≥92% of participants will achieve current knowledge in care aid, nursing assistant, and home health worker level healthcare professionals.
After completing this course, the learner will be able to:
Patient’s rights are the basic rules of conduct between healthcare workers and patients. Patient’s rights are determined by state and federal law and inspection agencies like the Joint Commission or Department of Health. Breaking a patient’s rights can lead to suspension, fines, or even prison. Patient’s rights include:
Patients have the right to get accurate information that the patient can understand about their health, treatments, health plan, health care providers, and health care facilities. If the patient speaks another language, has a physical or mental disability, or just does not understand something, the patient will be helped so the patient can make informed health care decisions.
A patient who has severe pain, an injury or sudden illness and is concerned they could be seriously ill, hurt, or could die have the right to Emergency Services. The patient can receive emergency services whenever and wherever needed and can be seen by a doctor. The patient has this right even if they are not asked for their health plan first, and the patient will not be charged a penalty.
The patient has the right to know all their treatment options, even if their health plan does not cover them, and make decisions about their care. Parents, guardians, family members, or others that the patient choose can represent the patient if the patient cannot make their own decisions.
The patient has the right to considerate, respectful care, and to not be discriminated against by their doctors, other health care providers, or health plan representatives. Simply put, respect means valuing the patients’ needs, desires, feelings, and ideas while treating them with common courtesy.
The patient has the right to talk in private with health care providers and to have their health care information protected. The patient also has the right to review and copy their medical records and ask their doctor to make corrections to their record if it is not accurate, is incomplete, or has information that does not relate to their health care.
Patients have the right to question, complain about, file grievances, or appeal decisions made about their health care. Every patient has the right to a fair, fast, and objective review of any complaint that they have about the health plan, doctors, hospital, or other healthcare personnel. This includes complaints about waiting times, operating hours, the conduct of healthcare personnel, and the adequacy of healthcare facilities. Many facilities have a patient care representative to deal with complaints or grievances. Many patient complaints can be addressed quickly. For example, if a patient complains about getting the wrong items on her lunch tray, make sure she gets the right items next time. The sooner the issue is resolved at the lowest level possible, the better patient compliance and satisfaction with the healthcare provided.
More than half of the patients who sue do so because of miscommunications, anger, and lack of information between physicians, hospital staff, and patients/families.
Grievance management is everyone’s responsibility. Handling grievances effectively from the start benefits everyone involved, helps keep small grievances from becoming big ones, and reduces the risk of liability. When complaints cannot be resolved quickly and easily, patients have the right to file a grievance. A grievance is a formal written or verbal complaint. If a patient wants to file a grievance, notify the person in charge. That person has to educate the patient and initiate an investigation.
Healthcare facilities must review, investigate, and resolve all grievances within a reasonable time. If the grievance has to do with the patient’s safety, it should be reviewed immediately. Examples include grievances about abuse or neglect.
Additional consumer benefits include1:
Information about both patients and staff must be kept secure and confidential. Any staff member working in the presence of patient information must know how to maintain and secure protected information.
The HIPAA is a federal regulation that addresses the privacy, confidentiality, and security aspects of the legislation.
The rule sets standards for patient privacy and confidentiality. It also sets severe civil and criminal penalties for people who violate a patient’s privacy. HIPAA requires protected patient information must only be shared with people who are directly involved in that patient’s care. This is especially important when talking in public areas (elevators, restrooms, hallways, cafeterias, etc.). Charts or documents should not be left out where unauthorized persons might see them; computer screens should not be angled in such a way as to allow unwanted viewing, and computers should be logged off when you leave the area. It is vitally important to observe surroundings when discussing patient care.
A worker who seeks information about a patient not under the worker’s care is violating the HIPAA rules. Protected health information can only be used for health purposes. Employers cannot use health history information to screen candidates for hire or promotion. Financial institutions may not use it to determine lending practices. Only the individual can explicitly authorize employers, banks, and others to have access to his/her medical information.
The HIPAA Privacy Rule protects individually identifiable personal health information, called PHI, held, or transmitted by a covered entity or its business associate, in any form, whether electronic, paper or verbal.
PHI includes information that relates to the following:
PHI includes many common identifiers, such as name, address, birth date, and Social Security Number.
HIPAA also established the “minimum necessary rule,” which stipulates that only the minimum necessary information may be shared, even with the patient’s authorization. A classic example would involve treatment for a case of domestic abuse. The worker should not provide information about the domestic violence that caused the injury. Only give enough information that is necessary to provide treatment and protect the victim. A summary of the information could be provided to legal and law enforcement entities.
Health workers who are directly involved in the treatment of patients are not subject to the minimum necessary rule and can have full access to all information that is needed to provide care. Health information that has implications for public health and safety.
There are a few situations where medical information can be shared:
The public health department is deemed a legitimate recipient of certain personal health information. HIPAA privacy regulations also mandate specific patient rights that include the following:
Electronically generated, stored, or transferred information also falls firmly under HIPAA privacy rules. Both individuals and facilities are responsible for defending electronic protected health information (ePHI).
Protected information that does get shared, either by accident or with purpose, must immediately be reported using the facilities established procedures.
The right to care is defined in the Emergency Medical Treatment and Labor Act (EMTALA). It ensures the public has access to emergency services regardless of lack of insurance or ability to pay.
A person requires E.R. services if he or she has signs or symptoms that a reasonable non-medical person would consider an emergency. If the patient has severe pain, an injury, or a sudden illness that convinces him/her that their health is in serious jeopardy, they have the right to receive screening and stabilization emergency services whenever and wherever needed without prior authorization or financial penalty. The patient has the right to ask for a transfer to another institution, providing it is medically permissible, and the other facility will accept the transfer.
The Patient Self Determination Act requires that all hospitals receiving Medicare or Medicaid funding provide information to all adult patients upon admission about advanced directives and to ask whether they have an advanced directive.12 Patients should receive information regarding advanced directives if they do not present with this information at admission.
Advanced directives can limit life-prolonging measures when there is little or no chance of recovery. For example, advanced directives may enable patients to make their feelings known about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators respirators, and dialysis. Advanced directives can address pain relief, either asking for or refusing it.
Culture is the way of life of a group of people. It includes shared knowledge, beliefs, values, attitudes, rules of behavior, language, skills, and world view.2 Culture shapes human behavior because it is the foundation of conscious and unconscious beliefs about “the proper” way to live. Cultures change constantly. Different members of a society internalize and express different parts of their shared culture. Subcultures are also always present and can reflect differences by geographic region or other subgroups within a larger shared society. Religion, faith, and spirituality have significant cultural and spiritual roles in illness care.
The trendy phrase cultural competence is simply the ability to give healthcare in ways that are acceptable and useful to patients because it is acceptable in their cultural background and expectations.
The Joint Commission’s National Patient Safety Goals provide a clear map of which areas will be the target of interest and inspection during accreditation surveys or inquiries. Communication between health workers and accrediting bodies is meant to flow both ways. Should you have concerns about patient safety or quality of care, both Medicare and Joint Commission have avenues of communication open to hear your concerns.
All healthcare facilities should have policies and procedures that guide workers to follow the safety goals.
|Identify Patients Correctly|
|Improve Staff Communication|
|Use Medicines Safely|
|Use Alarms Safely|
|Identify Patient Safety Risks|
|Prevent Mistakes in Surgery|
All patients should be screened for abuse. Facilities and care organizations must have procedures for identifying, reporting, and treating victims of abuse. Patients have the right to expect access to protective services in the case of abuse.
Supervisory staff is trained in the assessment, action, and reporting of suspected abuse. If you have any concerns about abuse, report it to the person in charge. Do not question the patient or anyone with the patient about suspected abuse. Special training is needed to question about abuse without making the problem worse or upsetting the patient.
Many victims of abuse are seen in healthcare settings. Healthcare workers often fail to identify victims due to a lack of training on what to look for and how to ask about abuse. Opportunities for intervention are missed, and victims continue to suffer the adverse health consequences of physical and emotional abuse. For example, physically battered victims seek assistance in healthcare settings, often repeatedly.
Trained professionals must do screening for abuse. Screening usually occurs by the R.N. or physician’s assistant or doctor. Screening questions should always be asked in a private room, away from the suspected batterer, and preceded by assurances of all the confidentiality allowed by law. Healthcare workers should find ways to separate the patient from the suspected abuser since abusers often demand to accompany the potential abuse victim into the examining room.
Abuse can take many forms. It may include emotional abuse, economic abuse, sexual abuse, threats, using the threat of removing children, using privilege, intimidation, isolation, and other behaviors used to maintain fear, intimidation, and power. There are many theories as to why some people are abusers. However, the reason abusers use this behavior is that violence is an effective method for gaining and keeping control over another person.
Sexual abuse is unwanted sexual activity with perpetrators using force, making threats, or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear, or disbelief. Long-term symptoms include anxiety, fear, or post-traumatic stress disorder. While efforts to treat sex offenders remain unpromising, psychological interventions for survivors, especially group therapy, appear effective.
Psychological abuse occurs when a person tries to control information available to another person with the intent to manipulate that person’s sense of reality or their view of what is acceptable and unacceptable. Psychological abuse often contains strong, emotionally manipulative content and threats designed to force the victim to comply with the abuser’s wishes. It can include constant verbal abuse, harassment, excessive possessiveness, isolating the person from friends and family, deprivation of physical and economic resources, and destruction of personal property.
Physical abuse is physical force or violence that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint. It often begins with what is excused as trivial contact that escalates into more frequent and severe attacks.
Child abuse and neglect are at a minimum, any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; and an act or failure to act which presents an imminent risk of serious harm. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include acts of violence like striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. This abuse may not have been intended to hurt the child, but an injury may have resulted from over-discipline or physical punishment. Neglect is the failure to provide for the child’s basic needs.
Child abuse or neglect is defined by the child welfare branch of the U.S. Department of Health and Human Services (DHHS) as:
|Supervisory staff is trained in the assessment, action, and reporting of suspected abuse. If you have any concerns about abuse, report it to the person in charge.|
|The Federal Child Abuse Prevention and Treatment Act (CAPTA) requires each state to have provisions or procedures for requiring reports of known or suspected instances of child abuse and neglect. Mandatory reporters are people, including healthcare workers, who come in contact with children and have the ability to identify abuse.|
Any suspicion of abuse involving minors requires consideration of cultural values and standards of care as well as recognition that the failure to provide the necessities of life may be related to poverty.
Elder abuse can take many forms. It, too, may include physical, emotional, psychological, sexual abuse, neglect, abandonment, or financial and material exploitation. With the frail elderly, neglect is a major problem. Neglect is the refusal or failure to fulfill any part of a person’s obligations or duties to an older adult.
Sometimes patients need to be kept safe from their actions. While individuals are encouraged to exercise internal control, at times, there may be a need for external measures of restraint. The use of restraints has resulted in patient injury and death. It must be done carefully following specific instructions.
A licensed, independent practitioner must order the restraint or seclusion. The facility may authorize qualified staff members, usually registered nurses, to initiate the use of restraints when needed before an order is obtained. The independent practitioner must evaluate the need for restraint or seclusion and assess the patient within one hour.
Restraints must never be used for discipline or convenience. When a patient requires external restraint, it is important to protect that person’s safety, rights, comfort, and dignity.
Review the equipment, policies, and documentation tools for each facility where you work, as there may be some variation in both practice and definition of restraints. Restraint standards for medical/surgical purposes apply when the primary reason for use directly supports medical healing. Please note that slightly different standards are used for behavioral management, such as in a psychiatric setting and long term care.5
|According to The Joint Commission:|
Behavioral use of restraints is a last-used option and should be considered only when a patient is imminently at risk of harming themselves or others with their behaviors. Less intrusive methods of regaining safety must be attempted before restraint is applied.
Medication to control behavior should be used only as part of a therapeutic plan, after appropriate assessment by workers.
Chemical restraint is a term used to describe the use of medications for purposes unrelated to the patient’s medical condition. An example is the use of a sedating psychotropic drug to manage or control behavior.
It is the intended use of a device or method that classifies the device or method as a restraint. For instance, IV arm-boards, postural support devices, orthopedic appliances, protective devices like helmets, are not restraints when used to promote healing or protect an easily injured tissue or surgical site.
According to The Joint Commission: Technically, a bed enclosure or side rails are neither purely a restraint nor a form of seclusion.
A bed enclosure (e.g., net bed) and likewise a side rail could potentially restrict a patient’s freedom to leave the bed and, as such, would be restraint.
If a bed rail is used to help with moving in and out of bed, it is not a restraint. If the patient can release or remove the device, it would not be a restraint.
Restraints or seclusion are to be used as a last resort after alternatives have proven to be unsuccessful. Restraints should not cause harm or be used as a form of punishment. Examples of alternatives to restraints include, but are not limited to:
If lesser interventions are not successful, and you need to apply a physical restraint as a last resort, use the least-restrictive device possible. For example, a lap buddy is a soft vinyl device that attaches to the wheelchair rather than the patient. Although the patient can remove it when they are oriented, it serves as a reminder that he/she should not get up without assistance and protects if he/she becomes confused again. Another alternative is a geriatric chair set in a reclining position or with a lapboard. This is less restrictive than a safety belt or roll belt. A roll belt, in turn, is less restrictive than a vest restraint. Mitts are generally more suitable than wrist restraints because they are less restrictive and allow the patient to move their arms freely. Another option is elbow restraints that keep the arm straight but allow free arm movement.
The authorized staff member can discontinue restraints or seclusion as soon as the assessment reveals that restraints or seclusion are no longer necessary. The use of restraints for acute medical or surgical purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 24 hours. The use of restraints for behavioral healthcare purposes in long term care must be reviewed and renewed if needed by the licensed, independent practitioner at least every 30 days.
Procedures for checking and documenting while a patient is in restraints are rigorous. Each facility will have a restraint or seclusion documentation tool that must be completed, which must include the following:
Physical restraints should always be fastened for easy release in an emergent situation. The restraint should be attached to a fixed part of the furniture, like the bed frame. Fixing it to a movable part, like a side rail, could inadvertently tighten the restraint causing patient injury or loosen the restraint causing it to be ineffective.
A high falls risk is not an acceptable reason to use restraints. The following can reduce falls risk:
The risk of violence to healthcare workers is much higher than for all other private sector industries. Fifty percent of healthcare workers have been and will be victims of assault in the workplace.6 The circumstances of hospital violence differ from workplace violence in other settings such as banks, convenience stores, or taxicabs, where violence most often relates to robbery.
Violence in hospitals is usually an outpouring of emotion rather than an attempt at a material gain, with the violence toward others resulting from patients or their family members who feel frustrated, vulnerable, and out of control. Common risk factors for hospital violence include the following:
Violence may occur anywhere in a hospital, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Studies indicate that violence often takes place during times of high activity and interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, tobacco, or alcohol use. Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mental activity. Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signs that may lead to violence:
Also, it is important to note how your co-workers behave. If a co-worker’s attitude or behavior has changed for the worse, notify your manager. For example, slamming equipment around is red-flag behavior.
Learn from history. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for him/her. Let security know if you feel threatened or if you find or suspect that he is carrying a weapon. Notify the supervisor if you suspect a patient is going to be violent. Help relieve the patient’s tension and anxiety by keeping him informed about when he will be examined or treated and what is going on.
Be alert to your environment:
In the presence of a potentially violent person:
Sexual harassment is not acceptable and can lead to civil prosecution and disciplinary action up to termination. Sexual harassment includes unwelcome:
State laws and requirements control the mandate for training about the prevention of sexual harassment in the workplace. Be assured that training will be needed for ALL employees, on a frequency specific to your state laws. The U.S. Office of Civil Rights provides national oversite of sexual harassment policies and complaints, and they are proactive in exerting authority when incidents are reported.8
Sexual harassment becomes unlawful when it becomes a condition of employment, of advancement, unreasonably interferes with work performance, or creates an intimidating, hostile, or offensive work environment.
Work environments vary, and people have varying levels of sensitivity. The worker has a responsibility to inform the people involved that they must stop because he/she/they are offended or feels sexually harassed. If the behavior continues, report it to your supervisor or the human resources department. Do not mistakenly think it will go away on its own. Like a lingering foul stench, harassment requires positive action in order to have it cease.
For most health workers and virtually every organization in the health industry, the major regulatory authorities expecting targeted annual training are TJC, CMS, and OSHA. Let us look at training topics that focus on safety in the workplace from the perspective of those organizations’ expectations.
If you are injured or exposed to a dangerous substance on the job, stop what you are doing; report the injury or exposure to your supervisor; seek medical attention if needed; and complete an employee accident report.
Accident hazards such as wet floors, stairway obstructions, and faulty ladders make the environment of care dangerous, eliminate them. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Stairway hazards can be minimized by the use of the handrail on stairs, avoiding undue speed, and maintaining an unobstructed view of the stairs ahead, even if that means asking for help to manage a bulky load.
Ergonomics is a science that designs equipment and work tasks to fit the worker. The goal is to prevent worker injury. Back injury prevention, safe lifting, and safe movements all fall under the heading of ergonomics. If you have pain, tingling, or numbness associated with a specific activity, reevaluate how you are performing the task to ensure you are doing it correctly. Consult your supervisor or employee health provider to have an ergonomic evaluation of your work. There may be equipment and methods available to reduce the risk of injury.
Injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs are known as musculoskeletal disorders (MSD). Injuries can result from cumulative trauma and repetitive strain, where small injuries over time build up until one more injury triggers a debilitating MSD. The following tasks have a high risk of cumulative trauma and repetitive strain:
The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks that are biomechanically stressful. The secondary approach is to train workers on how to perform stressful tasks while minimizing the biomechanical forces on their backs and how to maintain flexibility and strengthen the back and abdominal muscles. To prevent back injury, workers should:
Back exercises can be used to strengthen the back muscles and help prevent back injuries. A physician, physical therapist, occupational therapist or athletic trainer should be consulted.
The benefit of using back belts is undetermined. The belt may lead to a false sense of security and a failure to use proper lifting techniques. This can lead to injuries. Patient transfers are particularly hazardous for healthcare workers. The following special points should be emphasized to prevent back injuries during transfers.
All healthcare facilities are needed to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Safety Data Sheet (SDS).
If no relevant information is found for any given subheading within one of the numbered sections, the SDS must indicate that no applicable information is available.
Chemicals may exert either acute or chronic effects on workers. The effects depend on the:
The new worldwide visual warning system is part of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS) and uses two sets of warning pictograms. One set is for the transporting of chemicals, and a second set for workplace use and storage.
|Health Hazard||Skull and Crossbones|
|Access the full list of new warning pictograms from OSHA here.|
Effects exerted by a substance may also be influenced by the presence of other chemicals and physical agents or by an individual’s use of tobacco, alcohol, or drugs. The exposure dose is the amount of a substance that enters the body during the period of exposure. The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals are rapidly metabolized, others are not and can be excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gases).
Toxic substances can enter the body through several routes, including intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures. Inhalation and skin exposure are the most likely. Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin. Exposure routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.
Not every toxic substance annual training requirement should be on your training list. You should not be handling asbestos, for instance. Someone in the hospital or at the care site does, however, as many of the buildings used for offices, clinics, and hospitals fall into the timeframe during which asbestos was used in flooring, ceiling products, building insulation, and a plethora of other practical products. Take the time to find out which specific substances are used and handled in your work setting, and whether you need any of the annual training about them.
Training on fire safety is not only needed by the major regulatory agencies; it is common sense. Any health worker who has lived through a fire in a care setting knows and most likely has night terrors about the complexity of moving ill patients out of harm’s way in an emergency.
For all of us, when you enter a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut off valves. One way to remember fire safety is the acronym, RACE.
Never hesitate to sound the alarm with any suspicion of fire, yet also never yell “fire!” Yelling “fire” creates panic. Instead, call out the facility’s verbal code for fire. Call the switchboard to report the fire and pull the fire alarm. When you call the switchboard, be sure to stay on the phone long enough to ensure they have received the correct information such, where you are!
If a fire is small and confined, you may be able to extinguish it. If a patient’s garments are on fire, wrap them tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug, or cut the electricity as soon as possible.
OSHA is very clear if you place hand-held portable fire extinguishers for staff to use in emergencies, you must train every staff annually how to use them. Portable fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source on which the material can be used. Class A puts out fires involving ordinary combustibles. Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher, remember PASS:
If a fire cannot be extinguished and smoke, fumes or flames threaten patient safety, you may need to evacuate. Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally for as long as you can. Then evaluate vertically down to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you and your patient trapped inside the elevator.
Healthcare units need to be separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. To confine a fire, close the doors, windows, and all vertical openings like the laundry chute. Stuff wet towels under doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually, facility policy designates someone in supervision to decide when to turn of oxygen supplies.
When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling and forms a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases.
Staff responsible for inspecting, maintain, or repair fixed fire extinguishing equipment such as sprinklers or fire hose reels must be trained annually about these essential safety items.
Katrina, Joplin Missouri, the Twin Towers: the list of disasters affecting hospitals and all of us in the health professions are limitless since emergencies come to us, either physically or by proxy, in the form of waves of injured.
Joint Commission asks for and requires annual training for emergency responses specific to healthcare facilities, including twice-yearly live emergency scenarios (e.g., bomb threat, hostage situation, facility fire, plane crash into the building, etc.).9 At least one of these annual training must involve the community around the organization, such as fire department, search, and rescue, police, etc. Be aware that TJC requires an assigned designee at these exercises to monitor performance and document deficiencies, with staff training following up to correct anything found lacking. Do not be tempted to take emergency response training lightly; not only will it be “graded” by regulatory agencies, but it could also very well save the lives of those precious to you.
Supervisors must know how to initiate the disaster plan and designate tasks to workers.
Each worker must be trained to:
Nearly every medical device possesses an audible or visual alarm these days, and the wild racket that is heard, and often ignored, in health settings is a cause of “alarm fatigue” to both the public and to regulatory agencies. Knowing when to set the alarm, how to set it, and how to respond to it promptly are all matters requiring proper training and accountability.11 Not all alarms can be turned off or reset by every worker. Look at the facility policy to determine what you can do.
As health systems move further into the age of electronic health records and systems, expect digital monitoring of essential medical equipment. In other words, should equipment alarms sound consistent without attention?
Under the current Center for Disease Control (CDC) handwashing guidelines, washing hands with soap and water are to be done whenever the hands are visibly dirty. If not visibly soiled, rubbing hands with an alcohol hand rub is the primary means of hand hygiene for routinely decontaminating the hands during routine patient care. Alcohol-based hand rubs increase compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. Hand hygiene is needed before:
Hand hygiene is also needed after:
Standard precautions are strategies for protecting healthcare workers from the occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to blood, all body fluids, secretions, and excretions except sweat regardless of whether they contain visible blood, non-intact skin, and mucous membranes. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.
The appropriate use of PPE is an important element of standard infection prevention precautions. Gloves provide a protective barrier between the patient and the healthcare worker and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.
Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare workers to protect against large-particle droplets during close patient contact. When tuberculosis is known or suspected, healthcare workers should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator, or a powered air-purifying respirator (PAPR).
Gowns are worn to prevent contamination of clothing and protect the healthcare worker’s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide additional protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission-based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.
Transmission based precautions and protective environment (P.E.) are terms used to describe protective measures that need to be employed for specific groups of patients. An older term for this was isolation. Patients requiring transmission-based precautions require a private room. Patients infected with the same organism can share a room; this is referred to as cohorting. The doctor and nurses collaborate on patient placement and isolation.
Contact precautions are used for patients with known or suspected infections, or who are colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact.
Contact precaution patients should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be in contact with the patient or environmental surfaces.
Airborne precautions are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done, and possibly infectious patients should be separated from others and asked to wear a surgical mask.
Airborne precautions require a specially ventilated room with at least six air changes per hour, negative air pressure relative to the hallway, and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. Health workers use an N-95 mask or a powered air-purifying respirator (PAPR) in airborne precaution settings.
Droplet precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures.
Droplet precautions require a private room, but no special ventilation is necessary, and the door may remain open. Masks should be donned upon entering the room and especially if working within three feet of the patient. The patient should be masked if transported.
Neutropenic precautions (aka., reverse isolation) are implemented to protect immunocompromised patients. Neutropenia is a condition that causes low neutrophils in the blood. Neutrophils are a type of white blood cell made in the bone marrow that aids the body in fighting infection.
Neutropenic precautions require a private room with positive air pressure relative to the air pressure in the hall. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the patient’s immunosuppression.
In healthcare, it is everyone’s responsibility to dispose of biohazardous material properly. One negligent act can result in a biohazardous exposure. Biohazard materials include blood and body fluids. If you are in doubt, use a biohazard container to dispose of the material. All biohazardous containers should be red and have the following biohazard symbol.
Image Source: www.cdc.gov/niosh
Biohazard sharps containers are to be red and come in varied sizes. Biohazardous sharps containers are made to store small glass objects and anything capable of piercing or puncturing the skin, whether it is contaminated or not. This includes sharps with protective devices like retractable sheaths.
Even if a sharp is not contaminated, if it is put in the regular garbage, someone may be stuck with that sharp and not know if it was contaminated or not. The common examples are needles, sutures, scalpels, disposable instruments, and lancets. Replace sharps containers when they are three-quarters full. Failure to do so may result in someone being contaminated because sharps are close to the top, or the closure device does not swing freely.
Biohazardous bags are red and are to be used for biohazardous material that is not sharp and may be contaminated with blood or body fluid. These bags are also used for the disposal of chemotherapy drugs and chemicals, even though they are not infectious.
General waste bags are used for general trash and some body fluids and equipment if there is no visible blood, urine, feces, disposable pads or chux, PPE, used gloves, respiratory care items, and suctions canisters. However, if in doubt, use a biohazardous bag.
Earl from housekeeping is tidying the hematology section of the clinical laboratory at the end of a bustling day. He notices fragments of glass tucked under the counter edge next to the microscopy station. Tsking gently, he carefully dons heavy gloves and disposes of the glass shards in the marked sharps container.
General cleaning done, he changes to vinyl gloves for better dexterity and grabs onto a partially filled general use garbage bag. As he bends his knees to lift, he feels a sharp pain in the palm of his gloved hand, supporting the bottom of the white plastic bag. Grimacing, he looks at his lacerated palm and the sharp jutting dagger of broken microscope slide poking through the thin material.
All sharps, not just needles, go into the designated red sharps container. Glass shards, metal fragments, empty vials, blood tubes, microscope slides, glass pipettes, everything that is sharp or can become sharp goes into the sharps box.
OSHA possesses a comprehensive bloodborne pathogen standard for workers in areas of risk, which, of course, includes healthcare, housekeeping, and emergency responders, to name a few. As a healthcare worker, be careful to take this topic seriously as some 295,000 hospital-based healthcare workers experience occupational, percutaneous injuries annually.9
The presence of an exposure control plan is essential in a healthcare setting, and as a healthcare worker, you must know your facility’s policies. The exposure control plan must describe how an employer will use a combination of engineering and work practice controls, ensure the use of personal protective clothing and equipment, provide training, medical surveillance, hepatitis B vaccinations, and signs/labels. Engineering controls are the primary means of eliminating or minimizing employee exposure and include the use of safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes. If a needlestick or exposure to blood occurs:
Please note that no scientific evidence has shown that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.
Notify your supervisor, who will initiate reports and treatment if needed.
A comprehensive exposure prevention plan and strategies play significant roles in decreasing the risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, yet they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare worker. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on several factors, including:
To be effective and reliable, the CDC and NIOSH have determined that respiratory protection programs must include at least the following elements:
Remember that latex is a high reactivity substance for some individuals, both staff and patients. If you use a latex product, on a patient allergic to latex, you could trigger a severe allergic reaction, including respiratory distress. Irritant reactions are the most common type of latex reaction. It is a non-allergenic condition due to latex gloves. The back of the hands may have a dry, itchy rash. Be discerning as irritant reactions may also have other causes, such as irritation from soaps or detergents, other chemicals, or incomplete hand drying.
A wide variety of products contain latex: medical supplies, personal protective equipment, and numerous household objects. Most people who encounter latex products only through general home use have no health problems from the use of these products.
Latex allergy should be identified during the initial assessment of allergies. When a latex-sensitive patient is admitted, follow the facility policy. This usually involves extra signage, asking for non-latex equipment, and perhaps even moving to a private room.
Workers should take the following steps to protect themselves from latex exposure and allergy in the workplace:
If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other latex-containing products until you can see a physician experienced in treating latex allergy. Notify your supervisor so reports and treatment can be initiated.
A major hazard in all hospitals is the widespread use and storage of hazardous, flammable, and combustible liquids and gases. Many liquids have vapors that are flammable or combustible and can be ignited by a spark from a motor, friction, or static electricity. Handling and storage directions must be followed and are located on the SDS for that material. All flammable liquids should have the following label(s).
Harmful / Irritant
Access the full list of new warning pictograms from OSHA here.
OSHA HCS HazCom 2012 Final Rule
Compressed gases are under pressure and flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. Storage areas for compressed gas cylinders should be well ventilated, fireproof, and dry. Cylinders should not be stored near steam pipes, hot water pipes, boilers, highly flammable solvents, combustible wastes, unprotected electrical connections, open flames, or other potential sources of heat or ignition. Cylinders should be labeled appropriately. The valve protection cap should not be removed until the cylinder is secured and ready for use.
Compressed gases used in hospitals include acetylene, ammonia, anesthetic gases, argon, chlorine, ethylene oxide, helium, hydrogen, methyl chloride, nitrogen, and sulfur dioxide. Acetylene, ethylene oxide, methyl chloride, and hydrogen are flammable, as are the anesthetic agents’ cyclopropane, diethyl ether, ethyl chloride, and ethylene. Although oxygen and nitrous oxide are labeled as non-flammable, they are oxidizing gases that will aid combustion.
Health workers need to pay special attention to electrical hazards because they work with tools comprised of electrical circuits. Encountering an electrical voltage can cause current to flow through the body, resulting in electrical shock and burns. Serious injury or even death may occur.
All equipment brought into a facility must be safety checked by the engineering department. Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires. Equipment and appliances that are frequently ungrounded or incorrectly grounded include:
The public sleeps better at night, knowing that healthcare has regulatory guardians assuring quality is being given to them, the patient.
While each one of us in the health professions works to give the best care possible, we sometimes get distracted. It is good that we have authorities, regulatory agencies, and accreditation organizations looking on from outside the fuss and flurry. They help us stay on the path of evidence-based care and give guidance when we stray.
Annual required training, not from our employer, but organizations with a more global viewpoint, aid us in keeping a solid foundation in our practice of quality patient care.
Required annual mandated training changes frequently, so each of us must stay current with what areas are the focus of state, federal, and independent organizations to which we owe diligence. This year’s topics may differ to a small degree from the previous year, or by a great extent. Whichever it may be, we know that proof of training will be needed on inspection, accreditation visit, or in our employer’s annual evaluation of our performance and readiness.