Environment of Care Page 1 of 51 ENVIRONMENT OF CARE Environment of Care Department Detroit Medical...

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ENVIRONMENT OF CARE

Environment of Care DepartmentDetroit Medical Center©Revised: January, 2009

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The goal of the Environment of Care Program is to provide a safe, functional, and effective environment for patients, staff and visitors. We accomplish this goal through activities that:

• Reduce and control the environmental hazards and risks• Prevent accidents and injuries• Maintain safe conditions for patients, staff, and visitors

ENVIRONMENT OF CARE

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Each facility has written plans and programs to design, implement, assess, evaluate and improve these areas. Each plan outlines activities that will reduce hazards in the workplace.

ENVIRONMENT OF CARE

There are 7 areas included under the Environment of Care:

• Fire Safety • Safety

• Utility Systems

• Medical Equipment

• Security

• Hazardous Materials

• Emergency Management

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The Environment of Care Committee is made up of employees like you.

This group monitors seven environment of care programs and their impact on the health and safety of our patients, employees, visitors and the environment.

ENVIRONMENT OF CARE COMMITTEE

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Each hospital has an assigned Safety Officer. The Safety Officer is available to answer safety questions, provide training on safety topics and follow-up on safety issues impacting you in the workplace. Safety Officers serve as resources during facility audits and inspections.

SAFETY OFFICERS HOSPITALS/CONTACT NUMBERS

Jerry Collins DRH – 313.745.4346 pager - 5071

Lynnelle Davis HUH/HWH/Old Hutzel – 313.966.7838 pager - 92752

Nancy Hunt DMC Surgery Hospital – 248.733.2422 pager - 9344

Ann Ward SGH – 313.966.1995 pager - 95119

Thomas Griffin RIM – 313.745.2247 pager - 94263

Jim Williams HVSH – 248.937.3334 pager - 248.527.8611

Sal Catanese CHM – 313. 745.7715 pager - 6844

Sheila Finch DMC Corporate – 313.745.8223 pager - 95926

DMC Compliance Hotline 1.888.484.9200

SAFETY OFFICERS

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You have the right to a safe work place! Here are some things you can do to keep your work environment safe:

• Know your job

• Remain alert; don’t take shortcuts

• Learn and follow safety rules, policies and procedures

• Attend safety training programs

• Participate in all fire and emergency drills

SAFETY MANAGEMENT

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HAZARD SURVEILLANCE

HAZARD REPORTING

You can also keep your workplace safe by reducing safety hazards in your area!

HAZARD DETECTION

REMEMBER TO: • Keep your area clean and hazard-free

• Be on the look out for hazards such as faulty equipment

• Report any safety hazards

immediately

SAFETY MANAGEMENT

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Promptly report all

incidents including near misses

via the web based reporting

system.

Notify yourunit manageror hospitaladministrationof any unsafeconditions,practices,hazards orinjuries.

INCIDENT REPORTING

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Patients have rights too! Make our patients’ visits to DMC facilities safe by:

• Helping to prevent slips, trips and falls

• Guarding against burns

• Lifting and moving patients safely

• Protecting patient’s rights

• Reporting all incidents immediately

PATIENT SAFETY

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RESTRICTED

Wear your ID badge at all times

Do not allow people in areas where they DO NOT belong

Call Security immediately if you need help

Park in assigned areas

SECURITY MANAGEMENT

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What is Safe Haven?

The Safe Delivery of Newborn law was introduced to end the tragedy of unwanted newborns being hidden and left to die. This law allows a parent to surrender their newborn (less than 72 hours old) in a safe and anonymous manner.

Safe Haven is a term used to describe our response to a newborn surrendered at a DMC hospital.

SAFE HAVEN

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DMC employees can accept a surrendered baby from anywhere inside the hospital. Confidentiality must be maintained at ALL times.

What should I do if I am handed a baby:

• You must confirm that the parent is surrendering their infant to you

• Contact security who will escort you and the baby to the Emergency Department

• Once infant is received, the child cannot be returned to the parent, either by request or with a change of mind

• The parent will be given a pamphlet on “Surrendering Parent Rights”

SAFE HAVEN

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You have a “Right-To-Know” about hazardous chemicals in your workplace!

Follow the DMC policies and procedures when working

with hazardous materials:• Review all policies and procedures before handling materials

• Locate emergency numbers and equipment

• Request a copy of a Material Safety Data Sheet (MSDS) if you have questions on the hazardous chemicals in your area

• Wear appropriate Personal Protective Equipment (PPE)

• Do not eat or drink while handling chemicals or blood/body fluids

HAZARDOUS MATERIALS & WASTE MANAGEMENT

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Material Safety Data Sheet(s) (MSDS):

MSDS is your guide to chemical safety. It is where you find information on hazardous chemicals. The MSDS contains basic information on chemicals such as:

• Chemical identification • Hazardous components

• Fire and explosive data

• Health hazards

• Spill response


MSDS

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Obtain a Material Safety Data Sheet (MSDS) by calling Poison Control at:

*Huron Valley-Sinai employees contact the Laboratory at - 248.937.3334

9.1.800.222.1222*You must:• Identify yourself as a DMC employee• Provide the name of the chemical and your fax number


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PPE provides protection from the hazards you may encounter on your job. Not all PPE are the same! It is important that you always wear the correct personal protective equipment (PPE) for the job.

Goggles

Gloves

Boots

Respirators

Face Shields

Aprons/Gowns

Suits

Masks

PERSONAL PROTECTIVE EQUIPMENT (PPE)

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We are committed to: • The prevention of pollution • Compliance with environmental regulations and other requirements• Continuous improvement

THINK GREEN Environmental Hotline 1-888-484-9200 THINK CLEAN

The Detroit Medical Center is dedicated to the health and safety of its patients, employees, customers, community and environment.

DMC ENVIRONMENTAL STATEMENT

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ENVIRONMENT MANAGEMENT SYSTEM (EMS) OVERVIEW

In 2001, the Detroit Medical Center implemented an Environmental Management System (EMS) that supports its commitment to the environment.

Our goal is to identify and proactively address all relevant environmental aspects and impacts associated with our operations.

In December 2001 the DMC successfully completed the registration process for ISO 14001, becoming the first healthcare system in the nation to achieve that distinction.

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The Detroit Medical Center regularly reviews its processes for regulatory and EMS compliance and conformance. We also seek opportunities to reduce, recycle, and replace hazardous materials used in our workplace by providing awareness training for our employees.

Examples of this activity include:

• Reducing the quantities of hazardous chemicals ordered, thus minimizing on-site storage and reducing the risk of spills

• Recycling items like paper, toner cartridges, cans, batteries and fluorescent bulbs

• Replacing or substituting hazardous materials with a less hazardous material. Reduce mercury usage in our facilities by using mercury-free alternative products

ENVIRONMENTAL MANAGEMENT SYSTEM (EMS)

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•As part of the DMC commitment, each hospital has identified activities that affect the environment and ranked their significance

•These activities are called Environmental Aspects

•These activities can range from recycling items like batteries and toner, to correctly handling and disposing of hazardous waste

•Each department has environmental aspects

ENVIRONMENTAL ASPECTS

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• Significant Environmental Aspects (SEAs) are those things that have a major impact on the environment

• Examples of SEAs include: - Medical waste

- Radioactive materials

- Hazardous chemicals • SEAs are found in many areas of the

hospital, including: - Laboratory

- Radiology

- Pharmacy

- Maintenance Shops

- Patient Care Units

SIGNIFICANT ENVIRONMENTAL ASPECTS

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• Once identified, departments must complete documents that outline how SEAs are managed in their area and in some cases, how these levels can be reduced

• Managers will verify that required procedures, protocols, records and staff training are implemented

How do you decide if an environmental aspect is significant?

SIGNIFICANT ENVIRONMENTAL ASPECTS

Regulated Environmental Aspects that impact air, land, water, human health, generate waste, use raw materials or natural resources may be considered significant:

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Objectives and targets are performance improvement initiatives. The DMC has identified three performance improvement initiatives for the EMS program:

• Reducing costs related to medical waste by 5% in 2009 through proper disposal practices

• Increasing recyclable items in 2009 • Reducing costs related to chemotherapy waste by 5% in 2009 through proper disposal practices

ENVIRONMENTAL OBJECTIVES AND TARGETS

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• Must have measurable goals

• Progress is tracked to measure our success and identify opportunities for improvement

ENVIRONMENTAL OBJECTIVES & TARGETS

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• You are responsible for following established protocols to protect yourself, co-workers, patients/visitors and the environment

• Your manager is responsible for developing department specific procedures and conducting training

• Your hospital Safety Officer is responsible for leading the implementation at your facility

• Contact the DMC Compliance Hotline at: 1-888-484-9200 to report environmental issues or concerns

EMS RESPONSIBILITIES

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Our environmental and qualitymanagement systems are periodicallyaudited for conformance andcompliance by a trained team of

auditors.

Auditors review: • Policies, procedures and protocols • Maintenance records and logs • Training records • Documentation A report of audit findings andrequirements for improvement (RFIs)is compiled for follow-up action.

AUDITS

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• The DMC Commitment to the Environment (Available on Cue Cards)

• The SEAs in your department• Your EMS management

representative is your Site Safety Officer

• How to report environmental concerns or questions

INFORMATION THAT EVERY EMPLOYEE SHOULD KNOW

ALL Vendors and Contractors are provided with information on the EMS at the DMC.

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• Management periodically reviews the performance of the DMC Environmental and Quality Management programs

• Activities are reviewed, reported

and acted upon by the appropriate site and system committees

• DMC Environmental and Quality

Management programs are evaluated annually for their effectiveness

MANAGEMENT REVIEW

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BE PREPARED!

Codes are effective December 1, 2007

Code Black – Severe WeatherCode Blue – Adult Medical EmergencyCode Brown – Neonatal EmergencyCode Evac – Evacuate PatientsCode Gray – Combative PersonsCode Orange – HazMat SpillCode Pink – Infant AbductionCode Purple – Child AbductionCode Red – FireCode Silver – Person with Weapon/HostageCode Triage External: External DisasterCode Triage Internal: Internal DisasterCode Violet - Radiation IncidentCode White - Pediatric Medical EmergencyCode YellowYellow - Bomb Threat

EMERGENCY PREPAREDNESS

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• Civil disturbance

• Utility alert

• Community hazardous materials releases

• Major communicable disease response

OTHER DISASTER PLANS

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Fires can happen anytime and in any place. If a fire does start, you need to know what to do quickly. Remember—stay calm and follow these rules (RACE):

• R = Rescue anyone from immediate danger to a safe area past the fire doors

• A = Pull the Alarm box nearest you. Contact your operator or security department and give exact location of fire

• C = Confine the fire. Close all doors

• E = Extinguish (put out the fire) with the appropriate fire extinguisher, if you are trained to do so

Cue cards are available.

CODE RED

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Expectations:

• DO NOT USE ELEVATORS• LIMIT TELEPHONE USE

You must be able to locate the following:

• Nearest extinguishers• Pull alarm boxes• Evacuation plan • Two exit routes in your assigned area

CODE RED

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• Keep your area clean and clutter-free

• Keep overhead storage at least 18 inches below the sprinkler heads

• DO NOT prop open doors

• DO NOT block fire doors, pull stations or extinguishers

• Keep corridors and hallways clear and free from obstructions

PRACTICAL TIPS ON FIRE SAFETY

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• “ABC” extinguishers = dry chemical: used on any type of fire

• “BC” extinguishers = dry chemical and CO2 : should be used on electrical or burning liquids only

• “A” extinguishers = pressurized water: should be used on ordinary combustible materials

TYPES OF EXTINGUISHERS

“ABC” extinguishers are the most commonly used extinguisher in hospitals and healthcare facilities.

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P A S S:

P = Pull the pin

A = Aim low, at the base of the fire

S = Squeeze the handle

S = Sweep from side to side at the base of the fire

WHEN USING AN EXTINGUISHER

CLICK ON BLACK BOX FOR VIDEO ON ‘PASS’ DEMONSTRATION

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Healthcare facilities have built-in devices to protect us from fire such as sprinklers and smoke detectors. The doors and walls are designed to prevent the spread of fire.

Evacuation plans are located throughout the facility.

FIRE EQUIPMENT

BUILDING COMPONENTS

EVACUATION PLANS

SMOKE DETECTION

FIRE SAFETY COMPONENTS

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During renovations or system failures the same level of fire protection must be maintained as during normal operations.

The special measures that must be taken in these circumstances are called INTERIM LIFE SAFETY MEASURES (ILSM), which include the following:

• Ensuring that exits are clear and unobstructed• Setting up a fire watch• Placing extra fire extinguishers in the area• Conducting more fire drills

INTERIM LIFE SAFETY

You can do your part by not entering areas under construction.

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To facilitate the arrival of crash cart and specialized personnel to the location of an individual found in cardiac or respiratory arrest.

Action: Call hospital operator to announce the specific code and location

Medical Emergency Codes

Code White – Pediatric Medical Emergency(Persons 8 years of age or less)

Code Blue – Adult Medical Emergency(Persons 8 years of age or greater)

Code Brown – Neonatal Medical Emergency(Patients of infant ages)

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Code Silver – Person with a Weapon/ Hostage

Code Black – Severe WeatherInitiated when unsafe weather conditions exist in the area.

Action: Close blinds, drapes, and unit doors Reassure patients and visitors Move patients from rooms to hallways. Cover non-ambulatory patients with blankets to avoid injury from debris.

Initiated when there is an individual in possession of a weapon, or one who has taken hostages.

Action: Clear area to avoid others being endangered.Call security to report the situation. Report as much information as possible.

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Code Yellow – Bomb ThreatCode Yellow – Bomb Threat

To facilitate the notification of a bomb or threat of a bomb (suspicious package).

Action: Take all reports of a bomb seriously. Keep caller on line, obtain as much information as possible. Complete the Bomb Threat Form. Contact Security.

Code Gray – Combative PersonCode Gray – Combative PersonTo facilitate the management and de-escalation of an abusive or assaultive person.

Action: Do not attempt to intervene. Contact security giving your full name. Provide as much information as possible about the incident; giving the location of the incident, number of persons involved, injuries and any weapons (if applicable).

Notify supervisor as soon as possible.

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What is Code Pink and Code Purple?

A Code Pink is called when an infant (<1) is confirmed missing from their assigned unit. A Code Purple is called when an child is missing or know to be kidnapped. The plan outlines staff responsibilities in each of these events.

Steps staff can take to prevent child abduction:

• Always display your DMC badge with your name and picture in full view

• Only give child’s information to the parents or legal guardian

• Do not release infant/child to any employee without proper DMC identification

• If in doubt, hold the child until verification of identity is confirmed

• Notify Security of any suspicious people in your areaFOLLOW YOUR FACILITY PLAN!

CODE PINK: INFANT ABDUCTIONCODE PURPLE: CHILD ABDUCTION

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Code Orange – Hazardous Material Spill/Release

To initiate prompt response in the event of a hazardous material spill or release ensuring the proper disposal of material.

Action:

Incidental Spills: Trained users clean up small spills, using the appropriate personal protective equipment, and decontamination materials. These spill represent NO hazard to trained employees or the environment. Materials must be appropriately disposed of and Environmental Service should be contacted for secondary cleanup.

Emergency Spill: Spills which may present a hazard to people or the environment or the effects are unknown. Isolate the spill (evacuate). Deny entry to others and notify the supervisor. Contact the Safety Officer.

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Action: •Upon notification, evacuate ambulatory, wheelchair, then bedridden patients. Take records if safety permits. Follow department plan. • Report to designated assembly area and account for all who were in previous area.• Report evacuation status and identify persons not accounted for to the “Incident Commander.”

Code Evac – Evacuation of Patients RequiredTo facilitate the evacuation of patients when remaining in area may be hazardous to life, health and safety.

To initiate prompt response in the event of a radiation incident or release of radioactive material.

Action: Isolate spill area and deny (evacuate) entry to others. Notify supervisor and security. Notify Radiation Safety Officer.

Code Violet – Radiation Incident

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To prepare the facility for an influx of patients due to an internal disaster.Action: If at work, return to department. Complete assigned duties. If at home, report as instructed.Implement department disaster plan. Perform employee call back procedures when instructed to do so or when additional staffing is required. Follow instructions of your facility. Complete the disaster evaluation form.

Code Triage: Internal Disaster

Code Triage: External Disaster

To prepare the facility for an influx of patients due to an external disaster.Action: If at work, return to department. Complete assigned duties. If at home, report as instructed.Implement department disaster plan. Perform employee call back procedures when instructed to do so or when additional staffing is required. Follow instructions of your facility. Complete the disaster evaluation form.

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ALL new clinical equipment must be evaluated by Clinical Engineering:

• Review procedures for the proper use of equipment

• Immediately remove faulty equipment from service and tag it for repairs

• Notify your unit manager if faulty equipment has caused serious harm to patients or employees

MEDICAL EQUIPMENT MANAGEMENT

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MRI SAFETY EDUCATION

Employees and all personnel entering the MRI room need to understand that the MRI is an extremely powerful magnet (30,000 times the force of gravity) and has the potential to be a dangerous place, if certain rules are not followed.

METAL OBJECTS: Ferrous metal (magnetizable) objects can become airborne as projectiles, and thus could cause serious injury and/or death to anyone in the MRI room.

Because of the dangers of metal objects in the MRI room, all metal objects must be tested and shown to be non-ferromagnetic BEFORE being allowed in the MRI room.

Examples of metal objects that can be strongly attracted by the MRI magnet include:

- Tanks - Tools of any kind- Wheelchairs - Office Chairs- Stretchers - Ladders- Traction devices w/metal shot - Keys, Pocket Knives- Suction Machines - Pens, Paper Clips- Carts and Crash Carts O2 - Lighters

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MEDICAL IMPLANTS:

Another area of great caution is that of medical devices and implants. Any person entering an MRI room with a non-MRI-approved medical implant could be subjected to serious injury and/or death.

Because of the danger of medical implants malfunctioning or being drawn by the magnetic field, every person must be screened for medical implants and not allowed into the MRI room until the specific brand and model is proven to be MRI safe.

Examples of medical implants that are NOT ALLOWED into the MRI room include: Cardiac Pacemakers, Defibrillators and Intra-Cranial Vascular Clamps (aneurysm clips).

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HISTORY OF INJURY BY METAL OBJECT:

Any person entering an MRI room with a history of having been injured by a metal object could be subjected to serious injury and/or death. Because of the danger of movement by metal objects remaining in the body after injury, everyone must be screened and further testing may be ordered to determine the location of the metal foreign body.

Examples of metal objects that may remain in the body after an injury include:• Bullets• Pellets• BB’s• Shrapnel• Metal fragments in the eye

If there is any degree of uncertainty about the remaining fragments, an x-ray will be performed to evaluate the location of fragments.

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EMERGENCY PROCEDURES:

• All technologists must be instructed in emergency shutdown procedures, i.e., abortion of measurements, table release, and transfer of the patient to a safe area.

• All housekeeping, maintenance and security personnel should be made fully aware of the procedure for notification of appropriate personnel in the case of an emergency situation.

• DO NOT bring the crash cart into the MRI suite. Wait for the MRI personnel to bring the patient out of the MRI to a safe area to resuscitate.

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Red outlets are connected to emergency power and continue to provide electricity in the event the hospital’s power supply fails. Only use them with critical equipment.

Medical Gas

Lights

Heat

Water

Electricity

Communications

Emergency Plans

UTILITIES MANAGEMENT

DMC hospitals have back-up or contingency plans for utility systems so we can continue to provide patient care services during an outage. Know your emergency plans and the location of the utility shut off valves in your area.

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We hope this NetLearning course has been both informative and helpful.

Feel free to review this course until you are confident about your knowledge of the material presented.

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SUMMARY

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