OBSERVATIONS FROM TJC SURVEYS THIS YEAR: IC.02.02.01 EP 1 and EP 4

by dawnconrey

OBSERVATIONS FROM TJC SURVEYS THIS YEAR: IC.02.02.01 EP 1 and EP 4

by dawnconrey

by dawnconrey

Recently, we wrote to discuss some EC and IC findings we are seeing in 2016 with a high degree of consistency during TJC surveys. These two chapters of the accreditation manual are causing havoc on survey and we wanted to share these common findings with you, while still protecting the confidentiality of the hospitals hit by these issues.  In the previous blog entry we discussed two standards and two EP’s, EC.02.05.01, EP 15 and IC.02.02.01, EP 2. Here today, we will discuss two additional elements of performance at IC.02.02.01 that are causing an array of issues on survey.

 

IC.02.02.01, EP 1: This EP requires the hospital to implement its infection control plan to reduce the risk of infection. It becomes somewhat of a dumping ground for any issue, which seems risky and could lead to infection. For example, we have seen multiple findings relative to the use of skull caps in the OR instead of a bouffant cover over all hair and failure to use a beard cover, or a beard cover that is improperly adjusted so it does not actually cover the beard. This EP is also where we are seeing the ever-present adhesive residue, which cannot be easily cleaned and grabs hold of dust and hair. This is also where the perennial favorite about storing clean supplies directly on the floor gets scored. Each time someone wet mops the floor you are potentially contaminating the clean supplies. A companion issue to storage on the floor is an equally old time issue regarding mixed storage of clean and dirty supplies in the same location, leading to potential confusion on which is clean and which is not, or cross contamination. This same EP is where one of the most frequently scored issues in physical therapy settings is scored, a failure to clean the hydrocollator in accordance with manufacturers specifications. This is the large silver colored box containing a water bath for heating hot packs in PT. In the small print from the manufacturer it recommends cleaning out the water every two weeks. Many organizations are used to doing this only once a month, or fail to document when they do it. The last sort of potpourri issue on this same EP we have seen this year is a failure to clean dishes in accordance with the dishwasher manufacturers specifications for temperature of the water. Hospitals often have a log for documenting the temperature of the water each cycle. Unfortunately, the same risk you have with medication refrigerator temperature, food refrigerator temperature, and warmers is that someone documents a temperature that is outside of the acceptable range, but fails to note this or do something about this. Designing these logs with clear demarcation of the out of range zones can help, but it is not always successful. Too often staff view the task to record the temperature without understanding the reason the temperature is being examined at all. EC rounding and IC rounding should help to identify some of these issues before TJC sees them, if the checklist you are using includes a reminder to look at these issues.

IC.02.02.01, EP 4: This is the safe storage of medical supplies EP and again, a potpourri of issues has been noted. Several years ago TJC began to look at storage of laryngoscope blades but unwrapped ones still pop up on survey. Taking this concept a step further we now see TJC looking at plastic, disposable oral airways, which many times are purchased in bulk bags and once removed, there is no protective cover to prevent contamination. Another item that seems frequently present in the crash cart is the Magill forceps, which as a semi-critical device must also be kept wrapped to prevent contamination after processing. We have also seen the surveyors looking at the semi critical devices used in the ENT clinic, to make sure they are staying wrapped and clean until use. Another classic, which has been looked at for an entire generation is a closed bottom shelf on supply carts and linen carts. If you use wire rack storage without a hard bottom shelf, again with wet mopping, this will contaminate the bottom row of clean supplies. Last but not least is expired suture material and laryngeal airway masks, or LMA’s.  A process needs to exist to search for these each month. A technique surveyors and consultants often use is just to look for different colors in packages of medical supplies, from suture material to blood collection tubes. Picking up the odd color package often identifies an out of date product. However, getting staff to actually look at the dates is the preferred method. EC and IC rounds may pick up some of these, but the first line of defense is a monthly process in each department to look for these types of storage issues.

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