Planning for the Ultimate Risk

In 1979 the United States became seri-ously aware of the dangers of nuclearenergy when the Three Mile Island

Nuclear Generating Station inPennsylvania experienced a core meltdownthat released radioactive gases into the air.Awareness was further heightened in1986, after the debacle at the ChernobylNuclear Power Plant in Ukraine, when thetesting of a potential safety feature resultedin explosions in one of the cores and therelease of radioactive material. And nowthis year at the Fukushima I NuclearPower Plant in Japan, a magnitude 9.0earthquake created a tsunami that led toflooding and loss of electrical power,which resulted in partial core meltdowns

and hydrogen explosions, releasing radio-logical material into the environment.These catastrophes highlight one ofhumanity’s greatest fears: a nuclear disasterthat maims, kills, and poisons the air,water, and land for decades to come—threatening the well-being of the regionand even the world.

“Although events such as these arresteveryone’s attention, there’s a whole spec-trum of radiological events,” says JohnHick, M.D., medical director for emer-gency preparedness, Hennepin CountyMedical Center, Minnesota. “Hospitalsshould understand that their radiation disaster planning must account for all

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Contents

1 PLANNING FOR THE ULTIMATERISK—Emergency Preparedness fora Nuclear Disaster

4 Case Study: FOR INFANT EARSONLY—Tri-City Medical CenterDiminishes Decibels in the NICU

6 WHAT’S THE SCORE?—WeissMemorial Hospital Creates a Tool toQuantify Performance DuringEmergency Management Drills

8 THIS PATIENT ROOM LOOKSCLEAN, BUT IS IT?—Options forEvaluating Environmental Cleaning

Visit the EC News blog at http://www.jcrinc.com/Blogs-All-By-Category/EC-News-Blog

Planning for the Ultimate RiskEmergency Preparedness for a Nuclear Disaster

Hospitals should be ready for radiation disasters of all types.

Continued on page 2

Environment of Care News

scenarios that might affect their area andfor a range of casualty numbers,” contin-ues Hick, who is also assistant medicaldirector for emergency medical services.“They need to coordinate their planningwith local, state, and federal governments.”

Hick describes three possible eventsalong the nuclear disaster continuum:■ A radiation emergency at a nuclear

power plant, including problems withthe reactor core or stored materials,with release of radiologic isotopes intothe ground, air, and/or water

■ Detonation of a nuclear dispersiondevice, such as a “dirty bomb” set offby terrorists. A dirty bomb involvesconventional explosives laced withnuclear material, and explosion of sucha device results in low levels of radia-tion release.

■ Detonation of an improvised nucleardevice, which is a weapon that gener-ates a nuclear explosion and potentiallydevastating consequences with veryhigh radiation levels

Any radiation emergency would likelyoccur without warning, signaled after theincident by announcements on radio, tele-vision, the Web, and other media. Thearea’s medical centers would need to acti-vate their emergency plans immediatelybecause a surge of patients would proba-bly rush to the hospital within minutes tohours for treatment and/or screening.Significant confusion about the presence,type, and effects of radioisotopes is proba-ble during the hours after an incident.

Responding to a NuclearEvent

How should a health care organiza-tion plan to respond to a nuclear incident?Regardless of the type of incident, anorganization would need to take the fol-lowing steps in response:

1. Perform triage2. Treat the seriously injured while con-

taining contamination and isolatingsome patients

3. Decontaminate patients4. Assess radiation exposure/effects,

including directed therapies, as neededOne Chicago-area medical center

recently practiced these steps in an emer-gency preparedness exercise. “We had adrill several years ago based on the sce-nario of a dirty bomb detonated by a ter-rorist,” says Robert Wagner, M.D.,F.A.C.N.M., F.A.C.R., professor of radiol-ogy and medical director of nuclear medi-cine, Loyola University Medical Center,Maywood, Illinois. Loyola planned theexercise with the idea that most of thepeople creating a surge would be “what wecall the worried well.” Wagner explainsthat these are people who fear they’ve beencontaminated by the radiation released inthe incident (see “Exposure vs.Contamination,” above). However, theymight not be contaminated—and more-over, they might not have any physicalinjuries. “It’s important to separate thosewho have no physical injuries from thosewho do,” says Wagner. “You certainlydon’t want the worried well to overwhelm

2 July 2011 http://www.jcrinc.com

Executive Editor: Kristine M. Miller, M.F.A.Senior Project Manager: Christine Wyllie, M.A.Manager: Lisa AbelExecutive Director: Catherine Chopp Hinckley, Ph.D.

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Planning for the Ultimate Risk(continued from page 1)

Exposure vs.Contamination

Humans in the developed world are

routinely exposed to small amounts

of radiation from the atmosphere and

during medical or dental procedures,

such as diagnostic X-rays.

Exposure, where no radioactive

material remains on or inside the

body, isn’t the same as contamina-tion. Radioactive contamination

refers to the presence of radioactive

material on or in a person’s body,

which may be hazardous to the per-

son, depending on the amount and

kind of radiation involved.

your ability to treat people with criticalinjuries from a blast, such as puncturewounds, lacerations, burns, or other trau-ma from an explosive device, complicatedby presence of radiation.”

Wagner recommends setting up atriage station at the hospital or at the siteof the incident. In the Loyola drill, triagewas conducted in a tent designed to beraised in just 15 minutes. Patients withserious injuries were sent to a designatedisolation section of the emergency depart-ment (ED), while patients without physical injuries were assessed—and, ifnecessary, decontaminated—in the tent.

If an organization doesn’t have atent for the worried well, it should desig-nate “a place such as a gym, a largemeeting room, or another shelter thatwill hold between 10 and 100 people,”says Wagner. While these people arewaiting to be assessed for contamination,Wagner advises that they not be allowedto eat, drink, or smoke. “If people arecontaminated, these activities wouldconvert external contamination to inter-nal contamination. External contamina-tion can generally be washed off, butinternal contamination can do seriousharm to bodily systems,” he explains.

The worried well can be assessedfor contamination using a surveymeter—a handheld radiation detector,or Geiger counter—unless there are toomany of them. “In mass casualty situa-tions, you can’t use a survey meter toexamine patients one at a time,” saysLawrence H. Flesh, M.D., F.A.C.P.E.,F.A.C.H.E., chief medical officer, VAHealthcare Network, Upstate NewYork. “What you need is a portal mon-itor. Just as its name implies, it’s adoorway with a monitor. As patientswalk through this doorway at thedecontamination center, the monitortells who is and isn’t contaminated,”

says Flesh, who lectures around thecountry on acute radiation syndrome.

Wagner suggests that organizationsconsider using medical students to helpwith the worried well. “Medical studentsare valuable members of the medicalteam,” he says. “They’re familiar with thebasics of medicine, and they know how togather information and take samples.”Once it’s determined that a patient doesnot have large amounts of contamination,medical students can be instructed in howto take patient names and contact infor-mation, and obtain samples. “The medicalstudents can have patients wipe theirhands with alcohol swabs, take oral andnasal samples, and put those samples intored-top tubes labeled with the patients’information,” says Wagner. These samplescan later be assessed for the presence ofradioactivity.

Staff protection is essential. Staffmembers who routinely work with nuclearmedicine and may be called on to treatpatients who might be contaminated usu-ally rely on a film badge dosimeter, whichmeasures how much radiation the employ-ee has been exposed to over time.However, for emergency situations, hospi-tals may wish to have on hand a limitednumber of real-time dosimeters, such aspen or digital display dosimeters, whichprovide better information about the actu-al exposure rate.

DecontaminationWhen patients are contaminated with

radiological material, they must be decon-taminated. “The hospital should have adesignated decontamination facilityequipped with warm showers,” saysWagner. “When people who are contami-nated remove their clothing, you often getrid of 95 percent of the contamination.”

If there is local contamination on thehands, face, or feet, only those areas needto be cleaned. “If large areas of contamina-

Environment of Care Newshttp://www.jcrinc.com 3July 2011

Continued on page 10

External ExpertiseOak Ridge Institute for Science and Education (ORISE) in Oak Ridge, Tennessee,

is sponsored by the U.S. Department of Energy and offers training, preparedness,

and emergency assistance; it’s also called REACTS (Radiation Emergency

Assistance Center/Training Site). For information, go to http://orise.orau.gov/

health-communication-technical-training/default.aspx.

The following sites also provide information and planning help:

■ The U.S. Department of Health and Human Services Radiation Emergency

Medical Management Web page for health care providers offers information

about patient assessment, decontamination, and incident response:

http://www.remm.nlm.gov

■ The Armed Forces Radiobiology Research Institute Web page provides a wealth

of information on planning and management: http://www.usuhs.mil/afrri

■ The Centers for Disease Control and Prevention Radiation Emergencies Web

page has useful reference and training information for hospitals and health care

providers: http://emergency.cdc.gov/radiation

Life-threateninginjuries must be

treated before theradiation contamina-

tion is dealt with.

—Lawrence H. Flesh, M.D.,

F.A.C.P.E., F.A.C.H.E.,

VA Healthcare Network

Upstate New York

Environment of Care News4 July 2011 http://www.jcrinc.com

Noise. The word evokes images ofconstruction sites, jets take-offs,traffic jams, and rock concerts.

But what about actions like closingdoors, setting down baby bottles, andconversing with a colleague? Can thesounds created by these actions also beconsidered noise? Absolutely. To a new-born in a neonatal intensive care unit(NICU), whose bed is a hard plastic isolette, sounds such as these can rever-berate and create a loud and uncomfort-able environment. Noise levels can havea negative impact on an infant patient’scomfort level and influence his or hersafety and outcomes, in addition toaffecting the satisfaction of the infant’sfamily, staff, and others.1 Because of this,Joint Commission–accredited organiza-tions are required to meet the needs oftheir patient population and make sure

that interior spaces are safe and suitableto the care, treatment, and services pro-vided (Standard EC.02.06.01, Elementof Performance 1).1

The NICU at Tri-City MedicalCenter, Oceanside, California, is madeup of four pods, each holding up to asmany as five isolettes at a time. In 2010,the NICU was functioning at an averagedaily sound level of 62 dB, according toSusan M. Bowles, M.S.N., RNC-NIC,CNS, clinical nurse specialist for theNICU at Tri-City Medical Center.However, current guidelines recommendan average hourly level less than 45 dB,2,3 where 10% should be at a levelof 50 dB or less, and transient noise lev-els should not exceed 65 dB.2 Noise cre-ated by conversing practitioners, staff,parents, and visitors, and noise createdby closing portholes, placing bottles onisolettes, closing cabinet doors, andbeeping alarms and monitors con-tributed to a noisy environment. Inorder to promote a healthier environ-ment of care for neonate patients in theNICU, the organization needed to findsimple solutions to reduce NICU noisewhile “working with the constraints ofan older building and limited budget,”says Bowles.

Guidelines for MinimizingNoise in the NICU

Although Tri-City Medical Centerhad policies to minimize noise throughoutthe hospital, it needed to find ways tomeet the unique situation of the NICUenvironment. Since the budget did notallow for either new equipment or a newbuilding, the organization had to modifythe existing guidelines. After reviewingevidence-based literature and learningwhat other organizations had done toreduce noise, Bowles began adapting exist-ing models to suit the Tri-City MedicalCenter NICU. She developed a set ofnoise-reduction guidelines for both staffand visitors to the NICU. By followingthese simple guidelines, the noise level inthe NICU was reduced from 62 dB to 54 dB between October 2010 andFebruary 2011. Although the noise level isstill above the recommended 45 dB, the 8 dB reduction is a significant improve-ment for the unit.

In order to provide protected sleep forbabies, the first implemented guidelinewas “Quiet Time.” During this time, staffand visitors are asked to speak softly, limitactions when near an isolette, reduce foottraffic, and refrain from performing elec-tive procedures. Quiet Time is in effect

For Infant Ears OnlyTri-City Medical Center Diminishes Decibels in the NICU

The Sound Ear is a visual reminder to staffand patients’ families to keep noise levels toa minimum.Source: Tri-City Medical Center. Used with

permission.

CASE STUDY

About Tri-City Medical Center and Its NICULocated in Oceanside, California, Tri-City Medical Center is a 397-bed, full-service

health care facility serving the San Diego area. Originally built in the early 1960s,

Tri-City Medical Center was expanded in the 1970s; the neonatal intensive care

unit (NICU) opened in 1986.


two times per day (from 1 to 2 in themorning and afternoon) and is signaled byturning down the lights. Other guidelinesthat were implemented include the follow-ing: using a “library” voice at all times,taking care of a crying baby or monitorbell within 30 seconds, and asking visitors(excluding parents) to visit at other timesso babies are able to sleep.

Educating andMonitoring Staff

Staff education is a vital part of thenoises reduction effort and takes place inmany arenas, including during rounds, instaff meetings, and in individual educa-tion. Staff members are asked what they’dwant for their babies if they were in theNICU and are educated on the benefits ofa quiet environment for patients, theirfamilies, and staff. Staff are also educatedon the sources and impact of noise in theNICU and methods for reducing oravoiding noise. They’re informed of factslike these: Actions in, on, or near an iso-lette—such as closing metal doors, closinga solid plastic porthole, or dropping in a

mattress—can be asloud as 90, 100, and120 dB, respectively.3

These levels are com-parable to the noises ofa pneumatic drill, alawn mower, and aboom box in a car.3

Even holding a con-versation at the bed-side can be as high as60 dB, and tappingfingers on an isolettecan be up to 90 dB.3 Being aware of theseactions and making sure to avoid or limitthem is very important to the NICU’senvironment of care.

Bowles educates staff on the floor ona one-on-one basis. She recommendsnoise-reducing alternatives such as the fol-lowing: temporarily suspending alarms onequipment that might sound when pro-viding interventions, conducting conversa-tions away from the bedside, minimizingthe number of times an isolette door isopened and closed, and pressing the latchon a porthole before opening it. During

these one-on-one training sessions, staffalso view a presentation featuring theguidelines and how following them bene-fits the babies. Figure 1, left, shows a slidefrom this presentation.

Bowles also created a continuing edu-cation (CE) package that staff can com-plete to earn CE credits toward their pro-fessional licenses. The CE package is aseries of evidence-based articles that sup-port the newly implemented guidelinesand illustrate how the guidelines can bene-fit the babies in the NICU. “The moreavenues you give to staff to understandwhy you are implementing change, themore buy-in you get,” says Bowles.

The NICU displays posters and signsthroughout the unit as additional visualreminders for families and staff to keeptheir voices down. Some isolettes evenhave signs posted directly on them to pro-tect the sickest babies.

Monitoring Noise LevelsTo help ensure that noise levels are

kept to a minimum, Tri-City MedicalCenter uses the “Sound Ear” to alert staffand families when noise levels are inappro-priate. The Sound Ear is a lighted devicein the shape of an ear that monitors deci-bel levels on the unit. It is green when thenoise level is acceptable, yellow when noiseis getting too loud, and red when noise istoo loud. (A photo of the Sound Ear is


Turn down the lights.

It’s Quiet Time

1–2 A.M. & 1–2 P.M.

■ Speak softly

■ Limit actions when near

an isolette

■ Reduce foot traffic

■ Refrain from performing

elective procedures

This slide is part of an educational presentation given to staff to help them under-

stand why maintaining a quiet environment is so important.

Tri-City Medical Center instituted quiet time in the NICU to helpbabies sleep.

Figure 1. Educational Slide Presentation

Source: Tri-City Medical Center. Used with permission.

Every emergency your organizationexperiences is a learning opportu-nity. Whether it’s an actual event

or a preparedness drill, you can observethe response effort and evaluate how yourorganization handles the six critical func-tions of emergency management—com-munications, resources and assets, security,staff, utilities, and patient support. Yourorganization can highlight successes andinvestigate shortcomings and use the les-sons learned to make improvements.

But how can your organization effec-tively evaluate the six critical areas duringa drill?

Weiss Memorial Hospital, a 236-bedacute care facility affiliated with theUniversity of Chicago Medical Center,created a scorecard that helps the organiza-tion quantify its response to an event,including efforts associated with the sixcritical functions (see “Emergency DrillScorecard” on page 7). The organizationuses the scorecard to complement its after-action reports and drive performanceimprovement efforts.

Why the Hospital Createdthe Form

“We have always critiqued our emer-gency management drills,” says ChrisPettineo, M.S., director of emergency pre-paredness, Weiss Memorial Hospital.However, those critiques have been morequalitative than quantitative. “We wantedto develop a measureable way to gaugeour performance, including efforts associ-

ated with the six different functions.” Theorganization felt this would not only helpit meet Joint Commission standards butallow a thorough analysis of responseefforts. “The six critical functions are morethan spokes in the greater emergencymanagement wheel,” says Pettineo. “Theyare, in fact, the hub of an all-hazardsapproach to emergency mitigation, pre-paredness, response, and recovery.”

How the Hospital Createdthe Form

The hospital spent five months creat-ing and finalizing the form, and the emer-gency management (EM) committee wasin charge of the process. “We discussed itat every monthly meeting, breaking eachof the 6 critical functions into differentscorable items,” says Pettineo. “With eachfunction having 4 facets, the tool offers 24elements to score.”

During one round of revisions, thecommittee added a section for commentsso that users could do more than justcheck boxes on a list. “We wanted users tobe able to discuss what they were seeingduring a drill and provide suggestions forimprovement,” says Pettineo. “We felt thatadding a comments section would allowfor a qualitative review in addition to aquantitative one.”

How the Hospital Usesthe Form

For every EM drill, the hospitalassigns at least one observer to assess per-

formance. “This is usually a member ofthe EM committee who is familiar withour incident command process and theEmergency Operation Plan,” saysPettineo. The observer uses the form toscore various aspects of the response, cate-gorized into the six critical functions. Foreach item on the scorecard, the observerchecks whether, during the drill, the areabeing evaluated “always complies,” “some-times complies,” or “rarely complies” withthe activity; each option corresponds to aset number of points. A sum of the differ-ent scores yields a total, which shows howwell the staff navigated the emergencyresponse. The score matches to a percent-age, which indicates next steps, includingdeveloping an action plan or launching aperformance improvement project.

“In some cases, a drill may have mul-tiple observers looking at different areas,such as the intensive care unit and emer-gency department,” says Pettineo. “Afterevery observer completes the form, we caneasily tabulate the different scores anddetermine a final total and correspondingpercentage for our overall response.”When the form is complete, the hospitaldistributes the tool electronically to all thedepartments involved in the responseeffort. This not only improves communi-cation but limits the need for excess paper.

In addition to drills, Weiss Memorialuses its form to measure response to actualemergencies. “Although we don’t assignobservers during an actual emergency, we

Environment of Care News6 July 2011

What’s the Score?Weiss Memorial Hospital Creates a Tool to Quantify PerformanceDuring Emergency Management Drills




Site: ________________________

Date: ________________________

Leader: ______________________

Observer: ____________________

Column 1 (3 points /

checkmark) Always

Complies

Column 2 (2 points /

checkmark) SometimesComplies

Column 3 (1 point /

checkmark) Rarely

Complies Comments:

Communication

Effectiveness of initial alarm—heard and correctlyidentified at all points on the site

All staff given effective briefing of the objectivesand kept well informed

Effective use of PA, radios, verbal briefings, back-up communications

Plans to communicate with community, RHCC,external authorities

Resources and

Assets

Obtains supplies needed at onset of emergencyresponse

Replenishes supplies used during response

Management of support activities

Knowing when to evacuate (96 hours)

Safety and

Security

Organization establishes internal safety and security operations

Establishes process for access control and lock-down

Identifies roles for community security support(police, sheriff, etc.)

The plan identifies means for isolation/decontami-nation

Staff

Responsibilities

Staff roles and responsibilities are defined in theEOP

Staff are trained for their assigned roles duringemergencies

The organization communicates to licensed independent practitioners their roles

There is a process for identifying care providers

Utilities

Management

Electrical backup? Fuel?

Water contingency plan?

Other essential utilities identified?

Clinical interventions…backup equipment available?

Patient Clinical

and Support

Activities

Manage clinical activities such as triage, assess-ment, treatment, admission, discharge, and evacuation

Establish strategies for vulnerable populations

Establish hygiene and sanitation needs of thepatient

Mortuary services considered?

Total

Source: Weiss Memorial Hospital, Chicago. Used with permission.

Total Score Percentage Evaluation Results Improvement Plan

72 – 66 ≥ 91% Best practice None needed

65 – 58 90% – 81% Good working habits Action plan

57 – 24 ≤ 80% Needs some improvement Performance improvement project

Emergency Drill Scorecard

Apatient checks into her room inpreparation for a procedure thenext day and runs her finger over

the bedside tray table. If the room looksclean, she may feel safe from methicillin-resistant Staphylococcus aureus (MRSA) orany of the other bacteria that cause thehealth care–associated infections (HAIs)she’s been warned about. But a surfacethat appears to be clean may in fact har-bor microbial contaminants.

The Centers for Disease Control andPrevention (CDC) has released a docu-ment that describes how to optimize thethoroughness of cleaning high-touch sur-faces—such as tray tables, light switches,and toilet seats—in patient rooms. TheCDC guidance document recommends atwo-level cleaning and monitoring program administered by infection pre-ventionists (IPs) and coordinated andmaintained through environmental services (ES) professionals.

Options for EvaluatingCleaning

The CDC document “Options forEvaluating Environmental Cleaning” wasprepared by Alice Guh, M.D., M.P.H., ofthe Division of Healthcare QualityPromotion in the National Center forEmerging and Zoonotic InfectiousDiseases at the CDC, and Philip Carling,M.D., of Carney Hospital and BostonUniversity School of Medicine in Boston.“The evidence shows clearly that the

transmission of many health care–associat-ed pathogens is related to contaminationof surfaces and equipment that are nearthe patient,” says Guh. “We encourage allhospitals to develop programs to optimizethe thoroughness of high-touch surfacecleaning as part of the terminal roomcleaning performed at the time patientsare transferred or discharged.”

A Two-Tiered Approach toEnvironmental Cleaning

In the CDC document, which is avail-able at http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html,the CDC has divided the cleaning and

monitoring program into two levels: Level I is a basic infection prevention andcontrol (IC) program coordinated throughthe joint participation of the IP staff andES management to promote compliancewith CDC guidelines.1,2 The Level I pro-gram includes a checklist of high-touchsurfaces to be used when cleaning patientrooms (see “CDC Checklist for

Environmental Cleaning,” page 9).Various measures for evaluating environ-mental cleaning can be used in a Level 1program to encourage and engage ES staff,including self-reporting by ES staff or acompetency evaluation of ES staff by ESmanagement and/or IP staff.

Level II of the CDC cleaning andmonitoring program is an advanced pro-gram that incorporates the basic elementsand infrastructure of Level I; in fact, thecleaning methods used in this level are thesame as those in Level I. However, in theLevel II program, objective monitoringmethods—direct observation, swab cul-tures, fluorescent gel, ATP system, andagar slide cultures—are used by an ES orIP evaluator or a joint IP/ES team toassess the thoroughness of environmentalcleaning.

The programs also encourage hospi-tals to educate ES staff about what isexpected of them in their cleaning work.The results of the evaluation of environ-mental cleaning should be reported to thehospital’s infection prevention and controlcommittee and, if the hospital is partici-pating in a state-based prevention collabo-rative, could be shared with the statehealth department.

“Some hospitals should considerimplementing the advanced program rightfrom the start,” says Guh, “particularlythose with increased rates of infectioncaused by health care–associatedpathogens, such as Clostridium difficile.

Environment of Care News8 July 2011

This Patient Room Looks Clean, But Is It?Options for Evaluating Environmental Cleaning


Studies show thatmany surfaces arenot being cleaned

thoroughly.—Alice Guh, M.D., M.P.H.,

Centers for Disease Control and Prevention

And all hospitals that have successfullyachieved the goals of a Level I programshould advance to Level II.” Moreover,Carling urges hospitals that have achieveda high compliance rate at Level II to gobeyond that to optimize their environ-mental hygienic practices in other areas ofthe hospital.

Studies Show RisksIn case hospitals need any encourage-

ment to advance their cleaning practices,Carling cites an article he co-authored inthe June 2010 issue of the AmericanJournal of Infection Control. That articlepoints out eight recent studies confirmingthat patients occupying rooms that previ-ously hosted patients with vancomycin-resistant enterococci (VRE), MRSA,Clostridium difficile, and Acinetobacter bau-mannii infection or colonization have onaverage a 73% increased risk of acquiringthe same pathogen compared to patientsnot occupying such rooms.3 “These stud-ies show that many surfaces are not beingcleaned thoroughly,” says Guh. Carlingadds, “There’s almost no way that subse-quent room occupants can pick up thosebacteria unless it’s through environmentalcontamination.” Guh also notes that manyother pathogens, such as norovirus, arealso being transmitted through the envi-ronment. “Furthermore,” she says, “theenvironment in hospitals has been foundto harbor many bacteria that are becomingincreasingly resistant to antibiotics.”

“The intention of the CDC docu-ment is to determine objectively whetherenvironmental cleaning has been per-formed,” continues Guh. “We encouragehealth care facilities to take a program-matic approach to improving their envi-ronmental cleaning, to educate their ESpersonnel about what’s expected of them,and to foster close cooperation betweenES staff and the IP team.”

Carling says, “The acceptance ofthese Level II programs by ES workers has

been amazing. The model for the last 50years has been to look for visual evidenceof imperfect cleaning. Now ES workerscan be shown how thoroughly they arecleaning critical surfaces through the useof Level II type programs.”

AHE SpeaksThe viewpoint of the ES workers who

do the actual work of cleaning patientrooms is articulated by the Association forthe Healthcare Environment (AHE; for-merly known as ASHES), part of theAmerican Hospital Association (AHA).AHE represents the health care environ-mental services profession, from workers

to housekeepers to ES management.“The important thing is to agree as a

team on what those high-touch surfacesare and what’s the cycle for cleaning,”says Patti Costello, executive director ofAHE. Costello describes ES as a labor-intensive department. “You need ade-quate staff and enough time to do a goodjob,” she says. “ES managers should sitdown with hospital administration andIPs and establish specific cleaning stan-dards, starting with clinical spaces such aspatient rooms and procedure rooms, andthen move to common areas such as hall-ways, floors, and so on.”



CDC Checklists for Environmental CleaningThe following are checklists for cleaning and monitoring.*

High-Touch Room Surfaces

The following are high-touch room surfaces that should be cleaned by ES workers.

These are some of the sites most frequently contaminated and touched by patients

and health care workers.

Equipment Present in the Room

In addition to the high-touch room surfaces, the following high-touch equipment

should be considered when cleaning is performed:

Monitoring Methods

The following is a list of monitoring methods to be used when evaluating cleaning:

* Selection of detergents and disinfectants should be according to institutional policies andprocedures.

❑ Bed rails/controls

❑ Tray table

❑ IV pole (grab area)

❑ Call box/button

❑ Telephone

❑ Bedside table handle

❑ Chair

❑ Room sink

❑ Room light switch

❑ Bathroom handrails by toilet

❑ Bathroom sink

❑ Toilet seat

❑ Toilet flush handle

❑ Toilet bedpan cleaner

❑ IV pump control

❑ Multi-module monitor controls

❑ Multi-module touch screen

❑ Multi-module monitor cables

❑ Ventilator control panel

❑ Direct observation

❑ Swab cultures

❑ Fluorescent gel

❑ Adenosine triphosphate (ATP)

bioluminescence system

❑ Agar slide cultures

tion remain on the body, taking a showermay be useful,” says Wagner. “After theshower, survey the patient again.”

Patients who have been moved tothe ED may also be contaminated.“Many hospital EDs do not have experi-ence with radiation incidents,” saysFlesh. “If an individual experiences asudden onset of nausea and vomitingand their leucocytes are quite low, itcould signal radiation sickness.”Hospitals can call on the expertise of theprofessional staff in their own organiza-tion, advises Flesh, such as the nuclearphysicians and the professionals in radi-ology or radiation therapy. “They aretrained and experienced in exposure andcontamination and can be recruited totrain the ED staff on how to handle apatient who may be contaminated,” saysWagner. Loyola sends all its nuclearmedicine residents to a facility in OakRidge, Tennessee, called the RadiationEmergency Assistance Center TrainingSite (REACTS) (see “External Expertise,”

page 3) for training in how to handleradiation incidents.

Isolation in the EDLoyola University Medical Center’s

director of disaster medicine is KatherineA. Martens, M.D., F.A.C.E.P., associateprofessor, Division of EmergencyMedicine, Department of Surgery. “In aradiation event, it’s definitely important totreat the patient first,” says Martens. “Butcontamination can be tracked all over thehospital by workers or patients, therebycontaminating the whole facility. Our planfor treating contaminated patients calls forus to confine them to a room with physi-cal barriers and removable floor coveringsto facilitate containment and cleanup.”

Under this plan, staff members wear-ing personal protective equipment (PPE)handle any potentially contaminatedclothing and other material from patientsand turn it over to someone outside theisolation area for disposal. “So everythingthat’s contaminated is physically confinedand then cleaned up,” says Martens.“Even though that part of the hospital iscontaminated, the idea is to limit it to a

confined space and not contaminate therest of the facility or compromise the safe-ty of other patients or staff.”

In the ED, Loyola’s Wagner recom-mends that hospital personnel be double-gowned and wear double gloves and dou-ble booties. “A lead apron is too heavy andreally provides no protection,” saysWagner. “But a cap and a mask are usefulto protect wearers from accidentallytouching their hair or face while caring forpatients.”

Advice from ExpertsWagner urges facilities to conduct

periodic nuclear disaster preparednessexercises. “Radiation has a lot of mysteryand fear associated with it. This may causeproviders to delay treatment,” he says.“That’s why providers in the ED shouldunderstand the intricacies of radiationexposure and contamination and how toprotect themselves and their patients.”And the VA’s Flesh says, “If the patient ishurt as well as contaminated, they may dieif not treated. Life-threatening injuriesmust be treated before the radiation con-tamination is dealt with.” EC

NEWS

Environment of Care News10 July 2011 http://www.jcrinc.com

Planning for the Ultimate Risk(continued from page 3)

included on page 4.) According to Bowles,“The Sound Ear is a visual reminder thatboosts awareness. Staff and parents look tothe Sound Ear to make sure noise levelsare appropriate for the NICU.”

Keys to the Program’sSuccess

The NICU’s program to reduce noisewas successful for many reasons. A keyreason for the program’s success is that theguidelines were simple and evidencebased. Also, staff buy-in was strong, espe-cially after staff witnessed the benefits forbabies. In addition, “Staff hold each otheraccountable,” says Bowles. “I am satisfied

that the staff got it, understands it, andsees the benefit of it.” Staff also reportedfeeling better and less stressed when offduty. Because of the benefits the programhas produced, says Bowles, “Some of thenaysayers are now the biggest supportersof the project. I have the privilege ofworking with a group of people [physi-cians and staff ] who are highly motivatedand extremely professional. They strive todo the best they can every day and arewilling to provide the kind of care thatwill result in optimum outcomes.”

Continuing to MakeImprovements

Tri-City Medical Center’s noise miti-gation initiative was a big step in the right

direction, but there is still room forimprovement, according to Bowles. TheNICU will continue exploring ways toreduce noise. Ideas for making futureimprovements include replacing old ceil-ing tiles with acoustic tile, reconfiguringpods, and replacing the automatic doorswith quieter equipment.

References1. The Joint Commission: Comprehensive Accreditation

Manual for Hospitals: The Official Handbook. OakBrook, IL: Joint Commission Resources, 2011.

2. Committee to Establish RecommendedStandards for Newborn ICU Design: Report ofthe Sixth Census Conference on Newborn ICUDesign: Recommended Standards for NewbornICU Design. Orlando, FL, Jan. 25–27, 2006.

3. The Committee on Environmental Health:Noise: A hazard for the fetus and newborn.Pediatrics 100:724–727, Oct. 1997.

ECNEWS

For Infant Ears Only(continued from page 5)


A Hospital’s Point of ViewCarol Sulis, M.D., is associate profes-

sor of medicine at Boston UniversitySchool of Medicine and a hospital epi-demiologist at Boston Medical Center. “Inthe old days, if it looked clean, peopleassumed the room was clean,” says Sulis.“But as more multi-drug-resistant organ-isms came along, Boston Medical Centerbecame interested in looking at the envi-ronment itself. We wanted to see whetherthe patient rooms were being cleanedeffectively, so we agreed to be a beta testsite for the type of program the CDC isadvocating to objectively evaluate environ-mental cleaning.”

Was there a problem with justifyingthe costs of this evaluation program?“Boston Medical Center is a private, nota public, hospital, and of course everyexpense must be weighed,” says Sulis.She explains that the cost of one inci-dent of an HAI caused by a contaminat-ed surface is “really huge” and thereforeis worth the cost of the evaluation pro-gram. She particularly appreciates theway the CDC program removes subjec-tivity and replaces it with objectivemeasures in evaluating cleaning proce-dures. “The cleaning measurement

scores are either on target or they’renot,” says Sulis.

In addition, since the process of eval-uating environmental cleaning went intoeffect, Boston Medical Center has noted amarked improvement in patient satisfac-tion surveys. “The room cleanliness scoreson the patient satisfaction surveysimproved more than any other measures,”Sulis reports. “What’s more, our ES work-ers feel like they’re appreciated.”

Sulis would like to see this type ofprogram extended beyond patient roomsto operating rooms (both in- and outpa-tient), intensive care units, clinics, dentalschools, and emergency medical servicesvehicles such as ambulances and helicop-ters.

Advice from theProfessionals

“Certain areas have to be cleanedevery day, no matter who has used themand no matter whether they look soiled ornot,” says Sulis. “Yes, it takes time to cleanthose areas adequately. But when ESworkers do a good job and are praised forit, everyone benefits—especially thepatients who aren’t becoming infected.”

The CDC’s Guh advocates a collab-orative and thoughtful effort. “The con-cept presented in the CDC document iseasy to understand and implement, and

it isn’t resource intensive,” she says.“This type of program should be viewedas a joint effort by IPs, the quality assur-ance department, and ES managementas a vital part of overall infection preven-tion. Many senior ES leaders in hospitalsaround the country support this form ofprogrammatic approach because theyrealize the impact it’s already having onpatient safety.”

Please note that the suggestions made in this arti-cle do not constitute current requirements of TheJoint Commission. Standard IC.01.05.01, EP 1,states, “When developing infection prevention andcontrol activities, the hospital uses evidence-basednational guidelines or, in the absence of suchguidelines, expert consensus.” Health care organi-zations accredited by The Joint Commission areencouraged to consider the content of this articlebut would not be required to comply with suchcontent because it is not currently part of an evi-dence-based national guideline.

References1. Centers for Disease Control and Prevention:

Guideline 1: Guidelines for EnvironmentalInfection Control in Health-Care Facilities, 2003.http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf.

2. Rutala W.A., Weber D.J., and HICPAC:Guideline for Disinfection and Sterilization inHealthcare Facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf (accessed Feb. 14, 2011).

3. Carling P., Bartley J.: Evaluating hygienic clean-ing in health care settings: What you do notknow can harm your patients. Am J InfectControl 38:S41–S50, Jun. 2010.

ECNEWS

This Patient Room LooksClean, But Is It?(continued from page 9)

do use the form to review the overallresponse effort at the next EM committeemeeting,” says Pettineo. “During themeeting, we use the form as a basis of dis-cussion, polling the group about the vari-ous activities and gathering feedback andopinions on how to score ourselves.”

The Benefits of the FormThrough its scorecard, Weiss

Memorial now has a method for quanti-

tatively critiquing its EM drills.According to Pettineo, the form is a“data-rich tool that allows us to simply,quickly, and consistently collect informa-tion about a drill and evaluate perform-ance.” The biggest benefit of the form isthat it allows the hospital to identify andframe improvement efforts in order toyield a more thorough and effectiveresponse in the future.

A recent improvement was in thevery first item on the scorecard, involv-ing communication—that the initial

alarm is heard and correctly identified atall points on the site. “Through the[process of collecting] feedback from thescorecard, we realized there were deadzones—places where people did not hearthe emergency code announcement onthe overhead pager,” says Pettineo. Thesolution? Redundant communication.“We now follow the overhead pagerannouncement with an alpha page,” saysPettineo. “Without the drill scorecard,we might not have caught this commu-nication gap.” EC

NEWS

What’s the Score?(continued from page 6)

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Volume 14, Number 7

July 2011

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