Strange Observations – Monitor Leads in the OR

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

When I consult at a hospital or an ambulatory surgical center, I always gown-up and take a tour of the operating rooms… the vacant operating rooms, of course. I have no desire to enter an OR that has an active case, nor would I be allowed to enter.

This picture is of an operating room table that I was told was waiting for the patient to arrive. Can you see what is laying on the floor…? Those are leads to the medical equipment to monitor the patient.

While this is not a Life Safety Code issue, it is a serious Infection Control issue. You cannot have monitor leads lying on the floor that will be used on a patient. Show this to your Infection Control specialist at your facility, and ask them what they think.

Offsite Locations

Q: For clinics that are in a facility classified as business occupancy, is an ICRA required?

A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations that are considered hospital departments even if it is not classified as healthcare occupancy. For example, if a hospital has an offsite therapy unit in a local mall, the Environment of Care and Life Safety chapter requirements must apply to the offsite location, in accordance with the respective occupancy designation. This means, where the hospital is a healthcare occupancy, an offsite therapy unit would likely be a business occupancy, but the requirements found in the EC and LS chapters still apply at the therapy unit, but in accordance with business occupancy classification.

So, the requirement for an Infection Control Risk assessment (ICRA) is found in EC.02.06.05, EP 2 in the Hospital Accreditation Manual. The expectation is the hospital would conduct an ICRA at an offsite location when planning for construction as long as it is a hospital department. This concept of the Joint Commission standards applying at offsite locations is explained in the Overview to the EC and LS chapters.

Negative Air-Pressure

Q: I’m butting heads with our Infection Control group regarding holes in construction barriers. They have started requiring the contractors to make the construction sites negative air-pressure, which is fine, if they have access to the outside of the building. If there isn’t any way to vent to the outside they want to install filters in the construction barrier so they can exhaust filtered air into the corridors. Our construction sites are fully sprinkled so we are not required to have fire barriers but I can’t find anywhere in the code that it says they can put holes in the corridor walls to exhaust air through. I’m telling them that if they put holes in the barrier I might as well hang beaded curtains because we don’t have a smoke separation anymore. What do you think?

A: I guess it depends on the level of construction, demolition or renovation. I like the idea of poking a hole in the corridor wall and exhausting through a HEPA filter into the corridor to create a negative air pressure in the construction area. That is a common process where there is no access to the outdoors. I don’t see a problem with this… just make your ILSM assessments for a corridor that no longer resists the passage of smoke and keep that exhaust fan w/HEPA filter running 24/7. Don’t let them turn it off.  Sometimes, IC people don’t like the airflow into the corridor because it stirs up the air in the corridor. But if your IC people are okay with this, then that would be considered best practice. I think you’re over-reacting… The Infection Control people are correct on this one.

Support Your Local Infection Control Practitioner

A ‘Conversation’ Regarding Environmental Services Closets

Q #1: Are housekeeping closets considered clean or dirty rooms and what type of supplies can you store in them? EVS is being advised by Infection Prevention that these are considered dirty and we cannot stores supplies, such as toilet paper, paper towels, trash bags, etc. Thanks in advance for any information you can provide.

A #1: I would agree with your IC people. Their opinion over-rides anything else. They’re the ‘boss’ when it comes to infection control issues, and if they say the room is ‘dirty’ then you cannot store clean supplies in there.

Q #2: Okay then going by that “policy” that means the EVS carts are also dirty, since they are of course stored in the EVS closets, and that then means the cleaners cannot carry supplies on the carts, which is what they are designed for?  I have been cleaning hospitals for 30 years and no offense but this does not make any sense at all.

A#2: Hey… it’s your IC people’s policy… not mine.

Ask them how they want you to deal with this. There is a difference with the cleaning supplies that are stored on the EVS carts, compared with the stacks of paper towels and toilet paper stored in these rooms. The general public does not come into contact with the EVS carts and the supplies on the carts, but they do come into contact with the paper towels and toilet paper. I can see the difference.

I would argue with the IC people that the cleaning supplies on the EVS carts are indeed ‘dirty’ but they can still be used to clean rooms, because the contents inside the cleaning supply bottles are clean. The paper towels and the toilet paper should be kept in a clean environment, but I would argue that the trash bags are dirty as soon as they are used, so there is no reason to store them in a clean environment.

All is well…. Just talk it out with the IC people. They are there to safeguard the health of your staff and patients. Work with them, not against them.

Infection Control in a Trauma Room

Q: I know it is inappropriate to place a flushing hopper sink in a trauma room between the hand washing sink and clean storage cabinets but I can’t find the standards to back me up. The hospital did not involve Infection Control during this planning phase and I need assistance.

A: My first look is to the Guidelines for Design and Construction of Health Care Facilities, written by the Facilities Guidelines Institute (FGI), 2010 edition. Section 2.1-2.6.10 says soiled workrooms or soiled holding rooms shall be separate from and have no direct connection with clean workrooms or clean supply rooms. It is obvious that a flushing hopper sink and a separate hand washing station are part of a “Soiled Workroom” as defined in 2.1-, and as such is required to be located in a soiled utility room and separated from clean supplies.

Table 7-1 “Design Parameters” in the same book requires soiled workrooms to have a negative air pressure in the room compared to its surrounding area, and clean workrooms are required to have a positive air pressure in the room compared to its surrounding area. That is physically impossible if the soiled and the clean are in the same room.  Also, a soiled workroom must have 2 ½ times the amount of air changes per hour than the clean workrooms.

It does not make sense to have a trauma room in a room that is defined as a soiled workroom. A room with a hopper sink is by definition a soiled workroom. According to Table 7-1, the air pressure in a soiled workroom must be negative, but the air pressure in a trauma room is required to be positive. Again, how can that be if the two rooms are together? The answer is, it can’t. The two rooms have to be separate.

Take this information to the project manager and explain the logic that differentiates their design. If they do not listen and do not change the design, then escalate this issue to a higher authority (your M.D. in charge of Infection Control; or the COO; or the CEO) and explain to them that CMS, Joint Commission, and any other accreditation organization will enforce the FGI guidelines for new construction and the arrangement you describe will be cited and the hospital will be required to resolve this at a later date. Better to resolve it now, while it is still being designed/built, than doing so a couple of years from now.

New Surveyor’s Finding on EC Standards

This post may not be about a Life Safety Code deficiency, but it may be of some relevance to those healthcare organizations that are Joint Commission accredited, and how their surveyors are interpreting their standards. I saw this finding on a client’s report after they had a tri-annual survey, and I was a bit surprised to find that the surveyor actually wrote it up. The standard which the finding was written against, is:

EC.02.05.05, EP 4, which says (in part):

Infection control utility systems must be inspected, tested, and maintained by the hospital. (This is one of those elements which requires documentation.) 

The actual written finding was:

“At the time of the survey there was no provision for recording temperatures of the dish machine to insure proper sanitizing of dishes. The facility’s written plan also did not reflect the need to monitor/record dish machine temperatures.”

My first reaction to this finding was one of surprise as I have never seen a surveyor cite an organization for not recording the temperatures of the dish machine. But, after thinking about it, I can see where improper water temperatures in the dish washing machine could lead to an infection control issue. The problem is, this hospital did not know that they should have been logging the temperatures of the dish machine.

When I was a surveyor at Joint Commission, and during one of the annual surveyor training sessions, I asked why we were not allowed to cite a certain Life Safety Code issue when on survey. The answer from the Joint Commission leaders was “We have not informed the healthcare organizations that we are enforcing that issue.” I thought that was a poor answer back then, as all hospitals are required to comply with the Life Safety Code. But, fast forward to today, and with that un-written policy of not citing organizations on issues that they have not been advised about, I am not aware of any directive from Joint Commission that they are now expecting temperature logs on dish machines. So, it looks like Joint Commission has changed their process and will cite an organization for anything they believe is a legitimate issue, regardless whether or not they have announced they will.

Back to the finding on the lack of temperature logs on the dish machine: is it a legitimate finding? I would say yes, it is. It’s not a ‘ticky-tack’ finding that has no positive impact on the safety of patients and staff, so I can see the validity in the finding. But it took this hospital (and this consultant) by  surprise and is chalked up to be another ‘life’s lesson’. I guess this is one reason why you have routine accreditation surveys; to learn about new testing, inspection and maintenance activities that can impact the safety of the patients and staff. But wouldn’t it have been better if the accreditation organization announced they were going to start requiring that activity?



Ugh. Here’s a topic I don’t care much about: Bugs. I have consulted in hospitals in the deep south where cockroaches are big enough to saddle and ride in the local derby. Well, maybe not that big, but they’re surprisingly large, especially to kid that resided in Northern Illinois all his life.

Here’s a picture of some roaches that I found when I opened the door to a janitor’s closet on an occupied nursing unit in a hospital. This was on a general medical-surgical unit and the closet was only 5 feet from a patient’s room door. The closet was otherwise clean and tidy, but those damn roaches were lined up on the sink faucet and hose like it was Sunday and they were out for a stroll. These roaches were about 3 inches long, but I was told that they can get much bigger.

The facility manager who was accompanying me didn’t seem all that surprised and took some sort of liquid (which I never did find out what it was) and sprayed the roaches, which instantly died. I found out later that the liquid he used was not an approved insecticide for controlling roaches, but it was very effective.

The Joint Commission standard EC.02.06.01, EP 1, requires the hospital to be safe and suitable for the care and treatment of patients. It’s pretty clear to me that roaches sunning themselves on the janitor’s closet sink does not qualify as a ‘safe or suitable’ environment.

I was asked by one of my fellow Life Safety Code (LSC) peers, why do I write about non-life safety subjects like ‘bugs’, when it is not a LSC compliance issue? I see that it is a LSC issue, as section (2000 edition) says:

“Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code, shall be determined by the authority having jurisdiction.”

Bugs in a patient care area is certainly an infection control issue, and the authority having jurisdiction (AHJ) such as Joint Commission and the state department of public health have standards that deal with the spread of infection caused by ‘bugs’. I believe there should be a very close relationship between the hospital Safety Officer and the hospital Infection Control manager. Controlling the spread of infection is a very large part of keeping a hospital ‘safe and suitable’ for patients, as the Joint Commission standard requires.

So, if you’re in charge of Life Safety compliance in your hospital, take an active role in assisting the Infection Control manager. Heaven knows they could probably use your help. You’ll kill two birds with one stone by doing so, although I do not advocate any stone throwing in a hospital. In fact, if you have birds in your hospital, you have bigger problems than roaches!