The update took effect March 12, 2021 and will remain in effect for 12 months.
This article was originally published July 1, 2021 on PSQH
In March, OSHA issued its Updated Interim Enforcement Response Plan for Coronavirus Disease 2019 (COVID-19). The updates extend existing OSHA protections for workplace safety whistleblowers, explicitly stating those protections apply to those who report COVID-19 related violations at the workplace by creating a National Emphasis Program (NEP).
In addition, the memo also classifies industries based on the inherent COVID-19 risks for their workers. Naturally, those in the healthcare industry are considered at higher risk. This means that healthcare clinics and hospitals should expect more OSHA scrutiny, and possibly more OSHA surveys, than before. Whenever practical, OSHA will perform on-site surveys, but remote or partially remote surveys will also be an option.
“The NEP targets establishments that have workers with increased potential exposure to this hazard,” according to the update. “In addition, this NEP includes an added focus to ensure that workers are protected from retaliation and are accomplishing this by preventing retaliation where possible, distributing anti-retaliation information during inspections, and outreach opportunities, as well as promptly referring allegations of retaliation to the Whistleblower Protection Program.”
The update took effect March 12, 2021 and will remain in effect for 12 months. In 2020 alone, OSHA collected over $3.5 million in COVID-19-related fines, with two New Jersey hospitals fined $13,000 and $25,000, respectively.
We spoke with OSHA expert Marge McFarlane, PhD, MT(ASCP), CJCP, CHSP, CHFM, MEP, HEM, about what these changes will mean for healthcare employers and employees. McFarlane is the principal of Superior Performance in Eau Claire, Wisconsin, and senior consultant with Compass Clinical Consulting in Cincinnati.
This Q&A has been lightly edited for clarity.
OSHA standards applicable to the update
29 CFR Part 1904, Recording and Reporting Occupational Injuries and Illness
29 CFR § 1910.132, General Requirements-Personal Protective Equipment
29 CFR § 1910.134, Respiratory Protection
29 CFR § 1910.141, Sanitation
29 CFR § 1910.145, Specification for Accident Prevention Signs and Tags
29 CFR § 1910.1020, Access to Employee Exposure and Medical Records
Section 5(a)(1), General Duty Clause of the OSH Act
Q: What does the update hope to accomplish?
McFarlane: I think it is to bring a more consistent enforcement for worker safety rather than [rely] on the General Duty Clause, which is a little bit vague. With the NEP I think they’re hoping to bring more specific guidelines. [The update says] that when they come, they are specifically asking these questions, like “What is your social distancing policy?” rather than the General Duty Clause that just says, “Protect your workers.”
So if I’m an employer and I see these five or six questions [in the update,] they’re much more focused and prescriptive. That’s what I think the NEP brings to this whole disease issue.
Q: Do these changes mean healthcare organizations should expect more OSHA surveys? And will they be looking for non-COVID-19 problems as well?
McFarlane: Absolutely. It is my opinion that now with this NEP, it has given OSHA a charge where they need to go out—especially on complaints of employers not providing the right personal protective equipment (PPE) and the right protocols.
[Healthcare organizations should] expect a follow-up inspection and possibly phone call or letter first, but an in-person inspection for the things [listed in the update].
But your question to me was “If they see something [not related to COVID-19,] can they be cited?” And if there’s some obvious violation going on like bloodborne pathogens or hazardous chemicals, they will absolutely be referred for citation. They might cite them that minute, [but] they have the option to refer them for additional citation.
Have you seen the OSHA summary of citations for 2020? Just as an FYI, the proposed fines are over $4 million. Specifically, they’re charging people for:
Not having a written respiratory protection program when workers are wearing N95 masks
Not including when people get COVID-19 in their OSHA 300 log
What is happening, in my opinion, is there is just a more cohesive approach to high-risk worker safety. The hope is this will standardize things nationally. But the CDC’s guidance is only a guideline. It is still a state-by-state decision what laws they pick, and some are less stringent than others. But OSHA is the force of law in all states no matter what their politics are, so they have 60 days from the date of this initiative to tell the feds how they’re complying with this. Remember, this NEP is in effect for a year.
Q: Is there any sign that this would be something that they would consider continuing? As a way of making everyone follow the same standard state by state?
McFarlane: One would hope. They’ve been talking about a national OSHA disease standard for quite some time. California is the only state that has an infectious disease standard, and that was passed in 2009 after H1N1. But California is the only one out there; the rest of them are kind of left to their own devices, and they fall under the General Duty Clause that says you have to provide a safe workplace.
This [update] is really an effort to say “You need to protect your workers.”
Q: What do these whistleblower protections in the update do? Are they new protections or extensions of existing protections?
McFarlane: There are people who have brought [COVID-19 violations] to the attention of OSHA and regulators and have been fired and harassed for it. All whistleblower protections are important and are already on the books; they’re not new. It’s just the emphasis that “This totally applies to COVID-19 also and we’re keeping our eyes on you.”
Whistleblower protection has been around since probably about 1998. But it’s a reminder to people that people have a right to a safe and healthful environment. So now [the federal government] is saying that “We will fund more [OSHA] inspections, and these are our expectations for providing a safe workplace.” Whistleblower protection is being highlighted so that people will take you providing PPE to their workers more seriously.
Q: So the update is making it clear that existing whistleblower protections also apply to COVID-19 cases?
McFarlane: Correct.
Q: Do you think OSHA will keep remote or semi-remote surveys as an option, even after COVID-19? If there’s another pandemic, for example?
McFarlane: I don’t know. I think this is all groundbreaking where they’re doing remote inspections. Whether they will keep that now, if they’ve developed a process now, one would think they would have that in the books that they could brush off if they needed it again.
Q: Is there anything else you’d like to say?
McFarlane: My recommendation to people is that they take a look at the new requirements, do a gap analysis on their plan. The new rules say you need to have a COVID-19-specific infection prevention plan; it doesn’t matter if it is an annex of your emergency management plan or part of your infection prevention plan or if it is a stand-alone plan. But you can’t just say “This is covered in my infection prevention plan” without specifically talking about social distancing, wearing masks, handwashing, and cleaning high-touch surfaces. You don’t need a stand-alone plan, but you have to be sure all of these elements are included. Including, “if I get sick on the job, who am I telling? How am I isolating myself from my co-workers?”
We are wearing more PPE than we used to, and if you’re a clinical person, you know exactly what it means to don and doff. If you’re working in materials management, you’re not necessarily a clinical person. When I told somebody to don a vest for an emergency management drill, he didn’t know who Don was and why he put on his vest.
PPE was not natural for some of the job brackets in the hospital, so make sure that your nonclinical people know how to wash their hands properly, put on PPE, and take it off and dispose of it properly.
The HRH model was developed by the Veterans Health Administration's National Center for Patient Safety (NCPS) and its process is open for all facilities to adopt.
In 2016, Truman VA Medical Center in Columbia, Missouri took part in a three-year project to become a high-reliability hospital (HRH).
By the end of the study, Truman reported that its patient outcomes had improved, low-harm errors were being reported more often, and that quality improvement education had become self-sustaining within the facility.
The HRH model was developed by the Veterans Health Administration’s National Center for Patient Safety (NCPS) and its process is open for all facilities to adopt.
In March, Patient Safety Monitor Journal interviewed one of the lead study authors, Gary L. Sculli, MSN, ATP, one of the study authors and the director of clinical training programs at NCPS, about how the HRH project came to be and what made it work.
Here are the 10 steps that Truman and researchers used to become an HRH.
A baseline and yearly assessment/patient safety site visit
During these visits, the NCPS used a standardized assessment tool comprising a series of questions, evaluated facility root cause analysis (RCA) reports, and assessed Truman’s compliance with NCPS Patient Safety Alerts and Advisories.
Patient safety culture assessment
The assessments were made using two different methodologies, a Patient Safety Culture Survey (PSCS) and a Teamwork and Safety Climate Questionnaire (TSCQ), which were done six and 12 months after staff received Clinical Team Training (CTT).
Annual frontline staff RCA training
NCPS provided annual RCA training to a group of Truman frontline staff, who then trained latter groups of staff. This training covered risk scoring, team composition, event flow diagramming, interviewing techniques, root cause statements and rules of causation, strength of action planning, and outcome measures.
Leadership walk-arounds
Truman implemented a Leader Walk-Around Program, where the leadership team conducted monthly in-person conversations with frontline staff to gather direct input, respond to concerns, and reinforce HRH principles.
Monthly patient safety forum
These patient safety forums were open to all Truman staff and leadership. During these, attendees would review adverse events that triggered an RCA, discuss system root causes and corrective actions, and celebration of staff members who identified and acted upon on safety concerns.
Annual assessment of infrastructure and processes for standardization
A standardization team was assembled annually to review infrastructure and processes that had high levels of variability to establish a strategic plan. The team then selected an annual project to work on.
Just Culture training
The NCPS conducted interactive Just Culture training for facility leadership, midlevel managers, and frontline supervisors to convey Just Culture core concepts including the application of a Just Culture decision support tool to case studies.
Clinical Team Training for all units
Clinical Team Training (CTT) comprised an initial training session, an annual unit-based safety project, monthly NCPS coaching sessions, and one-year refresher training on topics such as high reliability organization theory, threat and error management, participatory leader behaviors, and effective follower behaviors.
Unit-based improvement project implementation and monitoring
Each month, staff were required to identify a patient safety challenge and implement an improvement project.
CTT simulation education
The NCPS educated the Truman staff in the use of simulation to provide opportunities for unit-based teams to practice the communication, teamwork, and situational awareness tools imparted in the program. The NCPS held an annual simulation “boot camp” instructing facility-based simulation educators on delivering unit-based curriculum.
The 32nd World AIDS Day will be held on December 1 this year. Internationally recognized, the day is meant to raise awareness, support, and money for the estimated 38 million people with HIV/AIDS worldwide.
While the world is focused on the COVID-19 pandemic at the moment, other diseases like HIV/AIDS are still with us. In the U.S. alone, there were approximately 36,400 new HIV infections in 2018.
For that reason, laboratory workers and clinicians must remain vigilant in regard to needlesticks, sharps safety, and bloodborne infection prevention, says Dan Scungio, MT(ASCP), SLS, laboratory safety officer for multihospital system Sentara Healthcare in Virginia.
Q: Does the heightened focus on COVID-19 prevention have any tie-in to bloodborne pathogens safety? Is there an increased awareness of bloodborne pathogen safety because everyone is paying more attention to infection control in general?
Scungio: There is definitely an increased awareness of bloodborne pathogen safety as a result of the COVID-19 pandemic. Employees who work in clinics, labs, and as medical couriers had new concerns about their personal safety on the job when the pandemic came to the U.S.
I dealt with many employees who were panicked about the idea of seeing sick patients, handling specimens, or transporting specimens. Many needed a reminder that they deal with bloodborne pathogens every day—including hepatitis and HIV, which can be more of a threat than COVID-19 virus particles. An overall heightened awareness about the importance of the use of standard precautions in healthcare jobs became necessary. Reminders about the use of PPE and proper hand hygiene were needed, including talking about the everyday existence of public high-touch surfaces like elevators and gas pumps.
Q: December 1 is World AIDS Day. What impact, if any, do you think this disease had on safety practices and general awareness around bloodborne pathogens?
Scungio: The HIV outbreak of the 1980s and 1990s had huge impacts on healthcare safety practices and helped usher in a solid understanding of standard precautions—treating all patients and samples as if they are infectious. [Before,] many employees in healthcare commonly worked without gloves, lab coats, or face protection, and exposures (reported and unreported) were far more common than they are today.
The fear of working with HIV patients and specimens drove many in the workforce to finally comply with safer work practices and the use of PPE. Today, there are still those who do not utilize safe practices, but the COVID-19 pandemic has pushed some people into better, safer work habits.
Q: Do you think people have gotten better or worse at sharps safety and bloodborne illness management and response in the past couple of years?
Scungio: Over time, people who work in healthcare in this country have become better with sharps safety and bloodborne pathogens, and some of that has to do with the enforcement of OSHA’s Bloodborne Pathogens Standard and standard precautions, as well as the Needle Safety Act. All needles are manufactured with a safety device (though they aren’t foolproof and many can be bypassed), and staff are to be part of the decision to choose a needle product.
That said, it is not difficult to find workplaces (labs, clinics, draw sites) where unsafe practices are the norm. While this is unfortunate, it tends to be the result of poor leadership and oversight, a lack of proper safety training, or a combination of the two.
Q: What does “sharps safety” look like within a culture of safety?
Scungio: In a workplace with a strong safety culture, sharps safety starts with good training for new staff with solid supervision. Make sure the employee understands which needles to use and when. For example, butterfly needles are overused and cause the majority of phlebotomy needle stick injuries and exposures.
And watch to make sure they activate the needle safety device and dispose of the unit as quickly as possible after the needle is used. Staff should know when and how to change out a sharps container, and to never attempt to place a needle inside an overfull unit. Staff should also be prepared for incidents that could occur, such as a patient moving suddenly or passing out during a venipuncture. Thorough training and regular competency assessments should be done for those who use needles every day on the job.
Q: Have there been any innovations (equipment or policy) to sharps safety and bloodborne pathogen safety in the past 10 years?
Scungio: Unfortunately, there has been very little movement. The OSHA standard has not changed since 1990, and while there have been a few needle safety product innovations, nothing significant has occurred which would drastically change the face of those fields.
Q: What are the challenges or roadblocks to bloodborne pathogen safety that still exist? What can be done about them?
Scungio: In my opinion, the biggest roadblocks include what I discussed earlier—staffing shortages, inadequate training, and a lack of safety oversight.
As always, the importance of safety needs to be at the forefront of the workplace, and awareness of safety issues must be made constant. Despite a lack of staff, employees should be fully trained on all aspects of sharps safety and bloodborne pathogen handling.
These areas are too important to be short-changed or ignored, and the consequences of an incident here can be career- and life-altering.
Now that you’re done reading this article, please take a moment to visit www.worldaidsday.org.
On October 7, The Joint Commission (TJC) released a new Quick Safety alert on telemedicine and telehealth care.
Since the COVID-19 pandemic began, the number of Americans participating in at least one telemedicine visit has increased from 14% to 57%, and telemedicine projected to account for 20% of medical visits in 2020.
This has been crucial in promoting social distancing and limiting the spread of the virus during the pandemic, but TJC cautions that there are still barriers and challenges to telemedicine that need to be addressed.
“Some of the challenges include patient populations who are not technologically capable; limited access to technological devices or connectivity issues; and problems monitoring the quality and safety of telehealth,” the organization wrote in a new Quick Safety alert. “An additional limitation is that not all conditions can be appropriately or safely managed via telehealth. Additional barriers include inconsistent reimbursement models; legal and regulatory issues; and questions about security, privacy, and confidentiality, including Health Insurance Portability and Accountability Act (HIPAA) concerns.”
The Quick Safety alert has many recommendations and resources for how to improve your facility’s telemedicine programs, overcome barriers, and make your telemedicine program safer and more efficient.
Coronavirus droplets and particles “can linger in the air for minutes to hours,” said the Centers for Disease Control and Prevention (CDC) in their updated COVID-19 guidance on October 5.
The infection can also spread between people standing 6 feet apart in the right circumstances.
“CDC’s recommendations remain the same based on existing science and after a thorough technical review of the guidance,” the agency said. “People can protect themselves from the virus that causes COVID-19 by staying at least 6 feet away from others, wearing a mask that covers their nose and mouth, washing their hands frequently, cleaning touched surfaces often and staying home when sick.”
The CDC emphasized that most infections come from close contact or touching contaminated surfaces, rather than airborne transmission.
And that while it is possible for COVID-19 to infect others more than 6 feet away, it only does so under certain circumstances—such as in within enclosed spaces with inadequate ventilation, or when the infected person was breathing heavily.
“Under these circumstances, scientists believe that the amount of infectious smaller droplet and particles produced by the people with COVID-19 became concentrated enough to spread the virus to other people.
The people who were infected were in the same space during the same time or shortly after the person with COVID-19 had left,” the agency wrote.
Accrediting organizations (AO) don't have a specific standard on waiting room infection control, but there are still issues you can be called out on.
This article was originally published September 16, 2020 on PSQH
A patient walks into your waiting room with a cough, a mild fever, and shortness of breath. Your waiting room is crowded, so she sits down next to other visitors.
She left her phone in the car, so she flips through a magazine and plays with the TV remote. Her name is called, and someone takes her seat as soon as she stands.
By the time you finish lecturing your patient about how she should have called ahead with these symptoms, several others have come and gone from your waiting room out into the community.
That patient had the flu. But she could have just as easily had any number of infections, from the common cold to the SARS-CoV-2 virus that causes COVID-19.
Cleaning and keeping a healthcare waiting room safe for patients is a difficult task, says Jennifer Cowel, RN, MHS, a former Joint Commission executive and CEO of Patton Healthcare Consulting. Many elements need to be considered: furniture, electrical outlets, sanitizer dispensers, toys, and high-touch objects. And unlike patient rooms, there’s no turnover time between people where the space can be cleaned or checked.
“Waiting rooms are challenging because you can’t control who is in there or what they touch,” she says. “You can have children, adults, or seniors. We are to clean high-touch surfaces, [and] if you have children in the room, every surface could be high touch!”
Accrediting organizations (AO) don’t have a specific standard on waiting room infection control, but there are still issues you can be called out on. In her many years as both a surveyor and healthcare consultant, Cowel has seen (and inspected) many waiting rooms. She’s shared some of the problems she’s seen most frequently, starting from the floor up.
Open outlets
“You’re going to have children in [waiting rooms, and many of those rooms] don’t have the protective covers over the electrical outlets. Those child safety outlets are recommended because little kids crawl under furniture and put things into electrical outlets,” Cowel says.
“There are child-safe outlets out there if you can replace your existing outlets,” she says. “The cheaper alternative is placing those little plastic caps over them so kids can’t jam things in there. The problem with those is that families take them off routinely so they can charge their electrical devices, phones, and such.
“I would recommend replacing [your outlets] with child-safe ones that the family can use to charge. I also suggest having enough charging spaces because you see that a lot, [people] moving furniture around to plug in their devices.”
Dirty toys
“If you have a children’s area, you do want to have things the kids can use,” says Cowel. “But then they have to be cleaned right afterwards.”
If you can, take your cleanable toys after they’re used to a “dirty area” where they will be collected and cleaned before going back into the play room.
(See below for a sample toy cleaning policy.)
Worn-out furniture
If your waiting room furniture is in good repair, you don’t have to replace it. However, if the cover on a chair or seat has cracked, the surface material has worn through, or the protective covering has been delaminated, that item would need to be repaired or replaced.
Some furniture surfaces are considered uncleanable and should never be used in a waiting room. An example would be furniture with a fabric cover or made entirely of fabric, as well as wall decorations, which are considered uncleanable by surveyors. It is possible to get a vinyl surface that mimics fabric and is cleanable, Cowel says.
Waiting rooms can have fabric curtains, but they should be cleaned often, and you should consider replacing them with a different material.
There are also rules for wooden furniture with a polyurethane laminate.
“Once [the laminate] is worn down, scratched, nicked, gouged and you see the inside surface, that can no longer be cleaned,” she says. “If you have a shiny original surface, that can be cleaned.”
Uncleanable items
There are some materials and items that will be touched often and simply can’t be disinfected. It’s for this reason that Cowel discourages the use of books or magazines in your waiting room. They’re uncleanable, high-touch items that present infection risks.
Cowel says that if you really wish to give out books or reading material, give it directly to visitors and tell them to take it with them when they leave.
In 2020, there are plenty of entertainment options for people that don’t involve high-touch items, such as TVs (with inaccessible remotes). And, of course, many visitors will bring in their own cellphones and tablets.
“That is entertainment enough,” she says.
Crammed seats
With the novel coronavirus that causes COVID-19 spreading around the world, the best practice is to have patients call in with their symptoms before coming to the facility. The goal is to limit the number of visitors in your waiting room during an outbreak, be it COVID-19 or the common cold. However, this isn’t always possible, nor do patients always listen. When that happens, Cowel recommends adjusting your seating arrangements to allow for extra space between people.
“With COVID-19, the thing is having enough space between seating groups, trying to ensure [social] distancing,” she says. “That’s an idea you want to put into place now and is a good idea in the future.”
If possible, she recommends having two waiting areas—one for people with potential respiratory issues, and one for those without.
Out of soap, signs, and PPE
Check and double-check your hand sanitizer and soap dispensers to ensure they are full. Also work with your facility team to ensure that the bathrooms are being cleaned frequently and properly, and that they are sufficiently stocked with paper towels and other sanitary items.
“Then allow sufficient hand sanitizers in the waiting room so that people can clean their hands if they’ve touched a high-touch surface,” Cowel says.
Also make sure your waiting room is stocked with PPE for patients who need it. Put up signs so that new arrivals know to self-identify respiratory illness symptoms so they can get PPE.
“Have signage to tell people if they’ve got a cold or a cough or something like that, they’re supposed to self-identify up front,” Cowel says. “Because then you’re going to be giving them a mask to wear throughout their visit or how long your infection control policy says.”
Wrong cleaner
Cowel explains that during the COVID-19 outbreak, the CDC expects more frequent cleaning of high-touch surfaces using a hospital-approved disinfectant.
“Your infection preventionists should weigh in using the most recent recommendations from CDC to guide your decision,” she says.
With all cleaning and disinfecting products, always check the expiration date and follow manufacturer instructions for use—concentration, application method, contact time, and so on.
With COVID-19, Cowel says, “you’re supposed to use a cleaner EPA-approved for emerging viral pathogens, and the CDC does have a list of those.”
CDC recommendations
In response to the COVID-19 outbreak, the CDC has put out recommendations for how one can clean and disinfect their home for the virus. The lessons from those recommendations also work for a healthcare waiting room setting.
Wear disposable gloves when cleaning and disinfecting surfaces and dispose of the gloves after each cleaning.
If reusable gloves are used, those gloves should be dedicated for cleaning and disinfection of surfaces for COVID-19 and should not be used for other purposes.
Consult the manufacturer’s instructions for cleaning and disinfection products used.
Clean hands immediately after gloves are removed.
If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
For disinfection, using EPA-registered disinfectants should be effective.
Diluted household bleach solutions can be used if appropriate for the surface. Follow manufacturer’s instructions for application and proper ventilation.
Check to ensure the product is not past its expiration date.
Never mix household bleach with ammonia or any other cleanser.
Unexpired household bleach will be effective against coronaviruses when properly diluted.
Researchers from Oxford University announced that the drug dexamethasone can cut the death rate for COVID-19 patients on ventilators by a third and patients on oxygen by a fifth. Their research suggests that up to 5,000 of the 41,736 coronavirus deaths in the United Kingdom could have been prevented had this drug been used at the start of the outbreak.
Dexamethasone is a steroid that has been used since the 1960s to reduce inflammation and is given to asthma and rheumatoid arthritis patients. While not a coronavirus cure, dexamethasone works by limiting the damage done to the body by its immune system, which can end up hurting the host as it tries to destroy the disease.
The drug is cheap and widely available, meaning it can be rolled out quickly to poorer communities hit by the disease. The results show that one death out of eight would be prevented for ventilated patients, or one out of 25 for patients requiring oxygen alone.
"There is a clear, clear benefit. The treatment is up to 10 days of dexamethasone and it costs about £5 [$6.31 USD] per patient. So essentially it costs £35 [$44.14 USD] to save a life. This is a drug that is globally available," lead researcher Prof Martin Landray told BBC News.
"This is the only drug so far that has been shown to reduce mortality - and it reduces it significantly. It's a major breakthrough," chief investigator Prof Peter Horby told BBC News.
This discovery came about through the world’s biggest trial testing existing treatments against coronavirus. The study included over 6,000 patients—2,000 given dexamethasone and 4,000 control patients.
On June 7, the FDA announced that it was changing what types of respirators can be decontaminated for reuse. Faced with a national shortage of these items, the agency had given the healthcare industry emergency authorization during the coronavirus pandemic to decontaminate single-use respirators and facemasks..
The FDA now says that decontamination systems can only be used on non-cellulose-compatible N95 respirators. Banned from reuse are any respirators that have exhalation tubes, or N95 masks made in China. The latter has been banned due to quality control issues. And, as always, the FDA stressed that decontaminated respirators should only be used when new respirators are unavailable.
These changes are in response to new information from the Centers for Disease Control and Prevention (CDC) and from pushback from healthcare workers worried about the safety of reused personal protective equipment (PPE).
"In response to public health and safety concerns about the appropriateness of decontaminating certain respirators, the agency is reissuing certain emergency use authorizations (EUAs) to specify which respirators are appropriate for decontamination. Based on the FDA's increased understanding of the performance and design of these respirators, the FDA has decided that certain respirators should not be decontaminated for reuse by health care personnel,” states the FDA news release.
This reversal was cause for celebration for members of the Massachusetts Nurses Association, which petitioned for the right of nurses to refuse to use decontaminated PPE during the COVID-19 pandemic, citing safety concerns.
"Government officials and healthcare executives wasted time and resources and put frontline workers at risk chasing the unproven and dangerous dream of mask decontamination. Nurses and healthcare professionals caring for patients during this pandemic knew all along that these processes lacked rigorous evidence, could damage N95 masks and may create lasting health problems,” said MNA President Donna Kelly-Williams, RN, in a press release response to the FDA reversal.
In April and March, the FDA issued two EUAs stating that single-use N95 masks could be decontaminated to make up for the shortage of these products during the pandemic. The most common method used involved spraying masks with vaporized hydrogen peroxide and letting them dry.
The FDA has issued two emergency use authorization (EUA) for sterilizing and reprocessing N95 masks, once in March and once in April. The agency says this “has the potential to decontaminate approximately 4 million N95 or N95-equivalent respirators per day in the U.S. for reuse by health care workers in hospital settings.”
“Authorizing this sterilization system will make it easier for hospitals to ensure that heroic healthcare workers on the frontlines have the protection they need,” wrote HHS Secretary Alex Azar. “Thanks to rapid work by the men and women of the FDA and President Trump’s vision for an all-of-America response, innovators are giving our healthcare warriors new tools nearly every day to fight the COVID-19 pandemic.”
Doesn’t degrade the mask material’s ability to filter particulates
Doesn’t affect mask fit
Doesn’t create any toxic byproducts
EUAs were issued to Battelle Memorial Institute and STERIS. The latter sells the hydrogen peroxide sterilizing equipment, with units 6,300 healthcare facilities equipped STERIS decontamination units. Depending on the unit, it can take between 24 and 55 minutes per reprocessed mask, with a single unit reprocessing about 480 respirators daily.
Battelle Memorial is a non-profit based out of Ohio, and claims its Battelle CCDS Critical Care Decontamination System™ can decontaminate over 80,000 masks per day.
Botched patient handoffs can cause major problems for patients, hospitals, and health systems.
A 2015 study by research and analysis firm CRICO Strategies found that communication errors accounted for over 1,700 deaths and $1.7B in additional costs to the healthcare system. Additionally, the study, which analyzed 23,000 medical malpractice claims filed between 2009 and 2013, found communication problems were contributing factors in 7,149 cases (30%).
Handoffs can break down in intense situations (air-lifting a trauma patient to a specialty hospital) and in more routine tasks (change of nursing shift). So, how can healthcare professionals improve communication during these daily occurrences?
Q:How much of an impact do patient handoffs have on care quality? What can happen if they go wrong?
Tomsky: Patient handoffs have a profound effect on the quality of care and patient outcomes. The information provided during a handoff plays a key role in ensuring that the care the patient needs is seamlessly provided. Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information. Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.
Q:Is there a national, standardized handoff procedure in healthcare? In other words, is there a set of procedures all hospitals are meant to follow, or do they decide individually how their facility will conduct handoffs?
Tomsky: There is not a current standardized handoff procedure that is used in healthcare. Each healthcare organization can establish its own procedures to meet the needs of their patients, providers, and patient care staff. That said, there are models, or formats, that are adapted by many hospitals to develop their procedures. For example, “ISBAR” (Identification, Situation, Background, Assessment, and Recommendation) and “I-PASS” (Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver) are two such tools.
Q:When handing off a patient within a healthcare organization, what information needs to be shared?
Tomsky: No matter who is handing off or who is receiving the patient, information should be consistently shared. The Joint Commission has identified the following elements that, at a minimum, should be considered for inclusion in handoff communications:
Sender contact information
Illness assessment, including severity
Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
To-do action list
Contingency plans
Allergy list
Code status
Medication list
Dated laboratory tests
Dated vital signs
I would want to be sure that IVs, other lines, and drains are included, as well as last medications given and times of administration with particular focus on those that could cause drowsiness or unsteady gait.
I would also include the patient’s preferred language and whether the patient has an advance directive in the list of information to be shared within these categories.
Q:What information needs to be shared when handing off a patient between healthcare organizations?
Tomsky: The information provided by a healthcare organization upon the transfer of an inpatient to another inpatient facility should be very similar to the handoff from one unit to another with the notable difference of an additional handoff from the transferring attending physician to the accepting physician at the other facility. A discharge summary is also provided to the accepting organization.
Between a primary care physician and an unaffiliated outpatient surgery center, a complete history and physical should be provided to the surgeon who will perform the procedure, ensuring that recent lab work is included. The outpatient surgery center will receive basic information from the surgeon upon scheduling the procedure, and the surgeon will provide an updated H&P.
Transfer information provided when a patient is transferred from an emergency department to another inpatient facility is driven in part by EMTALA (Emergency Medical Treatment and Active Labor Act) regulation.
The transfer document does acknowledge a handoff from the ED nurse to the nurse who will provide care upon arrival at the other institution as well as acknowledging the physician-to-physician handoff. A discharge summary is provided and the transfer form also specifies the mode of transportation as well as other support needed during transport.
Q:Is using an electronic health record the best way to ensure a proper handoff? What about handwritten and verbal information exchanges?
Tomsky: I believe that the best way to ensure a proper handoff is a verbal exchange. This allows the person to whom the patient and his or her care is being handed off to ask clarifying questions and to discuss potential issues and concerns.
That does not mean that the electronic medical record and handwritten handoff documents aren’t part of the process. Developing an electronic or handwritten document that is used during the verbal handoff can help ensure that information isn’t unintentionally missed and gives the receiving area a document to refer to if needed. An electronic or handwritten handoff document is extremely helpful as a resource when a patient is being handed off to a support department such as radiology for a test.
Q:What sorts of things can cause a bad handoff? And what can be done to prevent them?
Tomsky: The two conditions that contribute most significantly to a poor handoff are related to distraction among those giving or receiving the handoff and incomplete information. If either of these occurs, it is much more likely that critical information will be missed.
To mitigate these causes, handoffs should occur, if possible, in an environment that allows participants to concentrate on the job at hand. Handing off in the middle of a busy hallway is not conducive to a successful handoff. As for incomplete information, I recommend using a template thoughtfully developed by members of the organization’s healthcare team to prompt documentation and sharing of all the necessary information.
Q:How much of a role does a patient (or family) play a role in the handoff? And what should patients know about the handoff process?
Tomsky: Whenever possible, it is helpful to include the patient and or family to ensure that they understand the plan and goal. This is especially important for shift-to-shift handoff. The patient or family can contribute to goal setting and is more aware of what they may need or want to communicate during the shift.
When handing off to a support department such as radiology, participation by the patient/family may be minimal, but it does offer an opportunity for the patient to ask questions and clarify information when appropriate.
Q: Do you have any other tips or advice on improving patient handoffs?
Tomsky: Organizational leadership’s commitment to establishing a clear and thoughtful process is important. Educating staff and physicians about the process and monitoring compliance will help.
Perhaps one of the most important drivers of handoff improvement is the analysis of adverse events of issues related to handoffs. Involving staff in analyzing what happened, including the barriers to providing the expected handoff, will help to continually improve the process.
