Strange Observations – Part 36

Continuing in a series of strange things that I have seen while consulting at hospitals…

 

Oh gross….

How would you like to have to use an eyewash station and this is what the hospital expects you to place your face into… Yuck.

Even though the eyewash station is in a mechanical room, you still have to test it weekly and maintain it.

Remember what I said in the July 5 ‘Strange Observations – Part 33’ posting? Equipment rooms are out-of-sight / out-of-mind for most people and no one is assigned to keep it safe. Stuff like this is the result.

 

Eye-Wash Risk Assessment

Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

Eyewash Stations

Q: I have been told several different ways that our facility didn’t have an eye wash station in our janitor’s closet. So, I was told to purchase the single-use portable squeeze bottles, and I installed one in each janitor’s closet. Now, I’m told we can’t use these as they are not ANSI approved. Not all of our janitor’s closets are near an eyewash station, and our chemicals used in these closets are not spillable, and they are located in a locked dispenser. Do I need an eyewash station in every janitor’s closet since the chemical would be diluted with water?

A: Well…Maybe yes and maybe no. It all depends on your organization conducting a risk assessment, which should determine if an eyewash station is necessary.

First, start with a review of the Safety Data Sheets (SDS) of the chemicals used in the work area (i.e. janitor’s closet). Does the SDS say to flush the eyes for 15 minutes? If so, then that is an indicator (but not necessarily a sure bet) that an eyewash station is needed. Next, evaluate the way that staff is using the chemical…. Is there a possibility that the chemical (even if it is diluted) can splash into the eyes of the individual? You make this determination assuming staff will NOT be wearing any PPE eye protection, because humans being the people that they are will eventually not wear their PPE.

If the risk assessment determines that there is a risk of splash into the eyes by chemicals that require 15 minutes of flush, then yes, you do need an eyewash station. The eyewash station needs to be ANSI Z358.1-2014 approved and while most of these are plumbed eyewash stations, there are a few that meet the ANSI standard and are self-contained and cost much less.

The portable squeeze bottles are not an acceptable substitute for an ANSI Z358.1-2014 approved eyewash station, but they are not illegal to have. They can be used as a first-aid device, but usually they are just a red-flag to surveyors that there is something going on here.

Eyewash Stations

When and where are eyewash stations required in a healthcare facility? That is one of the more frequent issues that healthcare professionals struggle with. There is a tendency to place them nearly everywhere, but in reality there aren’t as many locations that require eyewash stations than one may think.

Eyewash stations are required wherever there is a possibility that caustic or corrosive chemicals could splash into the eye of an individual. It is important to note that blood and body fluids are not considered to be caustic or corrosive. It is also important to note that the use of Personal Protective Equipment (face shields, glasses, goggles) does not exempt the need for an eyewash station.

Most accreditation organization’s position on whether or not an eyewash station (or an emergency shower) is required is based on the healthcare organization conducting a risk assessment of the situation. Working with corrosive and caustic chemicals does not necessarily require an eyewash station (or emergency shower) unless the possibility is present that the chemicals could be splashed into the eyes (or onto the skin).

For example: If an environmental services worker opens a 1 gallon container of a liquid cleaner that is considered caustic or corrosive, and inserts a suction tube for a mixer, that doesn’t really present much of a splash hazard and a risk assessment could state an eyewash station is not warranted. However, if the employee pours the same chemical from its original container to another container, now the risk of splash is much greater and a risk assessment would likely require an eyewash station. All risk assessments are conducted with the presumption that staff will not be wearing any personal protective equipment.

If there are no corrosive or caustic chemicals present, then there is no need to conduct a risk assessment and there is no need for an eyewash station. Whether the term “corrosive” or the term “injurious corrosive” is used to describe a chemical, it’s all the same. Both would cause an injury.

A portable squeeze bottle is not prohibited, but it is not a substitute for a plumbed ANSI Z358.1-2014 approved eyewash station. Portable squeeze bottles are a potential problem for healthcare organizations, since they are usually placed around an area where a potential hazard can or may occur. In other words, somebody decided there is some sort of risk of splash present, that a portable bottle would be of some use.

That can lead to an incorrect assumption that the portable bottles are an approved eyewash station. Also, they need to have their water changed every two years (or so) and that can also be overlooked at times which can lead to a citation. Also, be aware that they are a huge flag to a surveyor who would likely conduct a tracer once he/she sees the portable bottle.

If the possibility of a corrosive or caustic material can be splashed onto the skin then an emergency shower would be required. But if a risk assessment determines there is no possibility of the chemicals splashing onto the skin through normal use, then there would not be a requirement for an emergency shower. The risk assessment should also consider emergency spills as well.

In regards to the ANSI Z358.1-2014 standard for eyewash stations, this standard is based on recommendations from OSHA letters of interpretation. OSHA requires the employer to provide suitable facilities for quick drenching or flushing of the eyes and body when employees may be exposed to injurious corrosive materials. ANSI standards become mandatory OSHA standards only when, and if, they are adopted by OSHA. ANSI Z358.1 has not been adopted by OSHA; however, ANSI Z358.1 provides detailed information regarding the installation and operation of emergency eyewash and shower equipment. OSHA, therefore, has often referred employers to ANSI Z358.1 as a source of guidance for protecting employees who may be exposed to injurious corrosive materials. Accreditation organizations seem to have latched onto the ANSI Z358.1 standard as the standard to comply with.

The organization is expected to conduct a risk assessment (or survey) of their facility’s operation and process areas to determine if and where eye wash stations are needed. If the facility has determined that an eye wash station is needed, then it needs to conform to the ANSI standard Z358.1-2014, which has the following specifications:

  • Only eye wash stations that are capable of providing a flow of clean potable water at a rate of 0.4 gallons per minute at 30 psi for 15 minutes are permitted. It is possible that some self-contained eye was stations may provide this flow requirement, but normally only plumbed eye wash stations do.
  • The flow nozzles of the eye wash station must be mounted a minimum of 33 inches and a maximum of 45 inches above the floor, and a minimum of 6 inches from any wall, post or other barrier.
  • Activation of the eye wash station must occur in one (1) second or less of operating the control valve, so this typically eliminates the faucet mounted eye wash stations that require the operation of three (3) levers to obtain a balanced flow of water. The control valve must remain open on its own until it is intentionally turned off.
  • Approved eye wash stations are required to be located within 10 seconds travel time (or 55 feet) of the hazard and the path to get to an eye wash station must not be hindered or obstructed. The ANSI Z358.1-2014 standard has changed to allow one (1) door in the path to get to an eye wash station, provided the door cannot be locked and the door swings in the direction to the eye wash station.
  • While there is no standard that prohibits the small supplemental personal squeeze bottles, they cannot meet the flow rate requirements for a 15-minute flush, and therefore are not a substitute for a plumbed eye wash station. They can serve as a supplemental aid but the plumbed eye wash station needs to be located within 10 seconds travel time (or 55 feet) of the hazard. The presence of the small supplemental personal wash bottles may indicate a need for a plumbed eye wash station.
  • The temperature of the water is required to be tepid. The ANSI standard defines tepid water as being between 60°F and 100°F. In order to achieve this temperature range, the organization may have to install mixing valves. Water temperatures outside of the 60°F and 100°F range may be permitted provide a risk assessment is conducted by qualified individuals which analyzes the hazard and the temperature of the water to flush the hazard. Qualifying individuals must include an individual with clinical or medical training.
  • Weekly activation of the eye wash stations is required to clear any sediment or bacteria. There is no specified time that the water must flow. An annual inspection of the eye wash station is required to determine conformances with the installation requirements are maintained.

Here are some recommendations on evaluating your existing eyewash stations for compliance:

  1. In a healthcare setting, eye wash stations are typically found where cleaning chemicals are mixed (such as housekeeping areas), plant operations, kitchens, generator rooms, environmental services storage room for battery powered floor scrubbers, in-house laundries, dialysis mixing rooms and laboratories. Determine if a risk assessment has been conducted to conclude the need for eye wash stations.
  2. All required eye wash stations must be the plumbed type, which can operate in one (1) second or less. This means the faucet mounted type that requires turning the hot water lever and the cold water lever and then pulling a center lever is not permitted.
  3. Access to the eye wash station must be within 10 seconds (or 55 feet) of the hazard. The individual seeking an eye wash station may travel through one (1) door to get to an eye wash station, provided the door does not have a lock on it, and swings in the direction to the eye wash station.
  4. If an eye wash station is observed outside of an area where they are typically needed, ask the staff who works in the area why it is there. See if they have a risk assessment that requires it to be there. Advise them if there is no valid reason for the eye wash station to be there, it can be removed and may save them time and resources in maintaining it.
  5. Eye wash stations may need to have a mixing valve to maintain a flow of water in the 60°F and 100°F range. Ask to see the risk assessment to determine if a mixing valve is required.
  6. Every eye wash station needs to be tested weekly by flowing water to clear any sediment and bacteria. There is no requirement how long the water must flow. Every eye wash station must be inspected annually to determine the eye wash station still conforms to the installation parameters. The weekly test and annual inspections must be documented.
  7. The presence of eye wash bottles indicates someone in the organization decided it was needed. Investigate and ask why the bottles are located there. Determine if they need a plumbed eye wash station within 10 seconds travel time (or 55 feet) of the perceived hazard. Check the expiration date on the bottles.

Always check with your state and local authorities to determine if they have any additional requirements.

Eyewash Station Locations

Q: Where are eyewash stations required in a hospital/ambulatory care facility?

A: They are required in areas where corrosive or caustic materials (i.e. chemicals) are used, stored or handled and could be splashed into the eye. A risk assessment must be made to determine where (if any) eyewash stations are necessary. The place to start is by looking at the Safety Data Sheet. If the SDS says rinse eyes for 15 minutes, then that is your first clue that an eyewash station may be required. The next step is to determine if the use, handling, or storage of the material could be splashed into the eyes. Note: When you evaluate this step you have to evaluate the process as if people are not wearing any PPE. If you conclude you need an eyewash station, then it has to meet the requirements of ANSI Z358.1-2014 which means it has to be plumbed and maintained, although there are some units that are self-contained that do qualify.

It is interesting to note that blood and body fluids are not considered corrosive or caustic.

Non-ANSI Approved Eyewash Stations

Q: Is it better to have an eye wash station that doesn’t comply with ANSI standards or to remove eyewash stations from ambulatory clinics setting which may contradict Joint Commission standards on safety in the workplace?

A: To be sure, it is not a violation of a CMS, Joint Commission, or an OSHA standard to have an eye wash station that does not meet the requirements of ANSI Z358.1-2014 guidelines in areas where there are no caustic or hazardous chemicals. However, if there is a need for an eyewash station due to caustic or hazardous chemicals being used, then OSHA has issued interpretive letters that states their inspectors will use the ANSI Z358.1-2014 standard to determine compliance. [Joint Commission and most state agencies that survey on behalf of CMS will follow likewise.] This means an eyewash station that is non-compliant with ANSI Z358.1-2014 in an area where an eyewash station is required (such as a laboratory, or an Environmental Services work room) will likely be cited because the organization has not provided adequate emergency response equipment for the safety of their employees.

I have seen hospitals place eyewash stations that are non-compliant with ANSI Z358.1-2014 on faucets in every nurse station just because they thought it was a ‘good idea’; not because they were needed. Was that a violation? I don’t think so because there is usually not a chance of splashing caustic or hazardous chemicals in the eyes at the nurse stations. But, it is a red flag for surveyors and inspectors. If they observe an eyewash station that is non-compliant with ANSI Z358.1-2014 standard, they will start snooping around to see why it is there. If they find any caustic or hazardous chemicals used in the area that could be splashed into the eyes, then it is likely they will cite the organization for not having an ANSI Z358.1-2014 approved eyewash station.

I often see the hand-held squeeze bottles of sterile water mounted on the wall in certain area. I always ask the hospital why are they there. In some cases, caustic and hazardous chemicals were a splash concern and the hospital did not want to spend the $1,000 (or so) to install a ANSI Z358-1-2014 approved plumbed eyewash station, so they bought the cheaper bottles instead. That is a serious issue and likely would be cited by a surveyor. However, I have also seen the hand-held bottles placed in areas where there was no hazard, and the hospital just wanted them there for a ‘first-aid’ device. There is no standard or guideline that prevents that arrangement, but again, it is a red flag to a surveyor to start snooping around to see why the bottles are there in the first place. Also, the water in the bottles are typically only good for 2 years, and the hospital must be diligent in replacing the bottles before the water expires.

To directly answer your question: I think the hand-held bottles and the eyewash stations that are non-compliant with ANSI Z358.1-2014 in locations where there is no potential of caustic or hazardous chemicals to be splashed in the eyes is a potential source of problems during a survey, and I recommend to my clients to remove them, even though technically, they are permitted. It is a matter of opinion, and I always like to remove red-flags from the hospital before surveyors walk through. However, to not provide ANSI Z358.1-2014 approved eyewash stations where caustic or hazardous chemicals could be a potential splash problem, is definitely a safety hazard and would most likely be cited by a surveyor or an inspector. It is far better to spend the extra funds to either install the approved eyewash stations, or relocate the function and process to an area where there already is an approved eyewash station.

Eyewash Stations in Labs

Q: Does an eye wash station need to be mounted over a designated “clean sink” or can it be in any sink? Some of our Labs only have one sink, so that sink is considered to be a dirty sink. Can we have a swing-out eye wash station located above that sink?

A: The OSHA and ANSI standards do not directly address this issue. But Joint Commission, CMS, CAP and the other accreditors will definitely perceive this as a risk to the health and safety of the staff that may use the eye wash station. The risk must be assessed by you, and the mitigation activities to lessen the risk are really what you will be judged on. I suggest you discuss this with the Lab safety officer and the organization’s Infection Control practitioner, and see what they think. If you wouldn’t want to put your face down into the dirty sink then I’m sure you would not expect your staff to do so as well. Do a risk assessment, run it past the Lab safety officer and the IC practitioner, then run it past the Safety Committee and see what they say. If everyone is okay with it (including your accreditation organization), then you should be able to use it for the eye wash station, as long as the eye wash station is maintained and kept clean.

Eyewash Stations in Kitchens

Q: Are we required to have an eyewash station inside a kitchen?

A: Maybe yes and maybe no…. It all depends on whether or not there are caustic or corrosive materials that could be splashed into the eye. The organization needs to do a risk assessment of the hazardous materials in and around the kitchen to see if there are any chemicals/ materials that are considered caustic and/or corrosive, and whether or not they can be splashed into the eye when used according to the manufacturer’s recommendations. I’ll say from my experience, there probably are not many such materials in a kitchen, as that would seem to be a bit risky to have hazardous materials where food is being prepared. But you may very well find such materials in a janitor’s closet nearby, or in the dishroom. If you do have caustic or corrosive materials, the eyewash station must be located no more than 10 seconds of travel away from where the materials are used or stored. All of these requirements are found in the ANSI Z358.1 standard, available through an on-line search.

Emergency Showers

imagesRFIMRIFGEmergency showers are often found in hospital laboratories and at times, in plant operation areas. There seems to be some confusion about emergency showers and eyewash stations, and what is acceptable to the accreditation organizations. To be sure, there are no standards that are being enforced by a national authority over hospitals that are specific to emergency showers and eyewash stations. Even OSHA does not rigidly enforce a specific set of rules concerning these emergency first-aid devices, although they do refer to ANSI Z358.1-2009 as a guide.

George Mills, director of engineering for The Joint Commission recently commented during a meeting of hospital engineers that they (Joint Commission) do not rigidly enforce the guidelines in ANSI Z358.1-2009. Joint Commission only requires a monthly water-flow test for an unspecified amount of time, and then it appeared to only apply to eyewash stations.

A lot has been written about eyewash stations (search: eyewash), but not so much for emergency showers. What should a hospital do in regards to testing and inspecting an emergency shower? In order to be prepared for any inspection by an authority who may enforce the full requirements of ANSI Z358.1-2009, here are the basics concerning emergency showers:

There are two types of Emergency Showers:

  • Plumbed Shower:      An emergency shower permanently connected to a source of potable water
  • Self-Contained Shower:      A shower that contains its own flushing fluid, and must be refilled or      replaced after use

 The specifications below are for plumbed showers only.

  • Heads
    • Positioned 82″-96″ from floor
    • Spray pattern will have a minimum diameter of 20″ at 60″ above the floor
    • Flow Rate equals 20 gallons per minute (GPM) at 30 pounds per square inch (PSI)
    • The center of the spray pattern shall be located at least 16 inches from any obstruction
  • Valves
    • Activate in one second or less
    • Stay-open valve (no use of hands)
    • Valve remains on until the user shuts it off
  • Installation
    • Emergency Shower shall be located in an area that requires no more than ten seconds to reach.
    • Shower location shall be in a well-lit area and identified with a sign
    • Shower shall be located on the same level as the hazard
  • Maintenance and Training
    • Plumbed emergency showers will be activated weekly to verify correct operation
    • All employees who might be exposed to a chemical splash shall be trained in the use of the equipment
    • All showers shall be inspected annually to make sure they meet with ANSI Z358.1 requirements

More on Eye Wash Stations

imagesCASBGE8PEye wash stations are required wherever there is a possibility that caustic or corrosive chemicals could splash into the eye of an individual. It is important to note that blood and body fluids are not considered to be caustic or corrosive. It is also important to note that the use of Personal Protective Equipment (face shields, glasses, goggles) does not exempt the need for an eye wash station.  Material Safety Data Sheets will specify whether or not an eye wash station is required, by the listed emergency treatment of flushing the eyes with water for 15 minutes.

Accreditation organizations (Joint Commission, HFAP and DNV) as well as CMS does not specify the location for eye wash stations. The organization is expected to conduct a risk assessment (or survey) of their facility’s operation and process areas to determine if and where eye wash station are needed. If the facility has determined that an eye wash station is needed, then it needs to conform with the ANSI standard Z358.1-2009, which has the following specifications:

  • Only eye wash stations that are capable of providing a flow of clean potable water at a rate of 0.4 gallons per minute at 30 psi for 15 minutes are permitted. It is possible that some self-contained eye was stations may provide this flow requirement, but normally only plumbed eye wash stations do.
  • The flow nozzles of the eye wash station must be mounted a minimum of 33 inches and a maximum of 45 inches above the floor, and a minimum of 6 inches from any wall, post or other barrier.
  • Activation of the eye wash station must occur in one (1) second or less of operating the control valve, so this typically eliminates the faucet mounted eye wash stations that requires the operation of three (3) levers to obtain a balanced flow of water. The control valve must remain open on its own until it is intentionally turned off.
  • Approved eye wash stations are required to be located within 10 seconds travel time (or 55 feet) of the hazard and the path to get to an eye wash station must not be hindered or obstructed. The ANSI Z358.1-2009 standard has changed to allow one (1) door in the path to get to an eye wash station, provided the door cannot be locked and the door swings in the direction to the eye wash station.
  • While there is no standard that prohibits the small supplemental personal wash bottles, they cannot meet the flow rate requirements for a 15 minute flush, and therefore are not a substitute for a plumbed eye wash station. They can serve as a supplemental aid but the plumbed eye wash station needs to be located within 10 seconds travel time (or 55 feet) of the hazard. The presence of the small supplemental personal wash bottles indicates a need for a plumbed eye wash station. Check the expiration date on the small bottles.
  • The temperature of the water is required to be tepid. The ANSI standard defines tepid water as being between 60°F and 100°F. In order to achieve this temperature range, the organization may have to install mixing valves. Water temperatures outside of the 60°F and 100°F range may be permitted provide a risk assessment is conducted by qualified individuals which analyzes the hazard and the temperature of the water to flush the hazard. Qualifying individuals must include an individual with clinical or medical training.
  • Weekly activation of the eye wash stations is required to clear any sediment or bacteria. There is no specified time that the water must flow. An annual inspection of the eye wash station is required to determine conformance to installation requirements are maintained.

In response to the question: “How do Accreditation Organizations survey a hospital (or nursing home) in regards to eye wash stations?” Here are my tips and recommendations:

  1. In a healthcare setting, eye wash stations are typically found where cleaning chemicals are mixed (such as housekeeping areas), plant operations, dialysis mixing rooms and laboratories. The surveyor will determine if the organization has conducted a risk assessment to determine the need for eye wash stations.
  2. All required eye wash stations must be the plumbed type, that can operate in one (1) second or less. This means the faucet mounted type that requires turning the hot water lever and the cold water lever and then pulling a center lever is not permitted.
  3. Access to the eye wash station must be within 10 seconds (or 55 feet) of the hazard. The individual seeking an eye wash station may travel through one (1) door to get to an eye wash station, provided the door does not have a lock on it, and swings in the direction to the eye wash station.
  4. If an eye wash station is observed outside of an area where they are typically needed, the surveyor may ask the organization why it is there. They will want to determine if you have a risk assessment that requires it to be there. If there is no valid reason for the eye wash station to be there, it can be removed and may save you time and resources in maintaining it.
  5. Eye wash stations may need to have a mixing valve to maintain a flow of water in the 60°F and 100°F range. The surveyor may ask to see the risk assessment to determine if a mixing valve is required.
  6. Every eye wash station needs to be tested weekly by flowing water to clear any sediment and bacteria. There is no requirement how long the water must flow. Every eye wash station must be inspected annually to determine the eye wash station still conforms to the installation parameters. The surveyor will likely ask to see the weekly and annual inspection reports.
  7. The presence of eye wash bottles indicates someone in the organization decided it was needed. The surveyor will likely investigate and ask why the bottles are located there. If the surveyor determines a need for a plumbed eye wash station within 10 seconds travel time (or 55 feet) of the perceived hazard, then you are ripe for a finding. Conduct a risk assessment to determine if a plumbed eye wash station is required. If so, have one installed or relocate the hazard. If not, then remove the portable eye wash bottles.  Also, if you retain the bottles, check the expiration date to ensure it has not expired.

While there may not be a direct standard in the Accreditation Organization’s manual that addresses eye wash station, any deficiency that a surveyor finds will likely be entered under a standard that addresses general safety in the physical environment, such as EC.02.01.01, EP 1 for Joint commission; 11.02.02 for HFAP; and PE.1, SR.1 for DNV.