Annual Review Topics for CNAs and HHAs

Patients have the right to get accurate information that they can understand about their health, treatments, health plans, healthcare providers, and healthcare facilities. If the patient speaks another language, has a physical or mental disability, or does not understand something, the patient will be helped to make informed healthcare decisions.

A patient who has severe pain, an injury, or a sudden illness and is concerned they could be seriously ill or hurt or die has 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 Emergency Medical Treatment and Labor Act (EMTALA) defines the right to care. It ensures the public has access to emergency services regardless of lack of insurance or ability to pay. A person requires emergency services if they have signs or symptoms that a reasonable non-medical person would consider an emergency. Suppose the patient has severe pain, an injury, or a sudden illness that convinces them that their health is in serious jeopardy. In that case, 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 request a transfer to another institution, provided it is medically permissible and the other facility will accept the transfer.

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 the patient chooses can represent the patient if they 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. Respect means valuing the patients’ needs, desires, feelings, and ideas while treating them with common courtesy.

The patient has the right to talk privately with health care providers and have their health care information protected. The patient also has the right to review and copy their medical records and ask their doctor to correct them if they are inaccurate, incomplete, or contain 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 healthcare. Every patient has the right to a fair, fast, and objective review of any complaint about the health plan, doctors, hospital, or other healthcare personnel. This includes complaints about waiting times, operating hours, healthcare personnel's conduct, and healthcare facilities' adequacy. 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 correct 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, which is a formal written or verbal complaint. If a patient wants to file a grievance, notify the person in charge. That person must 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.

Information about both patients and staff must be kept secure and confidential. Any staff member working with patient information must know how to maintain and secure protected information. HIPAA is a federal regulation that addresses the legislation's privacy, confidentiality, and security aspects.

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 to be shared with people 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 their 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:

• The individual’s past, present, or future physical or mental health or condition
• The provision of health care to the individual
• The past, present, or future payment for the provision of health care to the individual

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 enough information should be provided to provide treatment and protect the victim. A summary of the information could be provided to legal and law enforcement entities.

Health workers directly involved in treating patients are not subject to the minimum necessary rule. They can have full access to all information needed to provide care, including health information that has implications for public health and safety.

There are a few situations where medical information can be shared:

• Emergency 911 situations
• When communicable diseases are involved
• When law enforcement agencies participate
• If national defense or security is a factor

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:

• The right to privacy notice requires disclosure and reasonable effort to ensure that the patient understands the agency’s policy about the privacy of information.
• Right to ask for restrictions - patients may specify health information that cannot be released and may restrict to whom information can be released.
• Right to access personal health information - patients must be allowed to inspect and copy the information contained in the agency’s record.
• Right to know what disclosures have been made - the agency must track all information released and be able to provide documentation to the patient.
• Right to amend the personal health information while the patients may ask for amendments, and the agency must allow for amendments; the agency can also deny some requests.

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 is shared, either by accident or with purpose, must immediately be reported using the facility's established procedures.

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. 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 express their feelings about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators, respirators, and dialysis. They can also address pain relief by 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 worldview. 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 patients acceptable healthcare in acceptable and valuable ways because it is acceptable to their cultural background and expectations.

All patients should be screened for abuse. Facilities and care organizations must have procedures for identifying, reporting, and treating abuse victims. Patients have the right to expect access to protective services in the case of abuse.

Supervisory staff is trained to assess, act on, and report suspected abuse. If you have any concerns about abuse, report them to the person in charge. Do not question the patient or anyone with the patient about suspected abuse. Special training is needed to question 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, 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 unable to 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 using 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 any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm.

Supervisory staff are trained in assessing, acting, and reporting 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 can 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 refusing or failing 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 restraint or seclusion. Before an order is obtained, the facility may authorize qualified staff members, usually registered nurses, to initiate using restraints when needed. 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, protecting that person’s safety, rights, comfort, and dignity is important.

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.

Medical vs. Behavioral Restraint Use. The decision to use restraints for medical/surgical reasons or behavioral health care reasons is not based on the treatment setting. Still, restraint is being used to address the situation. The simplest way to determine what a behavioral health reason is is first to determine what it is not. When restraints must be applied to support medical healing directly, this is not a behavioral health reason.

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 using medications for purposes unrelated to the patient’s medical condition. An example is using 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, and protective devices like helmets are not restraints when used to promote healing or protect an easily injured tissue or surgical site.

A bed enclosure or side rails are not always a restraint nor a form of seclusion. A bed enclosure (e.g., net bed) or a side rail could potentially restrict a patient’s freedom to leave the bed and would be a restraint. A bed rail is not a restraint if it is used to help move in and out of bed. It would not be a restraint if the patient could release or remove the device.

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:

• Interaction on 1:1 basis with staff
• Redirection
• PRN medication with patient consent
• Staff or patient-initiated time out in a quiet room with an unlocked door. It should be presented as a way for a patient to regain control, not as a threat
• Staff presentation of limits where consequences are presented for the patient to choose
• Remove stimuli from the patient or vice versa. Keep in mind that moving a patient close to a busy nurses’ station so you can keep a close eye on them could over-stimulate and worsen symptoms
• Relaxation exercises
• Calming music

If lesser interventions are unsuccessful, and you need to apply 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 they should not get up without assistance and protects them if they become confused again. Another alternative is a senior 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 when the assessment reveals that they are no longer necessary. 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:

• Assessment of patients in restraints in an acute care setting or long-term care setting:
  • The patient is to be checked at least hourly
  • Restraints removed to allow movement at least every 2 hours
  • Assess, turn, reposition, range of motion exercises, offer nourishment and fluids, and toilet the patient at least every 2 hours
• Psychiatric setting assessment of patients in restraints or seclusion:
  • Continuous observation is needed
  • Vital Signs every hour
  • Ongoing assessment of airway and respiratory status
  • Assess hydration and offer fluids at least every two hours
  • Toileting offered every two hours
  • Nutrition at mealtimes as safety permits
  • Assess circulation and range of motion every fifteen minutes
  • Check for injury associated with the application of restraint or seclusion
  • Assess psychological status, including readiness for discontinuation of restraint or seclusion
  • Documentation of all activities

Physical restraints should be fastened for easy release in an emergency. They 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 loosening it, making it ineffective.

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 using 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 perform the task to ensure you do it correctly. Consult your supervisor or employee health provider for an ergonomic evaluation of your work. There may be equipment and methods available to reduce the risk of injury.

OSHA ergonomic-focused rules apply to all general industries, including workers involved with healthcare. Training should be done when first hired to avoid ergonomic injury. Injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs are known as musculoskeletal disorders (MSDs). 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:

• Repetitive activity (typing)
• Contact stress (hammering)
• Twisting while lifting or carrying
• Pulling or dragging
• Sitting or standing in one position for a long time
• Reaching above your shoulder
• Lifting
• While stooping low
• Heavy objects
• Unwieldy objects
• An object that is positioned far from your body
• Frequent lifting without rest between lifts

The main way to avoid back injury is by reducing manual lifting and other stressful load-handling tasks. 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:

• Use tools to avoid lifting when possible:
  • Lifting devices
  • Slide boards
  • Shower chairs
  • Gait belts
• Use proper lifting techniques:
  • Keep your back in its normal upright position when lifting
  • Keep your head and shoulders up, and tighten your abdominal muscles when lifting
  • Bend at the knees, not at the waist
  • Get a good grip and slightly bend your elbows
  • Lift with your legs in a smooth, even motion, not with your back
  • Bear the weight with your arms and legs, not your back
  • Bear the weight as close to your body as possible
  • Pivot on your feet to change direction; do not twist
• Lower an object by widening your stance and bending your knees
• Do not reach higher than your shoulders to lift
• Limit the number of lifts per day
• Ask for help. When in doubt about whether a task may strain the back, a worker should ask for help rather than take a chance

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 unknown. The belt may lead to a false sense of security, which can lead to a failure to use proper lifting techniques and injuries. Patient transfers are particularly hazardous for healthcare workers. The following special points should be emphasized to prevent back injuries during transfers.

• Obtain lifting equipment as applicable.
• Do not do a manual transfer alone.
• Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles.
• Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves.
• Use a wide, balanced stance.
• Ensure good footing for the patient if applicable (patients should wear slippers that provide good traction).
• Maintain eye contact and communication with the patient. Be alert for trouble signs.
• Record any problems on the patient’s chart so that other workers will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift.

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 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 even moving to a private room.

Workers should take the following steps to protect themselves from latex exposure and allergy in the workplace. Use non-latex gloves for activities that are unlikely to involve contact with infectious materials, such as food preparation, routine housekeeping, and maintenance. If you choose latex gloves, use powder-free gloves with reduced protein content. So-called hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and maintain glove barrier protection. After removing latex gloves, wash your hands with mild soap and dry them thoroughly. Use good housekeeping practices to remove latex-containing dust from the workplace. Learn to recognize the symptoms of latex allergy: skin rashes, hives, flushing, itching, nasal, eye, or sinus symptoms, asthma, and shock.

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.

All healthcare facilities need detailed information about the chemicals at the worksite, which 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.

1. Product Identification
2. Hazard(s) identification
3. Composition/ information on ingredients
4. First-aid measures
5. Fire-fighting measures
6. Accidental release measures
7. Handling and storage
8. Exposure controls/personal protection
9. Physical and chemical properties
10. Stability and reactivity
11. Toxicological information
12. Ecological impact information (Non-mandatory)
13. Disposal considerations (Non-mandatory)
14. Transport information (Non-mandatory)
15. Regulatory information (Non-mandatory)
16. Other information, including date of preparation or last revision of the SDS or the last change to it

Chemicals may exert either acute or chronic effects on workers. The effects depend on the following:

• Extent (concentration and duration) of exposure
• Route of exposure
• Physical and chemical properties of the substance

The worldwide visual warning system is part of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS). It uses two sets of warning pictograms: one for chemical transport and a second for workplace use and storage.

Image 1: Health Hazard Symbol

• Carcinogen
• Mutagenicity
• Reproductive Toxicity
• Respiratory Sensitizer
• Target Organ Toxicity
• Aspiration Toxicity

Image 2: Skull and Crossbones Symbol

• Acute Toxicity (Fatal or Toxic)

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 should be on your training list. You should not be handling asbestos, for instance. However, someone in the hospital or at the care site does, 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 many 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.

A major hazard in all hospitals is the widespread use and storage of hazardous, flammable, and combustible liquids and gases. Many liquids have flammable or combustible vapors 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).

Image 3: Flammable Symbol

Image 4: Explosive Symbol

Image 5: Compressed Gas Symbol

Image 6: Harmful Symbol

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. Severe 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:

• Three-wire plugs attached to two-wire cords
• Grounding prongs that are bent or cut off
• Ungrounded appliances resting on metal surfaces
• Extension cords with improper grounding
• Cords molded to plugs that are not properly wired
• Ungrounded, multiple-plug spiders that are often found in office areas and at nurses’ stations
• Personal electrical appliances brought by the workers from home (radios, coffeepots, fans, electric heaters) that are not grounded, have frayed cords, poor insulation, or are otherwise in poor repair

The primary sources of radiation exposure in a healthcare facility are X-rays and radionuclides used in diagnostic tests and therapy. Areas where radiation is used are marked with the international tri-foil symbol.

Image 7: Ionizing Radiation Symbol

Image 8: Non-Ionizing Radiation Symbol

Ionizing Radiation is concentrated energy waves that destabilize atoms, such as those used in X-rays, tomography, angioplasty, fluoroscopy, and nuclear medicine. It poses a risk of tissue damage and other health risks, and damage can accrue with repeated exposures.

A high fall risk is not an acceptable reason to use restraints. The following can reduce fall risk:

• Check the patient at least every hour.
• Remind the patient to call for assistance if they want to visit the bathroom.
• Use low beds or put the mattress on the floor for high-risk patients who will not call for assistance to get up.
• Arrange furniture so that it does not block the walkways.
• Use a nightlight and keep debris and liquids off the floor.
• Keep the patient’s items, water pitcher, and call light within reach always.
• Make sure the patient wears eyeglasses, hearing aids, or other assistive devices.
• Ask family or friends to stay with them at night or at other times when they try to climb out of bed.

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. 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 material gain, with 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:

• Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
• Working when understaffed-especially during mealtimes and visiting hours
• Transporting patients
• Long waits for service
• Overcrowded, uncomfortable waiting rooms
• Working alone
• Poor environmental design
• Inadequate security
• Lack of staff training and policies for preventing and managing crises with potentially volatile patients
• Drug and alcohol abuse
• Access to firearms
• Unrestricted movement of the public
• Poorly lit corridors, rooms, parking lots, and other areas

Violence may occur anywhere in a hospital but 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 patients with normal mental activity. Neurologic conditions, seizures, hypoglycemia, or dementia may cause confusion and impaired judgment. Watch for signs that may lead to violence:

• Verbally expressed anger and frustration
• Body language, such as threatening gestures
• Signs of drug or alcohol use

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 them. 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 informing him about when he will be examined or treated and what is happening.

Be alert to your environment. Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor. Be vigilant throughout the encounter. Do not isolate yourself from a potentially violent person. Plan your exit. Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door. When you are with an upset patient or co-worker, avoid room areas without an accessible exit. If you are going to an isolated part of your facility, let others know where you are going and when you expect to return. Consider asking for an escort. Note anyone not wearing staff ID and lingering where they should not be. Politely ask if you can help them and notify security if you are not satisfied with the answer. Call security and provide a full description if you would rather not approach someone. Evaluate how you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or I.D. badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an I.D. badge necklace with a breakaway feature. If you wear a necktie, opt for a clip-on style. If your hair is long, wear it in a way that is not easy to pull, and do not wear dangling jewelry.

In the presence of a potentially violent person, plan a clear exit route. Keep 5 to 7 feet between you and him. Never turn your back on him or let him get between you and the exit. Keep your voice calm and quiet. Acknowledge that he has a right to his feelings. Assume that he has a valid concern and address it. Try to meet reasonable demands. Offer alternatives when possible. For example, tell an angry patient that although he cannot order take-out pizza, you will see if you can get him an early dinner. Tell an angry colleague that you see her anger and would like to work with her and your manager to resolve the situation. Call for backup or security if a situation grows increasingly tense. Ensure access to bathrooms, a phone, a T.V., and something to read. Track equipment and return it to its rightful place. When you take an item into a patient’s room, dispose of it properly or take it with you when you leave. Take these steps if you cannot defuse the situation quickly:

• Remove yourself from the situation.
• Call security for help.
• Report any violent incidents to your management.

Do not ignore the agitated person or avoid him. Do not threaten or demand obedience. Do not argue or become defensive or judgmental. Do not laugh, move suddenly, make threatening gestures, or invade his personal space. Do not try to handle a dangerous situation alone. Call security or initiate your facility’s violence prevention protocol. In the presence of a weapon, maintain behavior that helps diffuse anger:

• Present a calm, caring attitude.
• Do not match the threats.
• Do not give orders.
• Acknowledge the person’s feelings (for example, “I know you are frustrated”).
• Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly).

Sexual harassment is unacceptable and can lead to civil prosecution and disciplinary action up to termination. Sexual harassment includes unwelcome:

• Sexual advances
• Asks for sexual favors
• Verbal, visual, or physical behavior of a sexual nature

State laws and requirements control the mandate for training about preventing sexual harassment in the workplace. Be assured that training will be needed for ALL employees at a frequency specific to your state laws. The U.S. Office of Civil Rights provides national oversight of sexual harassment policies and complaints, and it is proactive in exerting authority when incidents are reported.

Sexual harassment becomes unlawful when it becomes a condition of employment or 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 is responsible for informing the people involved that they must stop because he/she/they are offended or 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 to have it cease.

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 regulatory agencies. Knowing when to set the alarm, how to set it, and how to respond promptly requires proper training and accountability. (Occupational Safety and Health Administration [OSHA], n.d.) 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?

Training about 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 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.

• R: Rescue
• A: Alarm
• C: Contain the fire (if possible)
• E: Extinguish or evacuate

Never hesitate to sound the alarm with any suspicion of fire, and 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, stay on the phone long enough to ensure they have received the correct information, such as 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 clear if you place hand-held portable fire extinguishers for staff to use in emergencies, you must train every staff member annually on 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:

• Pull the pin
• Aim the nozzle at the base of the fire
• Squeeze the trigger while making
• Sweeping strokes with the extinguisher plume

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 the doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually, facility policy designates someone under supervision to decide when to turn off oxygen supplies. When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling, forming a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases.

Staff responsible for inspecting, maintaining, or repairing fixed fire extinguishing equipment such as sprinklers or fire hose reels must be trained annually about these essential safety items.

Under the current Centers for Disease Control (CDC) handwashing guidelines, washing hands with soap and water is 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:

• Patient contact
• Donning gloves when inserting a central venous catheter (CVC)
• Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery

Hand hygiene is also needed after:

• Contact with a patient’s intact skin
• Contact with body fluids or excretions, non-intact skin, or dressing of a wound
• After removing gloves

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 when splashes or sprays are likely. Healthcare workers wear surgical masks 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 clothing contamination and protect the healthcare worker’s skin from exposure to blood and body fluids. 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, 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 transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. They 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 made, and 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.

• These masks and respirators should be labeled and stored in a paper bag between uses.
• These masks and respirators should be discarded if they are soiled or no longer maintain their structural or functional integrity.
• The N-95 mask should also be discarded at the end of each work shift.
• The disposable respirator should be discarded at the end of 2 weeks.
• Each employee who may work in an airborne precautions setting must be fit tested to ensure that the N-95 mask or PAPR fits the employee’s face so that droplet nuclei cannot get in gaps between the mask and the face. Be aware employees with beards will not pass fit testing.
• When a patient in airborne precautions needs to be moved or transported, they should wear a surgical mask from when they leave the isolation room until they return.

Droplet precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performing 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, especially if working within three feet of the patient. The patient should be masked if transported.

Neutropenic precautions (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 traffic limitations to extensive precautions using gloves, gowns, and masks. The reason for the precautions and the degree of the patient’s immunosuppression varies.

In healthcare, everyone is responsible for properly disposing of biohazardous material. One negligent act can result in 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 9: Biohazard Symbol

Biohazard sharps containers are red and come in varied sizes. They 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 object is not contaminated, if it is put in regular garbage, someone may be stuck with that sharp object and not know if it was contaminated. 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 to dispose of chemotherapy drugs and chemicals, even though they are not infectious.

Image 10: Biohazard Sharps Container

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 suction canisters. However, if in doubt, use a biohazardous bag.

OSHA has a comprehensive bloodborne pathogen standard for workers in areas of risk, including healthcare, housekeeping, and emergency responders. As a healthcare worker, you should take this topic seriously, as some 295,000 hospital-based healthcare workers experience occupational, percutaneous injuries annually.

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 personal protective clothing and equipment use, and provide training, medical surveillance, hepatitis B vaccinations, and signs/labels. Engineering controls are the primary means of eliminating or minimizing employee exposure, and safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes, are used. If a needle stick or exposure to blood occurs:

• Provide immediate care to the exposure site
• Wash wounds and skin with soap and water
• Flush mucous membranes with water
• Irrigate eyes with clean water, saline, or sterile wash

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 significantly decrease the risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, yet they are real. Understanding how exposure occurs and the risk 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:

• Type of body substance involved
• Route of exposure
• Volume of blood or body fluid involved
• Severity of exposure
• Pathogen suspected
• Degree of viremia (e.g., viral count or quantity of virus in the blood)
• Immune status of the healthcare worker at the time of exposure
• Whether appropriate post-exposure prophylaxis (PEP) was used

To be effective and reliable, the CDC and NIOSH have determined that respiratory protection programs must include at least the following elements:

• Assignment of responsibility to one person with enough knowledge who is given the authority and responsibility to manage all aspects of the program
• Standard operating procedures that include information and guidance for the proper selection, use, and care of respirators
• Screening by a physician or other licensed healthcare worker of all healthcare workers (HCWs) who might need to use a respirator for pertinent medical conditions at the time they are hired, and then re-screening periodically
• Annual training of HCWs with a specific focus on prevention, transmission, and symptoms
• Selection of filtering facepiece respirators approved by CDC/NIOSH
• Fit testing performed during the initial respiratory protection program training and periodically after that, per federal, state, and local regulations
• Inspection and maintenance of respirators according to manufacturer instructions
• Evaluation of the respirator program periodically to ensure its continued effectiveness