push to limit use of these drugs due to antibiotic resistance.
The authors of the study, published online Thursday, say their findings suggest that "current initiatives to improve the use of antibiotics in outpatient settings may not be enough to change clinicians’ prescribing practices." And they feel clinicians must be better equipped "with the tools and knowledge to know when antibiotics are needed."
"It is one of the most important steps towards reducing antibiotic-resistant bacteria, as well as adverse events associated with these powerful drugs,” the study's lead author, Michael Durkin, MD, MPH, assistant professor of medicine at Washington University School of Medicine, said in a statement released by SHEA. “There has been progress in reducing antibiotic prescriptions in hospitals, but there needs to be more research and attention on how to address this issue in the outpatient setting.”
The researchers conducted a retrospective analysis of outpatient antibiotic prescriptions from administrative claims data from 2013-2015, using a sample from Express Scripts Holding Company’s database of insured members. They tracked monthly prescription rates for all antibiotics, in addition to the five most commonly prescribed antibiotics: azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin.
While the researchers found no change in the overall annual antibiotic prescribing rate, or the prescribing rate of any one drug in particular, they did observe variation in rates of antibiotics prescribed based on the season. Overall, they say, seasonal prescribing peaked in February and was 42% higher than the lowest rate in September.
That, the researchers argue, makes sense despite other studies suggesting the spikes in antibiotic prescriptions during winter could be chalked up to inappropriate treatment for viral conditions. They pointed out, for example, that azithromycin, amoxicillin, and amoxicillin/clavulanate were most often prescribed during February, when pneumonia is more common. And ciprofloxacin and cephalexin were most often prescribed in the summer months, when skin and soft-tissue infections are more common.
“If quality improvement guidelines were sufficient to improve antibiotic prescribing practices, then we would have expected to see an overall decrease in antibiotic prescribing rates over time. However, standalone educational materials are rarely successful for changing clinician behavior,” Durkin stated. “A more rigorous framework and greater investment of resources is needed to substantially improve outpatient antibiotic prescribing rates, helping to combat antibiotic resistance and improve patient safety.”
He advocates that healthcare systems incorporate the CDC's Core Elements of Outpatient Antibiotic Stewardship, recommendations that include education, creating accountability for optimizing antibiotic prescribing, implementing at least one policy to improve anti-biotic prescribing, and tracking and reporting antibiotic unitization to providers.
The researchers advise the healthcare industry to empower existing coalitions 'to connect community resilience efforts with a network of hospitals equipped to handle disasters.'
The U.S. has been rocked in recent months by major emergencies, from the flooding in Houston, the hurricanes that ripped through Puerto Rico, and the mass shootings in Las Vegas last fall and a high school in Parkland, Florida just last month.
Those tragedies should have healthcare organizations across the country asking, "Would we be prepared to handle a similar crush of patients if disaster struck here?"
A report published last week by the Johns Hopkins Center for Health Security found that, while U.S. healthcare organizations are "reasonably well prepared for relatively small" events such as tornadoes and local disease outbreaks, they are less ready to respond to large-scale ones such as hurricanes and mass-casualty shootings and bombings.
The Johns Hopkins researchers have also concluded that organizations are "poorly prepared" for catastrophic health events such as a severe pandemic (which some experts are bracing us for) and large-scale bioterrorism.
In a press release announcing the report, the researchers argued the healthcare industry "would be far better positioned to manage medical care needs during emergencies of any scale by empowering existing healthcare coalitions to connect community resilience efforts with a network of hospitals equipped to handle disasters."
In that press release, lead author Eric Toner, MD, a senior scholar at the Johns Hopkins Center for Health Security, said: "We wondered what an optimal system would look like and how we would get there. Change is needed, but the change should be evolutionary, not revolutionary. We need to build on the resources we already have."
Toner's team looked for preparedness gaps in four distinct categories of emergencies and, upon finding them, particularly in the response to large-scale events, theorized that they "exist due to different operational challenges and resource needs."
The authors gave the healthcare industry four recommendations to try to close those gaps:
Build "a culture of resilience."
Create a "network of disaster centers of excellence."
Increase the support for and encourage collaboration with healthcare coalitions.
Designate a "federal coordinator for catastrophic health event preparedness."
“It is now widely recognized that resilience of communities and systems should be the goal rather than just preparedness,” Toner and the study's other authors wrote in the report. “Resilient communities seek to resist the impact of disasters, recover promptly to normal operational capacity, and learn how better to withstand future events.”
Emergency preparedness for natural disasters and mass-casualty events like bombings and shootings is a topic we often address in our HCPro safety newsletters, such as this, this, and this. But this report suggests healthcare organizations could benefit from more guidance on the topic, so look for that from us in the coming months.
Only 11 of the 69 hospitals on Puerto Rico had access this week to either electricity or fuel for backup generators, as the U.S. territory seeks to recover from the extensive damage caused last week by Hurricane Maria.
San Juan Mayor Carmen Yulin Cruz told CBS News that two patients died in one of the capital city’s hospitals due to the diesel shortage. In the tearful interview, Cruz pleaded with federal officials to pick up the pace of their response activity; without quick action, hundreds of lives will be lost, she warned.
The Federal Emergency Management Agency (FEMA) said it had more than 500 personnel on Puerto Rico and the U.S. Virgin Islands supporting response and recovery operations from both Maria and Irma as of Tuesday. Among other duties, they will establish seven temporary hospitals on the island, FEMA noted.
Fuel deliveries are so important that armed guards are being employed to prevent people from intercepting some of the limited supply, Reuters reported, citing cardiovascular surgeon Ivan Gonzalez Cancel, MD, director of the heart transplant program at Centro Cardiovascular in San Juan.
“Another hospital wants to transfer two critical patients here because they don’t have electricity,” Gonzalez Cancel told Reuters. “We can’t take them. We have the same problem.”
Without air conditioning, condensation is clinging to OR walls and making floors wet and slipper, he added, noting that most patients had been evacuated or discharged.
The dire situation comes as 44% of the population lacks potable water, and heat indices surpassed 100° Fahrenheit this week, with scattered showers and thunderstorms forecast for Thursday through Saturday.
Even if linens in storage during a flood remain dry, each facility's infection preventionist should consider other factors when deciding whether they need to be reprocessed.
As the hurricane season continues to interrupt day-to-day normalcy for millions in and around the Caribbean, healthcare organizations in the affected areas—and elsewhere—should take steps to ensure that their linens remain safe for patient use.
To that end, the Association for Linen Management (ALM) published a short guideline last week with advice on how to ensure linens are safe and clean in facilities affected by flooding. The document, which cites reports by CDC, EPA, NIOSH, and others, is available as a free download.
“To best serve the public, ALM is providing disaster recovery guidance for textiles to ensure laundries, hospitals, nursing homes, and hotels have the direction they need,” said ALM Board President Cindy Molko, RLLD, in a statement. “We are happy to provide this information to all interested parties regardless of ALM membership status.”
The hazards associated with poor linen hygiene have had tragic consequences in the not-distant-enough past: An outbreak at Children’s Hospital in New Orleans led to the deaths of five children in 2008 and 2009. Although the patients, who all had severe illnesses, were unrelated and admitted to different wards in the hospital, they all contracted the flesh-eating fungus mucormycosis, which eventually killed them.
“When providing services to vulnerable populations, it is important to understand that building material, equipment, and supplies may become heavily contaminated with microorganisms, such as mold, mold spores, and bacteria, as a result of exposure to contaminated water or even high moisture conditions from excessive rain, humidity, and loss of ventilation,” Fontaine Sands, DrPH, MSN, RN, CIC, ALM’s clinical advisor, wrote in the ALM report.
Linens and textiles must be discarded, rather than reprocessed, if they have been submerged, can’t be cleaned easily, don’t dry out completely within a day or two, or an odor lingers, Sands wrote. Other situations are less clear-cut.
“There are no evidence-based guidelines as to which linens and textiles should be reprocessed before using after a disaster,” Sands added, “so each facility’s Infection Preventionist will need to determine the facility guidelines, using known epidemiological, infectious, and microbiological principals.”
The CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities notes that its recommendations “are evidence-based wherever possible.”
“However, certain recommendations are derived from empiric infection-control or engineering principles, theoretic rationale, or from experience gained from events that cannot be readily studied (e.g., floods),” the CDC document states.
Despite the lack of hard-and-fast rules for post-flooding linens reprocessing, Sands outlined several general factors to consider when assessing whether linens in storage during the flooding event are safe to use. If linens remain dry, they are likely still safe—but even if stored linens are found to be dry, you should consider whether the facility in which they were stored suffered an extended loss of electricity or widespread flooding in the building, Sands noted.
Healthcare facilities in the Houston region have largely returned to normal operations as cleanup continues, less than two weeks after Hurricane Harvey made landfall and dumped more than 4 feet of rain in some areas.
Unfortunately, it looks like the historic storm that battered southeast Texas and parts of Louisiana will soon be followed by another major hurricane with its sights set on shores a bit farther east. States of emergency were declared in Florida, Georgia, and South Carolina as Hurricane Irma, which attained Category 5 status as it approached Puerto Rico, could make landfall in the continental U.S. this weekend.
“In Florida, we always prepare for the worst and hope for the best[,] and while the exact path of Irma is not absolutely known at this time, we cannot afford to not be prepared,” Gov. Rick Scott said Monday in a statement. “This state of emergency allows our emergency management officials to act swiftly in the best interest of Floridians without the burden of bureaucracy or red tape.”
In southern Florida, at least three hospitals had reportedly begun evacuating patients as of Wednesday afternoon: Lower Keys Medical Center in Key West, Mariners Hospital in Tavernier, and Fishermen’s Community Hospital in Marathon.
“There’s a fear factor I haven’t personally observed before,” Wayne Brackin, chief operating officer of Baptist Health South Florida in the greater Miami area, told STAT’s Max Blau. “The magnitude of the storm and the vulnerability of the Keys make [the closures] an extraordinary decision for us.”
In central Florida, Adventist Health’s Florida Hospital System was among those collecting supplies in case Irma knocks out the electricity as far north as the Orlando metro area.
“We have stockpiled thousands of gallons of water, generators are standing by to run the hospital on emergency power if necessary, and sandbags have been deployed to secure doors and windows,” the system said Tuesday in a statement. “Family members of patients can rest assured that the hospital will be a safe place for their loved ones during the storm.”
Georgia Gov. Nathan Deal declared a state of emergency in six coastal counties, The Atlanta Journal-Constitution reported Wednesday. South Carolina Gov. Henry McMaster held a press conference Wednesday afternoon after declaring an emergency in his state as well.
The proactive preparations come as Houston continues to recover from Harvey, which forced the evacuation of some 1,500 patients due to flooding. Despite the interruption, nearly all affected hospitals are expected to be fully operational again by the end of September, according to Darrell Pile, chief executive of the SouthEast Texas Regional Advisory Council (SETRAC), which coordinated efforts among medical facilities during the worst of the storm’s aftermath.
“The majority of our hospitals stayed open,” Pile told STAT. “The teamwork of hospitals and EMS agencies through our coalition kept it from becoming an even bigger disaster.”
About two dozen hospitals affected by Harvey declared an “internal disaster,” which helped SETRAC pass timely information along to first responders who could divert incoming patients to other facilities when needed, Pile said.
For those facilities affected directly by floodwater, the recovery process entails a thorough inspection and cleaning. A checklist put together by the CDC for healthcare facilities reopening after extensive water and wind damage demonstrates just how daunting the process can be. Each affected area—from lab spaces to OR suites, burn units, and pharmacies—has its own risks to consider. Ensuring that each risk has been addressed can be particularly challenging in an environment with so much overlapping oversight from regulatory and accrediting bodies. (A PDF version of the checklist is available for download at the top and bottom of this page.)
The Joint Commission released survey data from the first half of the year showing that the overwhelming majority of hospitals are struggling to demonstrate compliance with certain fire hazard provisions of the Life Safety (LS) chapter.
About 86% of the 763 applicable hospital surveys conducted in January through June revealed deficiencies under the most-cited standard, LS.02.01.35, which addresses the provision and maintenance of fire-extinguishing systems, according to the September edition of Perspectives.
The second-most-cited standard, LS.02.01.30, deals with features designed to protect people from fire and smoke hazards. About 74% of surveys found deficiencies on that front.
There’s nothing terribly new or tricky about these two standards, says HCPro’s resident hospital safety expert Steve MacArthur, safety consultant for The Greeley Company in Danvers, Mass. It’s the lack of leeway that seems to be behind such high citation rates.
“What is now required for everything in the physical environment is perfection, and that is really tough to pull off under the best conditions,” MacArthur says.
A violation under LS.02.01.35 could be as simple as dust found on a sprinkler head or a box stored within 18 inches of a sprinkler deflector, he says.
The days of emerging from a survey without findings under the LS and/or Environment of Care (EC) chapters are “pretty much gone forever,” so rather than looking to assign blame, hospitals should focus on managing their performance data, identifying weak spots, and taking steps toward corrective action, MacArthur adds.
Two other standards from the LS chapter made it into The Joint Commission’s Top 10 list: LS.02.01.10, which addresses features that aim to hamper flames, smoke, and heat in the event of a fire; and LS.02.01.20, which governs means of egress.
There were four standards from the EC chapter in the Top 10 list, too: EC.02.05.01, EC.02.06.01, EC.02.02.01, and EC.02.05.05. The remaining two standards came from the Infection Control (IC) and Record of Care, Treatment, and Services (RC) chapters.
The Joint Commission confirmed Thursday afternoon that a key figure in standards interpretation for the healthcare accrediting organization will be departing this fall.
George Mills, MBA, FASHE, CEM, CHFM, CHSP, who has served as director of the organization’s engineering department for the past six years, will leave his post effective October 9. Mills has been with The Joint Commission for 14 years.
“During his tenure he has served as an advocate for healthcare organizations as they strive to improve the quality and safety of their physical environments,” a spokesperson for The Joint Commission said in an email.
The confirmation came after Steve MacArthur, safety consultant for The Greeley Company, blogged Thursday on murmurings of an impending Mills exit. The Joint Commission also confirmed MacArthur’s report that John D. Maurer, SASHE, CHFM, CHSP, will take over as acting director of engineering on an interim basis.
“I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process,” MacArthur wrote, noting that he has always found Maurer to be “thoughtful, helpful, and equitable.”
Beginning October 9, Maurer will serve as acting director while a search for Mills’ successor is undertaken, the spokesperson said. Mills declined Thursday to comment on his forthcoming departure, and Maurer could not be reached.
A hospital that lost control of its computers last spring when hackers unleashed ransomware on its systems has paid nearly $10 million recovering in the past few months.
The hackers had demanded nearly $30,000 worth of bitcoin as ransom, but officials with Erie County Medical Center in Buffalo, New York, declined, knowing there would be no guarantee that the attackers would fully remove their malicious software once paid off, The Buffalo News reported Wednesday.
Instead, the hospital invested in new hardware and software, and it paid for expert advice. Those categories accounted for about half of what has been spent thus far. The other half accounts for overtime pay, lost revenue, and other expenses. Moving forward, officials expect to spend at least $250,000 more per month to continue upgrading technology and educating employees to ward off future attackers.
In the wake of this incident, healthcare workers had to resort to old-school pen-and-paper recordkeeping techniques. But this sort of situation could also threaten patient care more directly.
“Cybersecurity can have a major impact on patient safety,” Mitch Work, MPA, FHIMSS, president and CEO of The Work Group, Inc., told the Patient Safety Monitor Journal. “If hackers are able to access patient records and information, they will conceivably have the capability to change and manipulate patient data, which could have disastrous consequences. Think of [someone] changing medications, patient vital signs, or even diagnoses.”
A hospital in the northern suburbs of Chicago reopened Tuesday, nearly a week after flooding forced the facility to evacuate 93 patients. The case serves as a reminder to hospitals, government officials, and accrediting organizations alike that evacuation preparedness is essential to emergency planning.
The bottom floors of Northwestern Medicine’s Lake Forest Hospital began to flood July 12 as torrential rain hammered the region. “We were almost an island,” hospital president Thomas McAfee told The Chicago Tribune. Staffers had made sandbag barriers to keep the water at bay, but the flood eventually spilled over and began interfering with the emergency power generators, prompting the evacuation.
A massive fleet of ambulances lined up outside the facility, and patients were seen being wheeled out on gurneys, as Chicago-based WGN-TV reported.
Although electricity was restored within a day, the hospital had to undergo both a life safety inspection and a health inspection. “The inspectors look at anything that flooding might have touched,” said Illinois Department of Public Health spokeswoman Melaney Arnold, the Tribune reported. As of Monday evening, both sets of inspectors had given the green light to reopen.
While it might be tempting to sigh in relief that this episode ended without any apparent mishap, this case should remind hospital safety professionals everywhere to take another look at their evacuation readiness, says Steve MacArthur, safety consultant for The Greeley Company. Don’t think for one second that The Joint Commission (TJC) hasn’t already taken notice.
“For a long time, I’ve predicted that TJC would change their emergency exercise requirements away from influx scenarios and towards evacuation scenarios—hospitals tend to be able to manage an influx better than an evacuation—basically because hospitals ‘do’ influx all the time,” MacArthur says.
Managing any emergency that threatens to compromise patient care brings a certain degree of regulatory scrutiny with it, MacArthur adds.
“In that regard, this event is not much different than the strike at Tufts [Medical Center in Boston] in that the state regulatory agencies are going to give the tires a good kick, potentially during the event as well as afterwards,” he says.
When healthcare facilities in New Orleans hunkered down for Hurricane Katrina in 2005, some waited too long to evacuate, making it more dangerous when they finally tried to do so.
“While this incident is nowhere near the size and scale of the flooding that took place after Hurricane Katrina, Mother Nature makes a point—emergencies and disasters know no bounds,” Jennifer Thew wrote for HealthLeaders Media.
MacArthur says he expects a full post-mortem of the evacuation. For the time being, though, it seems the hospital responded appropriately to minimize risk to patients.
“And that is a pretty darn good outcome—and only to be expected—hospitals are generally well-prepared to respond to emergencies,” MacArthur says. “They might not have all their I’s dotted and T’s crossed from a strict regulatory perspective, but when it comes to the actual response, most—if not all—folks know what they’re doing.”