Table ofContents Introduction................................................................. One Useful Publications.......................................................Three The Safety Committee................................................... Four The Physical Plant........................................................ Five Evaluating The Facility ................................................. Six Specific Areas To Evaluate............................................ Seven Smoking Policy ........................................................ Seven: Fire Walls/Fire Partitions......................................... Seven Fire and Smoke Doors.............................................. Eight Glass....................................................................... Eight Doors To Patient Rooms........................................... Eight Other Doors............................................................. Nine Hallways .................................................................. Nine Exit Signs................................................................ Nine Sprinklers................................................................ Nine Ceiling Tiles ............................................................. Ten Stairs....................................................................... Ten Pipes and Valves ...................................................... Ten Gas Cylinders.......................................................... Ten Documentation........................................................ Ten BISON LOCKWOOD UBRARY UNIVERSITY AT BUFFALO DEC 1 6 l992 00..,....... ~~~~;;, DEPOSITORY LIBRARY 0433 Page i The Emergency Preparedness Plan (EPP)...................... Eleven Function ofThe EPP ..................................................... 1'welve EPP Contents............................................................... Thirteen Utilities.................................................................... Thirteen Electric ................................................................ Fourteen Water.................................................................. Sixteen Sewage ................................................................ Sixteen Central Gases..................................................... Seventeen Waste Disposal.................................................... Seventeen Climate Control. .................................................. Eighteen Steam.................................................................. Eighteen Medical Supplies..................................................... Nineteen Equipment.............................: ................................ Nineteen 'Transportation........................................................ 1'wency Linen....................................................................... 1'wency The Hazard Programs................................................... 1'wency-One Hazardous Materiel (HAZMAT) Program................... 1'wency-1'wo Hazard Communications (HAZCOM) Program.......... 1'wency-Five Hazardous Waste (HAZWASTE) Program.................. Thircy-1'wo Regulated Medical Waste Program........................... Thirty--Six Medical Maintenance Issues......................................... Thirty--Seven Summary-..................................................................... Thirty--Nine Technical Assistance.................................................... Forty" Page ii Introduction We in the Army Medical Department (AMEDD) have many aging medical treatment facilities (MTFs). Because of funding constraints and uncertainties, we do not upgrade or replace our facilities as frequently as our civilian counterparts. The safety of our staff, patients, and visitors depends upon how well we maintain our facilities and the built-in safety features. Further, we need to keep our facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A major portion of the accreditation involves the area referred to as Plant, Technology, and Safety Management (PTSM). This is a difficult portion to pass successfully. In recent years, the JCAHO has written more Type 1 Recommendations (deficiencies) in PTSM than in any other area. There are many reasons for this difficulty. Facility age is one, and the volume of requirements which must be met is another. There are many other reasons, many of which are location-unique such as particularly weak engineering support. One other reason, which this guide will hopefully help solve, is a lack of knowledge within the facilities. We have many relatively young logisticians who were not able to gain experience before they suddenly found themselves as a Logistics Division Cqief. These topics are not taught routinely either. The requirements themselves, as mentioned earlier, are many and complex. The codes themselves are difficult to read and interpret. To make matters worse, the "Family of Hazardous Programs" are also looked at by the JCAHO. Now, before you experienced old-timers disregard this guide, read on. Look at the next few paragraphs and you'll fmd that your peers contributed to this (they don't know they did}, so this sharing of information might still be of help. Ifyou read and follow this guide, can we guarantee that you will pass the next JCAHO survey? Probably not. There are too many other variables involved such as the personality, or lack of personality, of the individual surveyor. We can probably guarantee that ifyou ignore this guide and fail to check your facility and make corrections, you will probably not achieve your accreditation goal. The information provided in this guide came from numerous sources. Of course, published laws and regulations are sig-· nificantly represented since the goal is to comply with these directives. Also, personal experiences, hints, ideas, and other brainstorms from many experienced logisticians and other technical specialties in the AMEDD are included. Finally, emphasis is placed on areas frequently discovered as problems by the Command Logistics Review Team and the JCAHO. Page One thing you may notice is that this guide often does not cite paragraph and verse of the applicable law or code. The specifics may change but the general concept will probably remain the same (e.g., the specific number of square inches for a maximum surface area of glass may change, but a maximum size restriction will remain). The logistician must maintain current reference regulations (i.e., code books). This guide supplements, but does not take the place of those regulatory guidelines. This guide is an aid for you to use, it is not policy or regulation. If you require further technical assistance, a telephone directory is provided in the back of this guide. One final word is in order concerning facility maintenance and engineering support. This guide often refers to the Directorate of Engineering and Housing (DEH). Concepts in this guide are equally applicable under the Director of Public Works (DPW) and reimbursable services concepts. In fact, as our activities convert to this concept, they will find they will have more control over funds, personnel, and how facility maintenance is performed. Innovation and sound business decisions should enhance facility maintenance. Besides, with DPW under our control, we will no longer be able to blame someone else for shortcomings. Page Two Useful Publications Use the most current versions of the following publications when preparing for a JCAHO survey of your facility: • The Accreditation Manual for Hospitals (AMH) Volume I published each year by the JCAHO. • The AMH Volume II (formerly, Key Items, Probes, and Scoring (KIPS) Manual) published each year by the JCAHO. • The National Fire Protection Association (NFPA) Code Manual 99, Health Care Facilities (NFPA 99). • The National Fire Protection Association (NFPA) Code Manual 101, Life Safety Code (NFPA 101). • Code of Federal Regulations 29 (29 CFR). • Code of Federal Regulations 40 (40 CFR). Page Three The Safety Committee Logistics Divisions must be actively involved in the safety program to include representation at Safety Committee meetings. The following areas of Logistics concern are expected to be documented in the Safety Committee minutes: • Any failures of medical equipment that could have or did have safety implications. For example, an x-ray unit producing an excessive dose of radiation, or an electrical short. • Also, failures resulting from "operator head space and timing" should be reported. • Any failures involving the physical plant or utilities which could have or did have safety implications. For example, the emergency generators failing to start in a timely fashion after the loss of commercial power. The Logistics Division Chief should be a voting member of the Safety Committee. To facilitate accuracy in reporting to the committee, you may want the chiefs of your Maintenance and Services Branches to at least attend each meeting with you. You may also want to document all failures listed above and allow the committee to discuss and decide which problems had safety implications. The Safety Committee can be the focal point for all JCAHO issues discussed in this guide. Use it as a forum to assist you in preparations for the survey, and as a means of providing and receiving status. The Safety Committee can also be used to meet the JCAHO requirement to track equipment and utility failures. Page Four The Physical Plant One of the first things you should notice when studying the NFPA Code Books is that there are separate standards for different building functions. The NFPA books refer to them as 'occupancies.' The most stringent, perhaps, are those standards pertaining to medical treatment facilities. These fire safety standards assume that total evacuation of the facility (particularly for inpatient facilities) is impossible because many patients cannot evacuate without significant assistance or they are dependent on life support systems. As such, only the zone containing the fire is evacuated and the protective features of the physical plant itself are expected to protect the other zones and keep the fire from spreading. This is exactly why you should place maximum emphasis on the condition of these features. It also helps you pass your survey. The standards also differ between older existing structures and newer facilities and between inpatient and outpatient areas. When reviewing the inpatient and outpatient standards, however, consider the location and total mission of the specific patient treatment area in the overall physical structure. In other words, just because a clinic is an outpatient facility does not mean the less stringent outpatient standards apply in all cases. For instance, ifthe clinic operates from a couple of rooms on an active inpatient ward, or is directly below an active inpatient ward, the more stringent inpatient standards apply. Similarly, if the outpatient function also has a significant inpatient mission, such as radiology, then the more stringent inpatient standards apply. Page Five Evaluating The Facility The JCAHO surveyor and other inspection agencies will evaluate how well your facility complies with the codes by conducting a walk-through survey. Ideally, you should conduct periodic walk-through surveys. You don't need to have a formal and scheduled walkthrough every quarter, unless that's how you want to do it. At a minimum, conduct a complete walk-through several months before the scheduled JCAHO survey. Then make every trip through the hospital a facility evaluation. Logisticians should be continuously out visiting their customers. Everytime you visit a customer, or go to one of those wonderful committee meetings, take different routes in the facility, look around you. Take the stairs when you move throughout the facility. That way you can check stairwells and exit doors. Incorporate a facilities checklist into your Command Supply Discipline Program (CSDP). Everytime you make your annual visits to customers, check the facility around them. Better yet, teach your customers what to look for and ask them to report problems to you promptly, and don't forget to stress why all of this is important. That gives youhundreds of eyes helping you look over your facility. Most importantly, correct all problems. Page Six Specific Areas to Evaluate We now know that the best way to evaluate is to wander about your facility. What specific things are you looking for? You have probably already made hundreds of laps in your facility and you can't recall much out of the ordinary. Let's discuss some specific concerns and I'll bet the next time you tour the building, things will not look quite so good. 1. SMOKING POUCY Your facility must have a hospital-wide no smoking policy. Surveyors will look for evidence of violations. Beginning in 1993, JCAHO requires all facilities to be "smoke-free". They know that cigarette butts are usually found in mechanical rooms, penthouses, and stairwells. They know that contract personnel have relatively private access to these areas and that the hospital staff also uses such "hiding places." Clean all these areas prior to the survey and increase enforcement of the policy. These areas also are frequently used to hide other "sins" such as flammables. Also check these areas for oily rags, oil spills, etc. 2. FIRE WALLS/FIRE PARTITIONS It is important that all designated frre and smoke containment walls feature continuous, slab to slab construction. Most surveyors request that someone bring a step ladder and flashlight on the walk-through. They will check several fire walls for penetrations. + An easy frre wall to check is the one in a mechanical closet. These are also likely to have penetrations since utilities (electric, phone, water, etc.) often originate or terminate there. + Another easy fire wall to check is the one on inpatient wards. Usually our wards are long hallways with several fire or smoke doors separating fire zones. They will simply climb the ladder, lift the ceiling tile, and look for holes. Since it is very expensive and timeconsuming to periodically repair every penetration in the facility, the best solution is to not let the holes get there in the first place. This requires cooperation from several elements. • The Services Branch can force cooperation by screening all work orders, projects, etc. + The Safety Manager can and should review any work which appears to involve fire walls or partitions. Page Seven • The US Army Environmental Hygiene Agency (USAEHA) can review projects beyond the scope of the local safety staff. The work order forwarded to DEH must include a statement about repairing penetrations to the frre wall with approved fire retardant material. Periodically check their work for compliance. The biggest violator is often associated with IMO functions such as phone or computer installations/moves/removals. Not only is work frequently ongoing in this area, but for some reason, these folks love to make holes that are six inches in diameter and then cram a oneeighth inch diameter wire into the hole. Bring IMO into this process. 3. FIRE AND SMOKE DOORS Fire and smoke doors must function properly. They are required to be held open with electromagnetic or similar devices which will release the doors and allow them to close when the frre alarm is activated. These must be tested for proper operation and the doors must close entirely by themselves. They must also swing closed at the correct rate. You should also remove any unapproved door stops to include wedges, and obstructions. The NFPA specifies the maximum gap permitted around closed doors. The construction of doors, frames, and door releases also must comply with the NFPA code. Replace doors damaged by continual striking with carts or gurneys. These doors are extremely expensive (usually inexcess of $1000 per copy) so the wise thing to do is prevent damage. Page Eight Doors must have a data plate on them indicating their frre ratings. Fire doors differ from smoke doors in that frre doors have positive latching devices. These devices must also engage and hold the door properly when closed. 4. GlASS Glass vision panels on doors or through mtemal walls must be wirereinforced and cannot exceed the specified square inches of surface area. Vision panels must also be installed in metal frames. There is also a type of "plexiglass" now available which meets the code for reinforced glass. 5. DOORS TO INPATIENT ROOMS Ensure doors on inpatient rooms can close securely but not lock. Typically this is done using a roller latch which, unfortunately requires frequent adjustments to function properly. Although the latch must hold the door closed, it must also open with no more than the specified amount of force. Long term, it is often more cost effective to replace roller latches with pushpull handle positive latching devices which require almost no maintenance. You can do this over a lengthy period.to control costs and avoid flooding DEH with a massive project. For example, convert one ward per quarter. 6. OTHER DOORS With the exception of rest rooms, and certain mechanical rooms, doors cannot have vents or louvers. Iffound on smoke/fire doors, replace the entire door. Other doors can have the vents covered with a tight fitting metal sheet. Dutch doors must have an astragal installed to help seal the area between the two halves of the door. 7. HALLWAYS Hallways must not be obstructed by equipment, carts, etc. The rule of thumb is that items in the hallways cannot extend into the hall from the wall any further than the distance from the wall the fire/smoke door is hung. In other words, if the fire/smoke door is hung on the frame and the edge of the frame extends away from the wall 12 inches, then no objects can be located along hallway walls that extend more than 12 inches into the hallway. Ifyou absolutely have to have items in the hallway, keep it to a minimum and ensure that you do not locate items on opposite walls of the corridor which will further restrict exit space. 8. EXIT SIGNS Illuminated exit signs must be clearly displayed. The rule of thumb here is, standing in the corridor midway between two fire/smoke doors and looking down the corridor in both directions, you should see the exit signs. Ifyou cannot, then you need more exit signs. Remember, each zone within the corridor must be marked. In other words, if the frre/smoke doors you are standing between do not have visible exit signs with the doors closed, you need more signs. Illumination for the exits must be on the emergency power circuit. Self-illuminated signs are not required. Ifthe corridor light above the sign is on emergency power, you meet the requirement. Exit signs must not be obstructed by other signage. If obstructed, move the other signage to one side or the other. Be careful in marking exits such that you do not mark one end of the corridor when there is no reasonable means of egress. Also, corridors longer than 30 feet which do not have an exit way at both ends must be marked by a sign stating "NOT AN EXIT'' or "DEAD END". 9. SPRINKLERS Certain areas of existing structures require sprinklers. Some of these areas are: flammable storage areas, records holding areas, and food preparation areas. Many areas also require automatic chemical fire extinguishing systems. New construction requirements require virtually all of a hospital to be protected by sprinklers. Page Nine 10. CEILING TILES Make sure that the ceiling tiles in drop ceilings are in place and do not have holes. These tiles are also considered part of the fire protection because they can delay the spread of smoke or fire for a short period. 11. STAIRS Make sure that stairs have no-slip features. Many times, rubberized treads are glued to the steps. Often, these become loose or tom, presenting a tripping hazard. 12. PIPES AND VALVES All piped-in utilities must have labelled zone valves and a corresponding chart depicting the locations of every valve. Label and chart all medical gases such as oxygen, nitrogen, etc. 13. GAS CYLINDERS Ensure that gas cylinders are properly secured in place, and that they are chained to carts when transporting. Analyze all oxygen cylinders and bulk oxygen for purity upon receipt. Label cylinders with DD Form 1191 and indicate on the label the percent of oxygen, the date, and the initials of the person who performed the analysis. 14. DOCUMENTATION Required maintenance and testing of equipment must be performed and documented. Surveyors will want to see the documentation. Equipment falling in this category includes: emergency eyewash/ shower equipment, emergency power generators, fire/smoke alarms, fire/ smoke dampers, sprinkler systems, etc. Page Ten The Emergency Preparedness Plan (EPP) This important document is not a direct logistics function. The annexes outlining logistics support are logistics functions. Review this document periodically. The frequency is dictated by the AMH. It requires that the disaster plan be exercised and evaluated at least twice per year. This is the old familiar mass casualty exercise. After each exercise the critique process should stimulate revisions or changes to the EPP. Unfortunately, many logisticians think about the sudden increase in demands for medical supplies that a mass casualty situation generates. Much, much more should be included in the EPP and the Logistics Division and/or Branches should have even more detailed SOPs as an extension of the EPP. Prior to discussing all these elements, let's frrst look at why we have an EPP and why it is important to include some of the commonly overlooked topics. Page Eleven Function Of The EPP The EPP exists to guide the hospital staff so they can respond appropriately to disaster or contingency missions. In the military, of course, we need to consider war and mobilization issues. We also must respond to natural disasters whether they occur on or off post. These two considerations are usually well addressed and exercised. One requirement that is often overlooked is for hospitals to conduct internal disaster response exercises. In other words, almost all mass casualties involve the very dangerous assumption that the disaster affected only the world outside the walls of the hospital and that the hospital is fully functional with all personnel, equipment, and supplies in place. Scenarios often read: • "Several tornados ripped through the installation, demolishing half the installation and creating hundreds of casualties." Or: • "An earthquake ofmagnitude 9.1 reduced the installation and surrounding community to a pile of rubble." Didn't you ever wonder how such calamities could occur while the hospital remained unscathed? Are our construction standards this great? Are we just lucky? The problem here is one of focus. Everyone can appreciate the fact that the proficiency of the practitioners is of paramount importance. They cannot provide adequate patient treatment without the many administrative functions, not the least ofwhich is logistics. Scenarios need to address unusually high numbers of patients requiring treatment within a short period of time. They also need to be more realistic and afford the rest of the staff the opportunity to exercise their plans and learn. How about part of the scenario saying: • "As a result ofthe tornados, one wing of the hospital is unusable, there is no commercial power or water available, damage to the warehouse occurred with supplies water-soaked, and 25 percent of the hospital staff are now casualties." Or: • ''While preparing for the onslaught of casualties, an autoclave malfunctioned and blew up resulting in a frre which rendered the CMS and half of the operating suites unusable and injured half the staff of both areas." Page Twelve EPP Contents By giving examples of scenarios, you now have a hint of a few key issues your EPP should address. Let's go over some of these realizing that you may have other concerns to address based on your unique situation. Do not prepare your portion of the EPP in a vacuum. A great deal of coordination is necessary to develop a good plan. Many things require someone else to make the decision. Remember, like the rest of the logistics mission, satisfying the customer is the name of the game. Use the Emergency Preparedness Committee to get input and discuss proposals. Have one-on-one discussions. The importance of testing, evaluating, and updating the plan cannot be overemphasized. 1. UTILITIES You should address all utilities and develop contingencies enabling the hospital to continue to function with the normal utilities unavailable. In order to know what to address, you probably should first learn what utilities are presently in use that support your facility, who provides them, and how they are provided. Ifyou think this is a silly waste of time, consider this: Ifyou have only one water line serving the facility and it breaks, you have a more serious problem than ifyou had two or three lines with only one broken. Also, what backup systems already exist for these utilities? Next, you should also prioritize the customers who are dependent upon the various utilities during normal operations and mass casualty situations. You must involve the medical staff in this process, they can best determine what they need to meet medical contingencies. Remember, the EPP facilitates disaster response, and the loss of certain utilities IS a disaster whether ten or one hundred patients are at the front door. Next, you need to see what is available in your area to help you replace lost utilities. What capabilities do TOE units on your installation have for power · generation, water hauling,·etc. These don't have to be just medical units either. The medical units are important though to plan contingencies for lost sterilization or Page Thirteen What next? You have identified one unit to provide some support. Do you pencil them in your EPP and head for the golf course? Not yet. Coordinate with the unit (preferably in writing) to get details on their capabilities and get them to agree to support you. You still should not stop yet. Your contingency planning should include several layers of protection. This is important because you have no idea what disaster you may face; you don't know how long it will last; and you don't know how many things will go wrong at once. Also, ifyou get too many casualties, you may have to provide support to administrative areas temporarily converted to patient care areas. Depending on the actual disaster, other units on post may respond and are now unable to provide the agreed upon support. Finally, what if the TOE unit you counted on is deployed elsewhere or is now the source ofyour casualties, or their equipment is deadlined? Don't forget to try to get your newfound support to participate in the next exercise. Actually working the plan will give you an idea of shortcomings and enable you to correct them. See if they will actually respond and bring their water trucks to the facility. Ifyou plan to splice into existing plumbing with their equipment, make sure in advance that it will work. What utilities are hospitals normally concerned with? There are, of course, the obvious ones such as electricity, water, and sewage. Remember the not so obvious ones too such as heat, air conditioning, ventilation, steam, and the medical Page Fourteen gases like oxygen and nitrogen. What are the possibilities? • Electric We all know that all hospitals are required to have emergency generators. We test them every week and we breathe a sigh of relief every time they successfully start after actual commercial power outages. So, you feel very comfortable about them and don't need to address electrical matters in your EPP, right? WRONG!!! o When was your facility built? o Did computers on every desk, CT Scanners, and MRis exist when the facility was built? o Did they exist when it was designed many years before it was built? o Have you had an electromechanical upgrade in recent years? o Have you reviewed your electrical requirements compared to what is available from your generators? If your facility is over five years old and you answered no to any of these questions, this could mean you are in serious trouble. Remember that your facility was probably obsolete when the first patient entered it. Going backwards in time, it took several months to move in and install equipment, it took years to build, it took months to design, and it took years to fund. The design process tries to project increased demands but predicting the unknown is not a precise science. Going forward from the first patient, probably more equipment was purchased and installed, activities within the facility moved around, expansions occurred.... Do you really believe now that your generation requirements are adequately met? Now you know you have a problem, but how do you fix it? First of all, you need to include a backup contingency for your emergency generators in your EPP. Remember your priorities. o Can you at least provide power for your most critical areas? o Will the several field generators or UPacks on post provide adequate support? If you are fortunate enough, you may have one of the few Engineer units called "Prime Power Units" who can power the entire post. There are also many commercial concerns that can provide quick response with portable generators on a lease basis. Determine the possibilities and coordinate to provide the maximum coverage. Remember that the electrical distribution system in your facility is a massive and complex network. There are many automatic switches, circuits, and other elements. o An expert needs to tell you how and where to tap into the system with your backup support. o Someone from DEH and someone from the contingency unit need to get together and determine the best way to provide the support. o Special connectors may have to be purchased and installed for the backup to work. o Pre-installation of connectors might be necessary. Finally, you should periodically review what demands are placed on the emergency power circuit. o Should things be added? o Will your generator power additional equipment? o Should things be realigned? o Should things be dropped? o Are there items that require support by battery-powered "Uninter ruptible Power Supplies" (UPS)? What if OR is in progress, several patients in the ICU are on life support equipment, the ER has two cardiac cases going, the commercial power goes out, and the generators don't come on, even though they were successfully tested the day before? Sound far-fetched? At least one of our hospitals had that happen. Suddenly, communications become the most important element. Somehow, doctors and nurses must shift immediately to assist in critical hospital locations. Both the overhead pagers Page Fifteen and the pocket pagers are on emergency power, but the generators don't work. These systems should perhaps be on UPS. Ifyou've lost all power, it may take time to restore. The best thing for the critical patients is to receive extra attention, be stabilized, and perhaps evacuated. That can't be done without communications. Don't forget other forms of communications either. With all our automated systems, can we really function without them in all cases? Should at least some of these systems be on emergency power? • Water o What key areas need water? o What about purification of the water? o How will deliveries to and within the hospital take place? We all know the ER and OR will require clean water in large quantities, especially for mass casualty situations. What we often forget is the Dining Facility, they are a particularly large user ofwater. Address conservation methods to reduce the demand. For example, meals can be served on paper plates to avoid using water for dish washing. (Don't forget, however, this creates the possible additional problem of increased trash). o Can you readily hook in to exist ing plumbing to pump water to at least parts of the hospital? o Do you need a detail to distribute water in five gallon cans? Page Sixteen More importantly, ensure safe water is provided. Coordinate with Preven tive Medicine for the details and re cord them as part of the EPP. • Sewage This is perhaps one of the most difficult utility losses to deal with. Instead of worrying about bringing things into the facility, we are concemed about removing waste from the hospital that is normally handled in a closed system of pipes. Indeed, we probably weren't even aware the system was malfunctioning until we already had a big problem on our hands. The first thing to address is that all input into the system must immediately stop. Notify the entire staff that all discharges into the system must cease. Your plan should also address temporary methods of removal such as five gallon waste water cans. Of course, you should also address where to safely empty these containers. You need to look at how they are filled. For example, can a TOE medical unit loan you field sinks or will drains need tapping? What areas can remain without this service until the primary system is restored? Don't forget to involve your Preventive Medicine staff in this planning process as well. Don't forget, others often may have to tell what needs to be provided, and you simply provide it. You don't have to dream up the requirements too. • Central Gases You need to address who uses what gases (oxygen, nitrogen, medical air, nitrous oxide, etc.) and what are the priorities (remember that specific priorities may change depending on what type of patients each area has at the time of the loss). The logical way to replace a loss of central gases is with gas cylinders. o Are you presently stocking enough cylinders of each type gas to last until more can be obtained? o How long does it take to get more cylinders? o Who has keys to the storage areas? o Can the AOD access the storage area? You're probably thinking: I have cylinders connected to the central line as backup already, that's all I need. Well, you forgot, we are addressing disasters here. What ifthe line itself breaks? You know, the central line that both your primary bulk tank and secondary cylinders use to convey gases throughout the facility. You don't even need an earthquake either, just old rusty lines. Don't forget you have central suction lines too. Just think of them as central gas lines in reverse. They serve the same basic function and are important to the functioning of a facility. You need to identify how many and where portable suction devices can be obtained and where they are needed. • Waste Disposal Develop and exercise contingencies for disposal of normal trash. Ifyou don't think this could be a problem, consider this: o Go count the large trash containers (dumpsters, compactors, etc.) outside your facility. o Determine the frequency with which they are emptied and the average weight and volume of trash each time. o Now, imagine how much trash you will have accumulated each time the containers are not emptied. Now you can easily see why you should have a contingency plan for this. You should see what civilian flrms offer this service and perhaps have prepositioned contract specifications. You also need to consider where you can reduce the amount of trash generated. Another option is to maximize recycling efforts. Don't forget to have written contingencies in place for your regulated medical waste. You should have these in place anyway. Look at contracts, or other acceptable waste disposal methods such as: incinerators, retort sterilizers, grinders, etc. Like always, make sure your waste is properly segregated to reduce the amount of waste classified as regulated. It is easier and less expensive to dispose of ordinary trash than it is to dispose ofregulated medical waste. Page Seventeen • Cllmate Control • Steam Loss of heating, ventilation, and air conditioning is another difficult problem to address. There are alternatives though. o If only portions of any of these systems are lost, can the functioning elements be redirected to the most critical areas? Here, we are concerned with medical necessity rather than staff comfort. o Also, are there portable units available that can be safely (consult with your Safety Manager before using alternatives) used? Look at TOE assets as well as lease or purchase of equipment. o Perhaps, the only workable alternative is to move patients to areas still functioning. This requires input from the medical and nursing staff. o What about transferring or discharging the least critical patients? o What about placing these patients in billets, administrative areas, or field shelters with minimal nursing staff? These same options may also be appropriate for addressing losses of other utilities or facility functions. There are typically three uses for central steam lines within a facility. The heating system often depends on steam, as do some cooking systems in the dining facility, and sterilizer units often use central steam. o We've talked about options concerning climate control. o Loss of steam to the autoclaves presents another problem. Smaller units that don't depend on central steam are often available in our facilities. The clinics and DENTACs often have several. These can be used. Also, other hospitals can be used to provide sterilization of instruments, but you may have to obtain transportation. Field medical units can support you as well. One important thing to remember about steam is that the central lines contain steam which is very hot and under pressure. If the loss of steam involves ruptured or leaking lines, don't forget the safety considerations. o Clearly mark and rope off the area. o Ensure that water is mopped .up frequently. o Turn off the flow of steam, at least to that zone. Page Eighteen 2. MEDICAL SUPPUES We all know about this area, we do a pretty good job rapidly providing supplies to customers. Don't forget to consider "push packages" as the initial increment of supply. Get with the designated chief for each mass casualty area (immediate, delayed, expectant, etc.). Have that person give you a listing of supplies he will need to support the patient category for the designated area. Use your current stockage list as a guide and ask him to give you total quantities needed for increments of five or ten patients. Ifyou have a cart exchange system, you may want to pre-stock (remember to rotate stocks to avoid losses) carts for each area to handle the initial five or ten patient increment. When a mass casualty is declared, virtually anyone can wheel the carts out in a most rapid fashion. Remember that after the initial influx of patients, you may retum to supplying on demand but responses must be extremely rapid. Don't forget to watch your warehouse levels and replenish accordingly. In advance, you should have identified altemate sources of supply which can give you rapid response to your needs. Neighborhood hospitals, if not already involved in the disaster, can help. Use existing contracts and the DPSC "life or death" system. You may want to station supply representatives, equipped with radios, in each area to assist customers. Of course, express.all your plans in the EPP. 3. EQUIPMENT Supporting a disaster will require both nonmedical and medical equipment. • Attempt to identify in advance those equipment requirements. Again, consult with the medical and nursing staff. • Next, identify sources to satisfy these requirements. o Some may come from within the facility such as transferring equipment from administrative areas. o Some may come from reserve stocks. o Still other items may come from units on post. o Borrow, lease, or purchase items from the surrounding community. • Always keep those items which you may need immediately on hand and serviceable. Obviously, litters, litter stands, N poles, and linen are needed just to receive patients into the hospital from the evacuation vehicles. Remember that these items will transfer with the patients at a rapid pace as they are moved throughout the facility and treated. Ifyou don't deal with this, you will soon run out. o First, make sure you have plenty on hand. Page Nineteen o Second, establish a mechanism to retrieve these items and get them back in use. Don't forget to plan for other equipment needs, such as additional chairs or field desks/tables. Personal equipment cannot be used in a hospital, whether a disaster exists or not. All equipment operators must receive continuing education on the equipment, and the education sessions must be documented. 4. TRANSPORTATION The transportation assets your facility presently uses in a normal day probably are insufficient for a disaster response. The priority will obviously have to go to transporting or evacuating patients. Perhaps there are vehicles within the facility which can be shifted. Other assets, whether from the installation motor pool or TOE units, can also be obtained. Other demands for transportation will also increase such as for moving supplies and equipment, or hauling water or linen. 5. LINEN If the disaster you are faced with ineludes a large influx of patients, especially surgical, your linen demands will sharply increase. • Do you have the linen to support this? • Do your linen areas, clean and soiled, have room to process increased volumes of linen? Page Twenty • Do you have transportation assets to handle the requirement? • Can your supporting laundry service provide the service at an increased tempo? • Do you have the manpower to perform the work? Remember you will initially have increased ope:.;.ating levels throughout the facility. This will later translate into increased levels in the laundry while you will still need large amounts to support the wards. Don't overlook this multiplicative effect. You may need to consider disposables as a temporary measure (remember the increased trash this alternative generates). Ifyou already use a lot of disposables, consider your stock. • Is it adequate to accommodate disasters? • How easily can it be replenished? The Hazard Programs The hazardous materiel, hazardous waste, hazard communications, and regulated medical waste programs have received much emphasis and attention in recent years. The JCAHO is no exception, these programs are closely reviewed by them too. Remember that you are also subject to inspections, announced or unannounced, from·vartous government (federal and state) agencies such as OSHA and EPA. Having these programs in compliance with the laws is essential to your survival as a logistician. As you will see, you are directly responsible for only one of these programs. The reality of these programs is that you play a key and central role in them all. Another reality is that these programs overlap significantly. As you will see, the only way these programs are effective is through cooperation and close communications among the managers of all the programs. These programs also contain a feature which you should always keep in mind. That feature involves penalties for violations. • In the past, if someone in the Army violated the law, but was properly performing his duties at the time, the Army paid any fines or otherwise answered the charges. • Under the current laws, however, you are personally responsible for the violations. You pay for and provide your own legal defense (no JAG consult or representation): you go to prison or pay any fines for the offense. Violating these laws will ruin your whole day, and possibly your whole life. These laws will not go away: if anything they are becoming more strict with each passing day. The penalties are also becoming increasingly more severe. With that in mind, give these hazard programs the full attention they deserve. The discussion on these programs deals almost exclusively with federal standards. You are reminded that each state has its own requirements for these programs. You are required to comply with the more stringent of the two. Obtain your state standards and ensure you comply with them as well. The penallies under state laws are also the individual's to bear. Page Twenty-One 1. HAZARDOUS MATERIEL (HAZMAT) PROGRAM We have participated in this program for years, we just never had a fancy name for it. The logistics community has direct staff responsibility for this program. It involves the appropriate and safe handling and storage of materiel which co_uld present a hazard to personnel, property, or the environment. The best way to maintain this program is to get back to basics in your storage operation. Ask your-Preventive Medicine Office and Safety Manager to inspect your operation. They are required to perform an annual inspection anyway. Review your inventory and determine which hazardous items you deal with. Then, review the specific requirements to safely handle and store those items. • Do you need special protective equipment for your warehouse workers? • Do you need emergency showers and eyewash stations? • Ifyou already have these items, are you properly maintaining and testing them? Page Twenty-Two • Are personnel aware of the requirements and have they been trained on protective equipment? • Does your facility have the necessary special storage areas and equipment, such as flammable storage areas, refrigerators approved for flammable storage, acid storage areas, etc.? • Is there an emergency response or action plan which describes your activity's spill response and clean-up procedures and are employees trained in the program elements? • Do you have appropriate equipment to contain and clean spills? Several items require special storage. Let's review a few of the basics. • Compressed gases require special storage and handling. There are many safety requirements listed in the Compressed Gas Association Pamphlet P-1. Become familiar with all of them. o Secure storage areas to prevent unauthorized persons from tampering with cylinders. o Post signs indicating which gases are stored where. o Dry, cool, and well ventilated cylinder storage areas are required. o Segregate incompatible gasses such as oxygen and flammables. o Segregate the empty cylinders from the full ones. o Store cylinders away from sources of heat or damage, and in an upright position. o Cylinders of compressed gas must be secured to the physical structure or some other device that will prevent them from being knocked over and becoming a missile. Commonly, cylinders are chained to eyebolts fastened to the walls. o The valve covers must remain securely screwed onto the cylinders. o Remember to secure cylinders to the carts when transporting. o Train your personnel on proper storage and handling techniques. • Another requirement is a written oxygen quality assurance program which describes procedures for receiving, inspecting, and storing medical oxygen. o Test medical oxygen, cylinders and bulk, upon receipt to ensure it has a concentration of not less than 95 percent. o Designate in writing those individuals wQ.o monitor oxygen deliveries and train them in the use of the oxygen analyzer. o Ensure that the monitor appara tus has been calibrated in accor. dance with its required schedule. o Record test results, date tested, and initials of tester on the DD Form 1191 affixed to each cylinder. • Flammables require rooms or buildings of special frre resistant construction. Pay particular attention to the standards if you store these items within the hospital. o The doors to this storage area require a fire rating. o Some flammable storage areas require automatic chemical fire extinguishers. o Special personal protective equipment may be required due to other chemical properties of some of these products. o Often the fumes found in these areas require special ventilation features. o Spark proof electrical switches, lights, and sockets are required. o Obviously, you must ensure that no flames or sparks occur in or around the area. Review what activities occur in and near this storage site to ensure there is no potential problem. For example, with most facilities now designated as nonsmoking, a lot of our loading docks are designated smoking areas. We also have several facilities that have special storage areas in rooms which Page Twenty-Three open only onto the docks. You guessed it, there is designated smoking right next to flammable storage areas. What happens ifa leak develops? In 1993, when all facilities will be smoke-free to comply with JCAHO, the defmition of a facility for these purposes will include any covered structure attached to the main building(s). This will also include loading docks. Review your areas carefully. o Remember to post flammable areas with required signage and enforce the policy. • Corrosives (both caustics and acids) are other chemicals requiring special consideration. o Store these items in areas with features, such as built-in berms to contain any spills that could occur. o If those features do not exist, store the items in pans containing absorbent material. Be careful that the absorbent material is not composed of substances which could react negatively with any caustics. o If possible, store glass containers at ground level within the storage area. Regardless of the type of physical properties, you should ensure that chemicals having incompatible chemical properties are not stored together. This can be done by generic chemical classification. For example, you wouldn't store oxidizers with flammables or caustics Page Twenty-Four with acids. Be especially careful to not have incompatible items side by side or one above the other on shelves. Ifleaks develop, the two chemicals could combine with disastrous results. There are numerous compatibility charts available to assist you in making these determinations. Before brushing this off because you don't think the chemicals you have are exotic enough to be of concern, or because you think you have little volume, consider this: There are two common chemicals almost everyone has in their household that can ruin your whole day (not to mention your whole house) if allowed to combine. Common household bleach and brakefluid, when combined, rapidly and spontaneously create an intense fire, and you only need very small quantities of each. Review your chemicals carefully. You should also review how your customers store their chemicals as part ofyour CSDP. 2. HAZARD COMMUNICATIONS (HAZCOM) PROGRAM The Safety Manager has the staff responsibility for this program because the program is designed to protect employees from the health and physical hazards associated with the chemicals. For a hospital, we also need this program to ensure our patients and visitors are safe when in our facilities. As a logistician, you play a key and central role in this program. Let's look at the main requirements of this program and some ways to satisfy them. • First, everyone who is exposed or potentially exposed to workplace hazards at the worksite requires training. o Obviously, laboratory technicians are exposed to certain chemicals because they transfer chemicals between containers and use them to perform various tests. It is clear that they will potentially inhale fumes and have chemicals splash on them. Therefore, the law definitely applies to laboratory technicians. o What about warehouse workers? They deal only in originally sealed containers. They still have a great potential for exposure. They deal in large quantities and use materiel handling equipment. What if a forklift fork penetrates a container? What if a container falls from a pallet? As you can see, a majority of the hospital needs some degree of train ing in this program. In DOD, there are two levels of training required. o The first level is a broad, four hour overview which must be given. > It is required that this training be documented on a DD Form 1556 and filed in the permanent personnel records for both military and civilian. > This training session is the responsibility of the Safety Manager to manage. He may train supervisors and have them train their subordinates. o The second level of training is a supervisory responsibility. > During this training, the supervisor must provide specific training on worksite hazards. > He must discuss the written program (SOP) and where it will be maintained. Part of the SOP must contain a complete and current listing Page Twenty-Five (inventory) of what hazardous chemicals are located at the worksite. > He must discuss the hazards, precautions, levels of protection, spill responses, and first aid measures. This can be done for each type of chemical by category (carcinogens, caustics, irritants, etc.) rather than each specific chemical. > The training must also discuss the target organ(s) if known that would be affected by exposure to the chemical. > You must also discuss the location and use of the Materiel Safety Data Sheet (MSDS) which will be discussed more later. > Of course, like anything else, you must document this training session. The law requires that you train your personnel before they are allowed to work with or handle these hazardous chemicals. It also requires you to provide additional training each time a new hazard is introduced to the worksite. Remember that this does not mean new chemical, this also refers to the category. Another key point when determining who to train is the relative exposure risk. If a person is exposed to a commercially available chemical having home use applications, and exposure levels are not expected to exceed those of someone using the Page Twenty-Six product at home, then they do not need the full program. o For example, the toner in a copier is classified as hazardous. > If an individual only replaces empty cartridges and is therefore minimally exposed, they do no~ need the full treatment. > If a person is employed by a copier firm and is constantly exposed, they need the full program. o Another example is the correction fluid commonly referred to as "white-out." > Although this contains hazardous chemicals, the normal exposure is about the same as if you used it at home. > The question always arises conceming the secretary who makes an excessive number of mistakes. Rather than confusing the HAZCOM issue, this person should probably consider another career. • Another required component ofthe program is the inventory of hazardous chemicals present in the workplace. o There are a couple of ways to establish the initial inventory. > One is to provide a complete listing of items in the warehouse to Preventive Medicine and the Safety Manager. They can review the listing and indicate which items require inclusion in the program. > Another way is to conduct a wall-to-wall inventory looking for items having a warning or cautionary label. o Once the inventory is complete, provide copies to Preventive Medicine, the Safety Manager, DEH Environmental Engineers, and the Fire Marshall for purification. o Attach a copy of your warehouse planograph to facilitate locating these items during a disaster response. o Your inventory should include the information required by HSC and your installation. o The inventory is considered a part of the written program (SOP) and should be collocated. o Ensure that as new hazardous items are added to the inventory, they are added to the listing. In other words, post changes to the hazardous inventory as they occur. o Annually, in conjunction with your normal warehouse inventory (either wall-to-wall or cyclic), update your hazardous chemical inventory too. Like any other inventory, you are trying to validate your postings to the inventory. • The MSDSs are another key component required by the HAZCOM Program. By reviewing a "typical" MSDS (there is no standard format), we can readily see the importance of this element. o The MSDS will list the ingredients of the container by common and chemical name. o It will include the physical properties such as flammability, and chemical properties such as "oxidizer". o The MSDS must list the hazards by target organ (if known), the usual mode of entry into the body, and the effects of each mode of entry. For example, the effects of inhalation may be different from skin contact. o The MSDS should also list protective measures, first aid procedures, and spill control. Since the HAZCOM Program is concerned with informing employees of workplace hazards, it is easy to see the central role the MSDS plays in the program. You should be cau tioned that merely giving employees the MSDSs to read does not satisfy the training requirement. o The MSDSs must be accessible to all employees on all shifts to comply with the law. Think carefully about their location. If you decide to keep them in your office, for example, and your employees work more than one shift, do they have access to your office on Page Twenty-Seven those other shifts or on week ends? Ifnot, you are violating the law. o In addition to having MSDSs on hand for employee use, you must also ensure that these forms are provided to customers. > You should provide the initial copy to each customer who is issued a particular hazardous chemical. It is up to them to add it to their collection of MSDSs and retain it. > Don't forget, this requirement is for all customers, including the TOE, Reserve, and National Guard units you support. o You should also provide an initial copy to Preventive Medicine and your HAZCOM Program Manager (Safety Manager). o Don't forget to provide MSDSs to your installation people such as the Fire Department and DEH Environmental Office (if they require them). These are the folks who will respond to spills and fires and they need to know what hazards exist when they respond. The burning question on MSDSs is, of course, where will I get them in the first place? o For standard items, MSDSs will not accompany the shipment. You must use the DOD Hazard ous Materials Information System (HMIS). This is available on CD ROM or microfiche. All Log Divs were provided with centrally pro- Page Twenty-Eight cured CD ROM readers several years ago. The disks themselves are regularly updated and are available through normal publica tions channels. Don't forget to indicate you want updates auto matically sent to you each time. o The General Services Administration (GSA) maintains an automated database of MSDSs for those hazardous chemicals they supply. This can be accessed using your computer and MODEM. The GSA database is especially helpful for obtaining MSDSs for nonmedical chemicals, particularly those used by Medical Maintenance. o For nonstandard items, the law requires an MSDS be included in the shipment. The DOD also requires the procurement instrument to specify this requirement. The theory is, if it's in the contract and the vendor doesn't ship the MSDS, he doesn't get paid. In practice, if you call the vendor, they will FAX the MSDS to you that same day. Remember not to issue the item without the MSDS. • There is also a requirement to perform certain labeling and placarding functions. o First, if the product is already labelled, you are not to remove it, cover it, or alter it in any way. The manufacturer is required to perform this function and you are required to leave it alone. o Why should you be concerned about labeling? There are several cases where you must label hazardous materials. > First, ifthe original label comes off or is damaged unintentionally, you must provide proper labeling prior to issuing the chemicals. > Another reason you may have to label containers concerns packing configurations. Often, the individual containers, let's say bottles, are adequately labeled but they are packed in boxes which hold 12 bottles and the box is unlabeled. Often the opposite is the case, the box is labeled but the bottles are not. Ifyou issue the customer bottles, you must affix labels to them prior to issue. For your warehouse, you can label the warehouse location to protect your employees without having to undergo an extensive labeling campaign. > The fmal reason you may have to label is ifyou transfer hazardous chemicals from their original containers into other containers to use them. I know what you're thinking, that's for the lab folks, not for us box-kickers, right? Well, think again. What about your housekeeping staff? The folks who take disinfectant out of one or five gallon containers and put in squirt bottles. Now you're thinking, they're contract folks, they play by different rules. Wrong again, we're talking about a federal law and no one is exempt. You manage the contract, it is your job to ensure they comply with the law of the land. There are even additional requirements you must comply with just because they are contract which we'll discuss later. Don't forget your Medical Maintenance crew. These guys frequently transfer lubricants and so on into smaller containers. o Before you get carried away with the labels, let's review the actual requirements. > If the container you are transferring the chemicals into is for immediate use by one individual, it does not need a label. Consider immediate use the present duty period. > So, ifthe container is used by more than one individual, or if it remains filled for use beyond the immediate duty period, it must meet the labelling requirements. > The labels are required to contain specific information. Obviously, the contents must be on the label. The information on the original warning label is Page Twenty-Nine also required, including the target organ, the name and address of the manufacturer, importer, etc. • Depending on the labeling system you use, you may have a placarding requirement too. o Your Safety Manager should establish a uniform labeling system for use throughout the facility. Some commercially available systems are good, but the completion of the label requires the assignment of a number which indicates the relative risk of the chemicals. o Unless you clearly post a placard which "translates" the information on the labels, the labels are meaningless. o So, to decide if you need placards, look at your labels. Ifthey can stand alone, you don't need placards. The DOD Hazardous Chemical Warning Labeling system (DOD 6050.5-H) uses the DOD label as a placard to mark tanks, piping, vats, or similar vessels for hazardous chemicals and for containers too small to accommodate a legible label. • Now, as promised, let's talk about people who work in the facility who are not assigned. o This includes government employees of installation support elements such as DEH and contract personnel. Page Thirty o Contract personnel include housekeeping, medical mainte nance contracts, or one time DEH contracts. These situations are what the law refers to as a "multi-employer worksite." Specific requirements apply under these conditions. o First, if there are hazardous chemicals in the area where these "outside" people will work, they must be informed of their presence. o It is also necessary to -inform them of the location of the written program, inventory, and MSDSs within that worksite. Similarly, the "outsiders" must provide per sonnel within that worksite the same information. You must control this within your worksites, and common areas you access, such as penthouses. o You should also help your commander police up other facility elements. You can do this by including these requirements in contracts and work orders. o One last thing to remember concems your own people. Ifyour Medical Maintenance folks perform maintenance in the lab, let's say, they are the "outsider" to the lab. So, the lab must inform them and your maintenance personnel must inform the lab personnel of hazards associated with their respective work. + The requirement for a written program was mentioned several times. o Keep the HSC Regulation on hand as well as any facility documents implementing the program. You may very well fmd it necessary to augment these with your own SOP. o In it, you should discuss such things as how you will ensure that you and your customers receive MSDSs, how you will perform labelling, and any other procedural issues needed to ensure you comply with the law. How will the JCAHO or other agencies check the validity of your program? + Of course, they'll want to see documentation, such as your SOPs, training records, inventory, and MSDSs. They will also check the "bottom line." + Remember that the program is called Hazard Communications. As the title clearly indicates, the program exists to communicate hazards to the employees. Bearing that in mind, the ultimate check of the effectiveness of the program is, what do the employees know. An inspector will interview the employees to determine their level of knowledge. o Do they know what hazardous chemicals are present in the workplace? o Do they know where the written program, inventory, and MSDSs are? o Do they have access to them? o Do they know their responsibili ties under the program? I think you get the picture. One fmal word is in order. Naturally, we think about Materiel Branch as having a large need for this program due to the volume of chemicals. Don't forget Maintenance and Housekeeping as we alluded to earlier. Also, include your Materiel Distribution function and Self Service Store. These smaller activities are often overlooked, and the inspectors know it. That should tell you that the inspectors will typically seek out these smaller activities. It should also tell you that you should not overlook them. Page Thirty-One 3. HAZARDOUS WASTE (HAZWASTE) PROGRAM This program is a staff responsibility of the Preventive Medicine activity at your facility. They have trained personnel who know the hazards present in certain wastes and what is the safest way to handle them. The HAZWASTE program is concerned with protecting the environment and is federally administered by the EPA. We all know, however, that the logistician is charged with the responsibility of receiving, temporarily storing, and safely disposing of wastes. So, here we are again in the middle of a program which requires us to institute and enforce precautions when dealing with certain substances. First, we need to define what a waste is. • For the purposes of this program, a waste is an item that is no longer needed for its intended purpose. • To expand the definition further, a waste is an item that can no longer be used because it was potency dated, and has expired with no extension granted. Page Thirty-Two • It is also an item which has been suspended and has been designated for disposal. • A waste is also an item that is excess and designated for destruction rather than redistribution. • Awaste can also be a byproduct or product resulting from the original chemical being used. o An example would be a chemical resulting from the mixture of two other hazardous chemicals required to perform a lab procedure. o Another example of this is formaldehyde which was used to temporarily preserve tissues removed during surgery. Once the tissue has been removed and the solution filtered, the remaining solution is a hazardous waste. The tissue and filtrate are regu lated medical waste and will be discussed later. We now have a working definition of waste. However, not all waste is hazardous. Hazardous waste requires special handling and disposal, which means disposal is more expensive. Therefore, we need to segregate the two types of waste. Hazardous waste is a waste which, if released into the environment, would cause damage to the environment (which also includes us humble humans). You say this doesn't help you much? There is other help available. • For instance, the USAEHA maintains a technical guide (TG 126) containing waste classifications. • There is also an automated system available through the USAEHA. similar to TG 126 called MIDI. Destruction codes are now available in your automated monthly catalog update: the MSDSs (remember them?) often contain disposal information: and you may consult the manufacturer. • When preparing your destruction documents, you should attempt to assign proper destruction information to the items. • Your Environmental Science Officer in Preventive Medicine is required to sign all destruction documents as well. He must certify that destruction methods are consistent with the law. He is your fmal check in the process to ensure we protect the environment. We'll discuss destruction documents more throughout the HAZWASTE portion of this guide. Take care in the way you accept, store, handle, transport, and dispose of hazardous wastes. • First, you must ensure that you are the only one disposing of wastes. Do not allow the pharmacy or lab to dispose of their own wastes. They should turn these in to you using an appropriate turn-in document. • Wastes must be accumulated and stored in Department ofTransportation (DOT) approved containers. These containers must be serviceable at all times (no rust, holes, etc.). The container must be clearly labeled as hazardous waste. This label must also be dated with the date that accumulation ofwaste began. The law is very specific concerning accumulation periods and quantities. You and your customers must strictly comply with these laws. Let's look at these laws first. • At the point ofgeneration (lab for example), they may accumulate up to 55 gallons for up to thirty days, whichever comes first. o Once either limit is reached, they have 72 hours to turn the waste in to you. In other words, ifthirty days has lapsed since the frrst drop was placed in the container, and the container is not full, they must turn it in. o Similarly, ifthe container is full, but thirty days have not passed, they must turn in the container. This applies to normal hazardous waste. For all practical purposes, most generation points do not have the room for 55 gallon containers, or they generate far less than that during a 30 day period. Our facilities typically ~se five gallon or smaller containers. • Wastes classified as acutely hazardous wastes must follow much more stringent standards. One example of such a waste in the medical business is epinephrine. The accumulation amount is one quart. You cannot accumulate acutely hazardous wastes for longer than 30 days. Page Thirty-Three • Unless you have your own permit for hazardous waste storage, which, none of our hospitals have, you must also follow certain accumulation rules. o For hazardous wastes, you have ninety days from the date accumulation began. At the end of that period, the waste must have been ultimately disposed of. > This does not mean you transfer it to DRMO after ninety days. This means it must have been transferred to DRMO, shipped out, and finally and properly disposed ofwithin that time. > You are responsible as the generating activity to meet these times. > You are also responsible to ensure that the disposal method was proper. Just because it was given to DRMO, who gave it to a contractor, does not absolve you and make them responsible. The law holds you liable forever. If, in ten years, it is discovered that your hazardous waste was dumped in a lake, you are responsible to pay for damages and cleanup. o Ifyou or someone on your installation has a storage facility that has been issued a permit for hazardous waste storage, waste may be stored for up to 180 days from the start of accumulation. In some cases, the local DRMO Page Thirty-Four accepts accountability for wastes but expects you or the DEH to assume physical custody until picked up by the contractor. This does not alter the accumulation standards. • You must ensure that hazardous wastes are signed for and that you receive copies of all other paperwork associated with their transport and disposal. o You must have a copy of the manifest used to transport the waste and the document which details the final disposition of the wastes. o You cannot transport hazardous wastes on public roadways unless you are licensed and perform the required manifesting. Normally this requires a contract. Be sure to check your state laws. Some states have strict definitions of "public roadways." One state, for example, has determined that all roads on the installation are "public roadways." Their logic is that since it is an "open post", anyone can use the roadways, and therefore could be exposed to hazardous waste spills. This means that ifyou wish to transport hazardous waste from an on post TMC, to your warehouse, or from your warehouse to the on post DRMO, you must have a contract. Clearly, transporting outside the gate requires you to comply with the law. • You must prepare a destruction document (DA Form 3161) to dispose of hazardous wastes, regardless of how it is disposed of. o You must list each item separately on the document rather than a one line entry of "hazardous wastes." Include the method of destruction codes for each line. o The ESO must validate the methods of destruction and sign the document. Also, you still need the signatures of the destruction officer and witnesses. Part of the HAZWASTE Program is the Hazardous Minimization (HAZMIN) Program, or Pollution Prevention Program. As the names imply, this portion focuses on reducing the amount of hazardous waste. • This can be accomplished by reducing the quantity on hand, or the number of lines. • You can substitute a nonhazardous item for the hazardous one. • You can also recycle locally or off-site. Fractional distillation devices are available for recycling wastes, such as xylene or alcohol. Page Thirty-Five 4. REGUlATED MEDICAL WASTE PROGRAM We have presented some elements of this program elsewhere in this guide. This is another program which is managed by the Preventive Medicine activity. Like the others, this program requires significant involvement by the Log Div. For one thing, your housekeeping staff collects the waste throughout the facility. In some cases, they may run the incinerator and actually dispose of the waste. They may also operate a retort sterilizer or deposit the waste into the dumpsters. The key to this entire program, as mentioned earlier, is to reduce the amount of waste classified as regulated. Earlier, it was assumed that if a patient even looked at an item, it became contaminated. That's why our red bags were bursting at the seams with pizza boxes and soda cans. It was not uncommon to find red bags outnumbering regular trash bags by several times. Use the HSC Model Medical Waste Regulation as a guide. It specifically tells you what is regulated and what is not. I know you don't generate the trash, but you can help educate those who do. Page Thirty-Six + Track the waste generated at each site, and report back to the DCCS and Chief Nurse on those who are doing a good job and on those who need "remedial training". You need to get Preventive Medicine and the Infection Control Nurse motivated on this too. + You could also charge the customer for their portion of waste removal, which could convince the typically more resistant activities, such as labs and operating rooms. Remember that it is more expensive and difficult to dispose of regulated medical waste than normal trash. It also requires special handling by your housekeepers too. You should roughly have one red bag for every three regular trash bags in use. Don't forget the sharps containers are also considered regulated medical waste. Medical Maintenance Issues Medical Maintenance has a significant responsibility for the successful completion of the JCAHO survey. We already mentioned the need to report certain conditions to the Safety Committee. There are other areas which are a normal part of their day to day mission which have a profound impact on the outcome of the survey. First, remember that all equipment entering the hospital for use must be processed through Property Management and Maintenance Branches. • It doesn't matter who owns the equipment, this requirement is still valid. If it is owned by the government, leased, borrowed, used for demonstration or evaluation, cost per test reagent purchase plan, regardless of the situation, it must all pass through these two branches. • The labs seem to be the current violators of this policy; keep visiting them and reminding them. Commonly, the original equipment was properly processed but was subsequently replaced by the vendor. Maybe it was easier or faster than repairing broken equipment in place. Some of these contracts also specify that any upgrades will automatically be provided during the life of the contract such that the activity always has the most modern version. Ifan upgrade means swapping out the hardware, you now have a different piece of equipment on board, often without the Log Div knowing it happened. Since it was a replacement, this new equipment must also be processed through the proper channels. Why is this so important? What does this processing involve? • First, Property Management must account for all property in the facility and ensure that someone (handreceipt holder) is designated to properly care for and feed the equipment. Even ifwe don't own the equipment, we don't want it walking off; we want to use it in the hospital. Besides, if it disappears, we may end up paying for it, even though we no longer have the use of the item. So, good old property accountability principles apply. • Secondly, Maintenance needs to establish maintenance records on every item, regardless of ownership or who will actually perform the maintenance. This is required by JCAHO and also protects us from liability. Maintenance will then establish scheduled maintenance frequencies and ensure they are met. • Further, the new equipment may need to be checked for safety, or perhaps be calibrated. Page Thirty-Seven So, as we can see, maintenance is also satisfying JCAHO requirements when they perform their duties. • It should be stressed that the key to meeting these requirements lies with how closely Property Management and Maintenance Branches work . with each other. • It also depends on how well other activities within the hospital communicate with these branches. • It is critical that the various activities properly communicate their requirements to Property Management and Property Management must keep Maintenance·Branch informed about the arrival of equipment. It is also important for those two branches to be alert to changes in other activities. o Property Management needs to ensure, not only that equipment on the property book are present, but also what equipment is present but not on the book. o Further, maintenance can look at equipment they are working on, or near to the equipment they are working on and ensure it is accounted for and being properly maintained. Page Thirty-Eight Summary In this guide, we attempted to present you with some tools to address several different issues. Hopefully, you can use this guide to become more familiar with the requirements, to determine how well you meet the requirements, and how you can more fully meet the requirements. As we indicated from the outset, this guide will not replace the many regulatory documents, but it should help you understand them. We hope that it gives you a quick reference to the key issues, and that it can be of benefit especially to those lacking experience in these often complex areas. Most importantly, we hope this guide can facilitate your accreditation and serve to meet the underlying reasons for the accreditation survey. The maintenance and safety of your facility and its utilities are extremely important to overall quality of patient care. The hazard programs are gaining in importance and are expected to demand more of your time in the future. The EPP should be the cornerstone document for your disaster response. Maintenance of medical equipment has always been critical to quality care and it will continue to be critical. We would appreciate your comments and suggestions. If there is a way we can improve on this guide, please let us know. Ifyou have suggested topics for future guides, let us know that as well. We would like to continue to use this approach rather than the customary and restrictive approach of regulating your operations from the headquarters level. Please submit comments: • By mail to: Commander U.S. Army Health Services Command ATIN: HSLO-PL Fort Sam Houston , TX 78234-6000 • By telephone: DSN 471-8566 Commercial 512-221-8566 • ·By electronic mail: hsclolrb@ftsmhstn-hsc.army.mil Page Thirty-Nine Technical Assistance For Assistance On- Ceiling Tiles Documentation Doors to Inpatient Rooms Emergency Preparedness Plan Equipment Evaluating the Facility DSN Phone No. 289-8232 584-2241 471-6838/8101 584-2488 289-8232 584-2241 471-6424 584-2488 471-8405 584-2488 584-2241 Source Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA Office ofAccident Prevention, HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA Directorate of Clinical Services, HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA DCSWG, Maintenance Branch, HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Page Forty For Assistance On- Exit Signs Facility Fire Safety Standards Fire and Smoke Doors Fire Wall/Fire Partition Gas Cylinders Glass DSN Phone No. 289-8232 584-2488 584-2241 584-2241 289-8232 584-2241 289-8232 584-2241 471-6440 584-2488 289-8232 584-2241 Source Healthcare Facilities Planning Agency Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA DCSLOG, Supply Management Division, HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA Page Forty-One For Assistance On- Hallways Hazard Communications Hazardous Materiel Hazardous Waste Linen Medical Maintenance Medical Supplies DSN Phone No. 289-8232 584-2241 471-6488 584-2488 471-6488 584-2488 584-3651 471-8792 584-2488 471-8405 471-6440 Source Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA DCSWG, Supply Management Division (HAZCOM Coordinator), HSC Healthcare Hazards Division, ASsessment and Support Branch, USAEHA DCSWG, Supply Management Division (HAZMAT Coordinator), HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA Waste Disposal Engineering Division, USAEHA DC SLOG, Service Branch (Linen Program Manager), HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA DCSWG, Maintenance Branch, HSC DCSLOG, Supply Management Division, HSC Page Forty-Two For Assistance On- DSN Phone No. Other Doors 289-8232 584-2241 Pipes and Valves 289-8232 584-2488 584-2241 Regulated Medical Waste 584-3651 Safety Committe·e 471-6838/8101 584-2488 Smoking Policy 584-2488 584-2241 Sprinklers 289-8232 584-2241 Source Healthcare Facilities Planning Agency . Healthcare Hazards Division, Engineering Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Waste Disposal Engineering Division, USAEHA Office ofAccident Prevention, HSC Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Hazards Division, Assessment and Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering.Support Branch, USAEHA Page Forty-Three For Assistance On- DSN Phone No. Stairs 289-8232 584-2241 Utilities 471-6441 584-2488 584-2241 Source Healthcare Facilities Planning Agency Healthcare Hazards Division, Engineering Support Branch, USAEHA DCSWG, Facility Engineering Branch, HSC Healthcare Hazards Division,· Assessment and Support Branch, USAEHA Healthcare Hazards Division, Engineering Support Branch, USAEHA Page Forty-Four