EVS and the environment of care

Environmental services (EVS) professionals play an important role in making sure their hospitals promote a safe, functional and supportive environment so that safety and quality are preserved, according to the preface of The Joint Commission’s hospital accreditation standards.

Any hospital, regardless of its size or location, faces risks in the environment, including those associated with safety and security, fire, hazardous materials and waste, medical equipment and utility systems.

When staff are educated about the elements of a safe environment, they are more likely to follow processes for identifying, reporting and acting on environmental risks, states The Joint Commission.

Making a difference

The environment of care is made up of building space, including how it is arranged and special features that protect patients, visitors and staff; equipment used to support patient care or to safely operate the building or space; and people, including those who work within the hospital, patients and anyone else who enters the environment, all of whom have a role in minimizing risks.

A few of the environment of care standards and the specific areas in which EVS departments can make an important   difference include the following:

Standard EC.02.03.03: The organization conducts fire drills. Surveyors often will ask EVS staff about their roles in their organization’s written fire response plan. Many organizations implement “badge buddies,” a practice that displays the acronyms RACE (rescue, alarm, contain, extinguish) and PASS (pull, aim, squeeze, sweep) on badges to help staff remember appropriate response steps to take during a fire or smoke event. 

However, a common element of written fire response plans that is often not well known is the process for horizontal evacuation/relocation to an adjacent smoke compartment: 

The 2012 edition of the National Fire Protection Association’s NFPA 101^®, Life Safety Code^®, defines a smoke compartment as a space within a building enclosed by smoke barriers on all sides, including the top and bottom. 

NFPA further notes that the health care organizations’ written fire safety plan address “evacuation of smoke compartment.” 

Why is this important? Because during a fire or smoke event, an individual room may be the fire’s point of origin and, due to smoke, a decision is made (after rescuing the patient from the room if the room is occupied) to evacuate the smoke compartment and move patients or residents to an adjacent smoke compartment for their safety. 

The NFPA 101 handbook notes, “in many fatal fires in health care facilities, staff either did not close doors or someone reopened them; the fire spread was sizable, and the loss of life was high. Emphasis must be placed on training staff to sound an alarm, to rescue patients (as needed) and then to close all doors. Closing of doors historically has had the most significant effect on limiting the spread of fire and smoke.” 

Many will ask how far an individual should evacuate or the location of the next smoke compartment. During the building tour, Life Safety Code surveyors use life safety drawings to identify smoke and fire barriers and assemblies and inspect them to ensure no penetrations exist where smoke or fire may migrate into the next smoke compartment. Without training or a visual clue, staff may not know where the next smoke compartment begins or ends. 

The NFPA 101-2012 handbook notes that any floor used by inpatients for sleeping or treatment must be subdivided into at least two smoke compartments, regardless of floor size or number of patients. Also, 18.3.7.1(2) requires any floor with an occupant load of 50 or more people, regardless of size or use, to be subdivided into at least two smoke compartments, using smoke barriers.

To help EVS staff understand where one smoke compartment ends and another begins, facilities may provide visual cues to help them. For example, they may place a decal or label (perhaps one that says “Smoke Barrier” or “Smoke Zone XX”) in a prominent place on both sides of the smoke or fire doors to illustrate this separation and to increase the hospital staff’s success rate for identifying smoke compartments. Facilities should try to make identification practical so staff remember.

Another point of concern is having wheeled carts in the corridor (NFPA 101-2012, 18/19.2.3.4). Although the code allows having wheeled carts with some exceptions, often the health care occupancy fire safety plan and training program does not address the relocation of the wheeled equipment during a fire or similar emergency.

Standard EC.02.02.01: The organization manages risks related to hazardous materials and waste. According to the Occupational Safety and Health Administration (OSHA), the Globally Harmonized System (GHS) is an international approach to hazard communication, providing agreed criteria for classification of chemical hazards, and a standardized approach to label elements and safety data sheets (SDSs). 

The GHS was negotiated in a multiyear process by hazard communication experts from many different countries, international organizations and stakeholder groups. It is based on major existing systems around the world, including OSHA’s Hazard Communication Standard (HCS) and the chemical classification and labeling systems of other U.S. agencies. 

OSHA has modified the HCS to adopt the GHS to improve safety and health of workers through more effective communications regarding chemical hazards. Since it was first promulgated in 1983, the HCS has provided employers and employees extensive information about chemicals in their workplaces. 

The original standard is performance-oriented, allowing chemical manufacturers and importers to convey information on labels and material SDSs in whatever format they choose. While the available information has been helpful in improving employee safety and health, a more standardized approach to classifying hazards and conveying information will be more effective and provide further improvements in U.S. workplaces. 

The GHS provides such a standardized approach, including detailed criteria for determining hazardous effects that a chemical poses, as well as standardized label elements assigned by hazard class and category. This will enhance both employer and worker comprehension of the hazards, which will help to ensure appropriate handling and safe use of workplace chemicals. 

Additionally, the SDS requirements establish an order of information that is standardized. The harmonized format of the SDSs will enable employers, workers, health professionals and emergency responders to access the information more efficiently and effectively, thus increasing their utility.

Adoption of the GHS in the U.S. and around the world also will help to improve information received from other countries — because the U.S. is both a major importer and exporter of chemicals, American workers often view labels and SDSs from other countries. The diverse and sometimes conflicting national and international requirements can create confusion among those who seek to use hazard information effectively. 

For example, labels and SDSs may include symbols and hazard statements that are unfamiliar to readers or not well understood. Containers may be labeled with such a large volume of information that important statements are not easily recognized. 

Given the differences in hazard classification criteria, labels also may be incorrect when used in other countries. If countries around the world adopt the GHS, these problems will be minimized, and chemicals crossing borders will have consistent information, thus improving communication globally.

OSHA required that employees were trained on new label elements (e.g., pictograms, hazard statements, precautionary statements and signal words) and the SDS format by Dec. 1, 2013, while full compliance with the final rule was in 2015. 

What does this mean for health care workers, specifically EVS staff? Life Safety Code and clinical surveyors will ask about cleaning products used on carts and mixed in environmental closets and how workers can access the SDSs. In addition, if an electronic system or online system is used, how would workers access SDSs if the online system was not available due to a server outage or other issues? 

EVS professionals must remember that training on new or replacement chemicals or solutions is required.

Standard EC.02.02.01: The organization manages risks related to hazardous materials and waste. Surveyors often ask about placement and need for emergency shower and eyewash stations. A good process to use is to conduct a proactive and ongoing risk assessment regarding the need for this equipment. 

A good place to start is to look at the OSHA requirements:

• 1910.151: Where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. 

Other OSHA requirements that should be referenced include:

• 1910.1048(i)(2): If employees’ skin may become splashed with solutions containing 1% or greater formaldehyde, for example, because of equipment failure or improper work practices, the employer shall provide conveniently located quick drench showers and assure that affected employees use these facilities immediately.
• 1910.1048(i)(3): If there is any possibility that an employee’s eyes may be splashed with solutions containing 0.1% or greater formaldehyde, the employer shall provide acceptable eyewash facilities within the immediate work area for emergency use.

Guidance also is provided by ANSI Z358.1- 2014, specifically appendix B5 regarding placement, and B6 that provides guidance regarding “Delivered Flushing Fluid Temperature,” as well as B7 that addresses “Weekly Activation for Plumbed Emergency Eyewash and Shower Equipment.” 

Also, acids with a pH less than 2.5 and alkalis with a pH greater than 11 require immediate flushing to prevent damage. Newer eyewash technology pushes the contaminates away from the lacrimal (duct) system of the victim’s eye.

Organizations should consider a comprehensive risk assessment to determine where emergency showers and eyewash stations are required. This process may assist health care organizations in determining if the facility has excess stations or may require additional stations to be installed.

Standard EC.02.01.01: The organization manages safety and security risks. Health care organizations are required to control access to and from areas they have identified as security sensitive. 

An EVS professional’s role in supporting access to security sensitive areas is very important. First, they should learn what areas are considered to be security sensitive for their organization. Is it obstetrics, pediatrics, pharmacy or other locations? 

EVS professionals may be granted access to these areas using a card reader or access code, but it is very important not to allow others to tailgate or follow them into these areas. EVS staff should consider taking an alternate route if people are aggregating at the entrance area.

Standard EC.02.04.01: The organization manages medical equipment risks. Magnetic resonance (MR) scanners are very large magnets used for imaging patients. The magnet is always on, and it is many times stronger than the earth’s gravity. MR scanners are very dangerous to patients and staff if any magnetic object (e.g., most metal objects) gets into the MR scan room. 

According to the American College of Radiology’s (ACR’s) website, four safety zones surround the MR scanner, and they are designated with posted signs. 

• Zone 1: Waiting area. A safe area for the general public, with no danger to patients or staff.
• Zone 2: Patient area. This is the area where patients are screened to be certain they do not have any magnetic objects in their body (such as pacemakers) or in their clothing.
• Zone 3: Control room and area directly outside the scan room. This is the area where the MR technicians work, and there is some magnetic field in this area, which may be dangerous to people with metal objects in their body.
• Zone 4: Magnet room. This is the room where the magnet is located, and this room is very dangerous to patients and staff if they have not been screened before entering, and very dangerous if unsecured magnetic objects enter this room

Examples of magnetic objects that should never enter Zone 4 include: cellphones; wallets with credit cards; mops and metal buckets or any cleaning equipment not specially made for magnet rooms; keys; pen knives; guns or weapons of any kind; wheelchairs unless made for magnet rooms; step stools; oxygen tanks unless made for magnet rooms; IV poles unless made for magnet rooms; and any other equipment or object that might be magnetic unless specifically made for MR.

For cleaning functions, the ACR website states that every EVS staff member should be screened by an MR tech before they work in the MR area. EVS staff also should tell MR staff if they experienced any changes since last screen. Also, specially designed equipment that is MR safe should be used for cleaning; any new equipment or supply must be checked to be certain it is not magnetic before it enters Zones 3 or 4. The magnet room should be locked when not in use.

An important role

The Joint Commission standards for the physical environment cover everything from emergency power to door latches to facility security. While EVS professionals don’t have overall responsibility for these areas, their role in ensuring safe and compliant operations gives them important influence in the effectiveness of the standards. 

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James Kendig, CHSP, CHCM, CHEM, LHRM, is field director for the Life Safety Code surveyors at The Joint Commission. He can be reached at jkendig@jointcommission.org.