EC.02.06.01 - Clinical Impact | Joint Commission
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Monday 7:23 CST, June 26, 2017

EC.02.06.01 - Clinical Impact

 

EC.02.06.01: The organization establishes and maintains a safe, functional environment.


This content includes information linking Environment of Care and Life Safety Code deficiencies and their impact on patient care and patient safety.

CLINICAL IMPACT - EP 1:

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided.

Safe interior spaces. Patients and staff assume when they come to our facilities that the physical environment will be safe. But what about that small tear in the carpet? This potential trip hazard is unsafe, and could cause any patient, visitor or staff to become injured. Who is responsible for managing this?  We have already discussed corridor clutter in Module 2, where general clutter (including equipment left unattended in the corridor, such as IV poles, med carts, linen collection hampers, etc.) creates an unsafe environment for patients, visitors or staff. One proposed solution is improving the Safety Culture, using a “Safety First” approach.

Any unsafe condition will be cited at EC.02.06.01 EP 1. This EP is equivalent to the OSHA General Duty Clause, which states that “each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards….”  This clause is used by OSHA whenever any unsafe condition is identified that does not have a correlating rule or regulation.  The Joint Commission uses this EP similarly.

Maintaining a safe physical environment is everyone’s responsibility, which is more than just a cliché. In our healthcare environment each of us must be sensitive to potential risks to one another, including where the risk came from.  In one nursing unit a staff member was walking down the corridor and saw a puddle of water.  They immediately went and got a towel to wipe it up.  Later that afternoon a someone else was walking in the unit, slipped on water and injured their hip. Did the person who first wiped up the water fail to exhibit a safety awareness?  No, of course not.  But what can we learn from this? The first person, acting correctly in removing the risk [water] failed to find the source and take appropriate corrective action.

To make reporting of unsafe conditions easier for staff, the use of Safety Champions can be extremely helpful.  Also, as staff rotate through the Safety Champion program a heightened sense of safety will develop. The Safety Champion program has one person from each unit/department specifically trained in safety awareness according to organization policy and unit/department policy. General safety education is also stressed to those participating.  One of the responsibilities of the Safety Champion is conducting the Environment of Care Tours, which is one way for staff to identify and seek corrective actions for possible unsafe conditions. For more on Safety Champions see Perspectives, February 2013.

Another concern related to the physical environment is hospital-acquired infections (HAI).  Coming in at fourth place in the CDC list of causes of HAI is the physical environment. CDC has stated, “There were an estimated 722,000 HAIs [Healthcare-Associated Infections] in U.S acute care hospitals in 2011. About 75,000 hospital patients with HAIs died during their hospitalizations. More than half of all HAIs occurred outside of the intensive care unit.”  [CDC Data & Statistics Web Page, 5/13/2015]

Unsafe practice can contribute to these numbers. Certainly ensuring the equipment and clinical areas are clean and suitable for patient care is important.  Clinical Alarm management is also important.  Following compartmentation policies to contain airborne contaminates is critical, which leads us to EC.02.06.01 EP 13.

CLINICAL IMPACT- EP 13:

The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided. (See also EC.02.05.01 EP 15)

Ventilation:
Ventilation in EC.02.06.01 EP 13 addresses general care and administrative areas.  All critical care areas, such as the operating rooms and sterile supply is addressed in EC.02.05.01 EP 15 (see module 1).

As mentioned above, maintaining appropriate pressure differentials will contribute to reducing HAIs (Healthcare-Associated Infections) through compartmentation.  For example, if a patient had an infectious disease that could be airborne, it is important to prevent the potentially contaminated air from leaving the patient room. Facilities assists in this by creating a negative pressure room environment.  What does that mean?  Mechanically we remove more air than we put into the room, so the contaminated air cannot escape under the door or other cracks.  In fact, a room operating as negative pulls air in from the corridor and other areas, which does not allow the contaminated room air to escape.  However, if a person were to leave the patient room door open for an extended period, the room balance could be affected and the contaminated air could escape into the corridor.

For those patients that may be immunocompromised (i.e. oncology patients) the room may need to have more clean air than adjacent spaces, or a condition referred to as “positive pressure.”  In this situation mechanically we push more clean air into the room than we remove, essentially blocking any possibly contaminated air from entering the patient room.

How can the care givers help ensure the physical environment is correct for patient care?

  • If there is a risk of others being contaminated by airborne contaminates, the room should be negative.
  •  If the patient could be harmed by contaminations outside their patient room the room should be positive.

A simple screening test is to take a clean tissue and hold it to the bottom edge of the closed patient room door.

  • If the room is negative to the corridor, the tissue should be drawn into the room.
  • If the room is positive to the corridor, the tissue would be blown away from the room, toward the corridor.

Humidity:
Humidity in all areas of the hospital are addressed at EC.02.06.01 EP 13.

On a hot summer day a glass of cold iced tea will have water on the outside of the glass. Does the glass have a leak or was it over-filled?  No, but the surface of the glass is cold enough to allow moisture in the air to condense on the glass surface.  This occurs because the air around us has a certain percentage of moisture, referred to as humidity.  The percentage is relative to the environment, so we use a term Relative Humidity or RH and assign a percentage.  The higher the percentage, the higher the moisture in our air.  Watching the weather report we often hear that it is 80%RH, and that rain is likely.  Generally, the more moisture in the air, the greater chance for the moisture to condense and create rain.

The authorities having jurisdiction (AHJ) have determined an acceptable range of humidity in patient care areas, which is 20 – 60% RH (note: in certain areas where sterile supplies or older medical equipment is used the range is narrower, at 35 – 60% RH).

The lower range was established to help prevent electrostatic discharge (ESD), which can occur when the air is low in humidity.  For example, in northern states during the winter when the air is dry (low RH) you may have experienced a slight shock after walking across the carpet and touching a door knob.  You generated an electrical charge as your feet rubbed against the carpet, which was discharged through you when you touched another object, such as the doorknob.  
Years ago in the Operating Rooms we used flammable anesthetics such as ether.  Ether is both flammable and explosive, and between the early part of the last century up to the late 1970’s many OR room fires and explosions were traced back to and ESD and an Ether plume.  To counter-act this we infect moisture into the OR air flow, which is where the 35% lower range came from.  However, it is often difficult (and often costly) to achieve the 35% RH, especially when we no longer use flammable anesthetics.  In response to the healthcare industry request, the leading authority on heating, ventilation and air conditioning, ASHRAE, lowered the RH to 20%.  Recent issues have been identified, so the RH in surgical supply areas must be at least 35% RH.  A risk assessment should occur for other areas in the building and if older, legacy equipment is used (which may be subject to damage from ESD because of poor grounding or equipment design).

There is also an upper limit to humidity, 60%.  Studies have shown that sustained RH above 60% may result in an environment where mold can grow.  If the organization experiences long periods where the humidity has been high the clinical users in those areas may be asked to help assess the physical environment for mold.   In older buildings one indicator that the building humidity may be high is if water condenses on patient windows.  Newer buildings often have high energy efficiency windows (or older buildings with new windows) that do not transmit the exterior cold temperature into the room, so the humidity may not condense. 
 

Temperature:
Temperature in all areas of the hospital are addressed at EC.02.06.01 EP 13.

Hot and cold issues related to the physical environment are cited at EC.02.06.01 EP 13.  So when we walk into a nursing unit and see a lot of blankets being used with the patients, we have to assume the area is not warm, but cold.  Improper temperature can result in a decline in patient satisfaction scores, possibly affect patient treatment and healing, and affect staff morale and satisfaction as well.

Temperature range is often difficult to set, as some like the area warm while others prefer a colder temperature.  The guidelines facilities follows have ranges available.  Generally the set point is established by leadership and policy, and then if staff want to deviate +/- 2° F the thermostats can accomplish this (NOTE: some newer systems no longer have user-adjustable thermostats, so a call to Engineering may be necessary).  Controlling the temperature in our healthcare settings is similar to a residential setting, where a thermostat is mounted on the wall, the user adjusts the thermostat to the specific temperature they desire, and the heating/cooling system responds.

True story: 
Staff on the third shift were chilly, so they went to the nearby thermostat and turned the control knob all the way up (to 90°).  The heating system takes time to achieve this demand, but by the end of the third shift the staff were warm and comfortable.  However, the heating system continued to try to achieve the requested 90° and by mid-morning shift, the unit was very uncomfortable, being too warm.  So staff went to the nearby thermostat and turned the control knob all the way “off” (setting the thermostat to 65°).  So the heating demand stopped, but the mechanical system, trying to meet this new request, began delivering a greater amount of outside, cooler air. By the end of the day shift the temperature was again comfortable and the staff went home.  Mid-way through the second shift, the unit was now getting colder, as the thermostat was still trying to deliver the 65° request.  So staff went to the nearby thermostat and

The staff need to understand that the thermostats in our hospitals are similar to your home, they will seek to deliver the temperature the user requests when they set the thermostat.  How much better if the staff would have just set the thermostat to what actual temperature they wanted.  The net result is not any faster, if the area is three degrees to cool, it will not warm up faster by asking for 90° or if the area is too warm it will not cool any faster asking for 65° temperature.  All staff must understand that they just need to set the thermostat to what they need and leave it there.


 

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