Patton Post – March 2025

March 2025

Inside This Issue

Clinical Fires:

This month’s lead article discusses clinical fires and TJC provides some very informative examples of clinical fires that impacted organizations during 2024:

• Fire caused by high flow oxygen humidifier
• Fire caused by a wireless speaker lithium battery pack while being charged
• OR table fire caused by a lithium battery pack in the table

The article summarizes some of the impacts of these fires, including damage to 25,000 square feet of hospital space due to water flow from sprinklers used to suppress the wireless speaker fire.

While we sometimes are encouraged by the thought that: “this has not happened at our organization,” these examples should give everyone pause, because it can. TJC reminds readers that standard EC.02.03.03, EP 7 requires an annual OR specific fire drill, and they have an informative standards FAQ on their website about which types of fire extinguishers to use in surgical areas and advice to consider sterile water rather than a water mist fire extinguisher during a surgical procedure.

We suggest that readers share this article with OR and facilities leadership and use it to help educate and plan for this year’s OR fire drill. We found the examples of fires and damage caused by lithium-ion batteries particularly helpful. We have seen many examples of phones, radios, speakers and other personal music devices in empty offices charging and this may be a hazard you want to mitigate.

Preventing Falls in the Physical Environment:

EC News has a good refresher article on preventing falls that the summarized national estimates of the total number of falls in all US hospitals is somewhere between 700,000-1,000,000 per year. They also advise that falls is their number one most frequently reported sentinel event with 672 falls reported in the database during 2023. This included 26 fatalities, 56 permanent harm events, and 538 severe harm events.  EC News also reminds us that falls don’t just happen to patients, falls from slipping can happen to staff and visitors as well.

TJC provides 16 suggestions for improvements that may help to reduce the risk of falls including:

1. Examine floors for wear or damage that might lead to a tripping hazard
2. Organize patient rooms so that patients can reach personal items
3. Repair broken nurse call lights or cords and implement no pass zone policies
4. Replace burned out or flickering lightbulbs
5. Eliminate unused equipment including canes and walkers from patient rooms
6. Construct floors using non-slip surfaces in toilet or shower areas and use no skid wax
7. Repair or replace broken wheel locks on beds, wheelchairs or stretchers, and ensure locks are in the locked position
8. Ensure corridors are free of clutter
9. Don’t block corridors with equipment, or power cords that cross the floor
10. During wet weather keep corridors and rooms clean and dry
11. Use caution wet floors signs during mopping
12. Clean up spills immediately
13. When wet processes are performed use platforms, mats or other dry areas
14. Avoid construction dust or other contamination in hallways
15. Encourage employees to wear appropriate nonskid footwear
16. Educate and train on fall prevention initiatives

Emergency Lighting Q&A:

The March issue of EC News has a very useful article on emergency lighting requirements and testing expectations. Testing is described in EC.02.05.07, EPs 1 and 2. EP 1 requires a monthly test of emergency lighting and exit signs required for egress, and task lighting for a minimum duration of 30 seconds. EP 2 requires a 90-minute test of the same, every 12 months. When you perform your 90-minute test, you don’t have to perform the 30 second test that month.

In addition, the life safety code chapter has three (3) elements of performance in LS.02.01.20, EPs 38, 39 and 40, with EPs 38 and 39 establishing requirements for egress illumination and exit illumination and EP 40 establishing requirements for exit sign placement and size. This article would be a good discussion document to begin a review of internal documentation of testing and verification of adequacy of illumination and placement.

Protection from Fire:

The last article in EC News discusses occupancy types and protecting patients from fire. One confusing issue that arises is: What exactly is the requirement for ambulatory occupancies in hospitals?

This article has a boxed advisory that CMS has established more stringent requirements for ambulatory surgery centers and outpatient surgery centers of hospitals that require the outpatient location to meet at least the ambulatory occupancy requirements, even if only one patient is mostly incapable of self-preservation, not the four (4) or more that are described in NFPA. This article also contains a link to another of the JCR tools for self-evaluation of fire prevention and control.

Natural Disasters and Evacuations:

The February issue of the new Joint Commission publication, EM Leader came out after we had published our February Patton Post newsletter. As you might anticipate, there are some articles relative to wildfires, given what just happened in California. The last article in this month’s issue, quoting from an article originally published in the American Journal of Public Health 2023, indicates that wildfires have accounted for 18.4% of hospital evacuations since 2001. This article also contains a link to a JCR tool created to help organizations prepare for wildfire situations.

EM Leader has another article with links to an AHRQ Hospital Evacuation Decision Guide. This then provides additional links to a decision guide to help determine when a hospital should evacuate given the nature of the pending disaster. The AHRQ material appears to be from 2018, but given what has recently happened, it certainly seems pertinent to today’s emergency management planning.

ACHC: Physical Environment Management Plans:

On February 11^th, ACHC posted a brief but helpful blog discussion: Bridging the Gap: Understanding the Interconnection Between the Physical Environment and Life Safety Code Standards for Hospitals. ACHC has requirements for management plans in their Physical Environment chapter. The plans they require should not surprise our readers:

• Building Safety
• Building Security
• Hazardous Materials
• Fire Safety
• Medical Equipment
• Utility Systems

The blog then includes advice for creating a fire safety management plan starting with two (2) building blocks, combining requirements from their Physical environment chapter for fire safety and requirements from their life safety code chapter for means of egress + fire alarm systems + fire suppression systems + fire safety systems.

ACHC then suggests a typical management plan outline including:

• Purpose of the Policy
• Scope of the Policy
• Policy Statement or Description
• Essential content expectations from the PE and LS chapters
• Evaluation of effectiveness, PI and monitoring activities

The content headers we bold coded could remain consistent across your management plans, and the essential content pieces would be derived from the standards for Safety, Security, Hazardous materials, etc.  As many people sometimes don’t know where to start or how to start a management plan, this seemed like a simple conceptual framework to use.

DNV: Compliance Automation:

DNV posted their HealthHub newsletter to LinkedIn on February 27^th, How to Leverage New Tools for Compliance Automation. Here you can access this newsletter article and subscribe to future publications.

CIHQ: Standards, Policies, and Survey Activity Guide:

We did not see the CIHQ newsletter posted as we were writing ours, but we did find a page on their website that allowed us to download their standards, accreditation policies, and survey activity guide: https://cihq.org/acc-default-hospitals.asp. As you might imagine, downloading their entire standards manual is a lengthy process.

NIOSH: Hazardous Medications:

The National Institute of Occupational Safety and Health, or NIOSH a division of the CDC has published an updated list of hazardous medications dated 2024, Hazardous Drug Exposures in Healthcare. The link will direct you to a landing page where you can access the recently published 2024 list, as well as the 2023 document for Managing Hazardous Drug Exposures, and another 2023 publication on how NIOSH identifies hazardous drugs – you will want all three (3).

The last official list was published back in 2016, when it had been on an update schedule about every two (2) years. The forward in the new 2024 document does contain an important warning stating that the new publication’s list of hazardous medication is “not all inclusive.” While they did add 25 new drugs to the list, the drugs added were approved by the FDA or received new warnings from the FDA during the period January 2014 – December 2015. Drugs receiving FDA approval or new warnings during and after 2016 are not yet part of this listing.

Hospitals will still have to evaluate drugs they may be using for possible inclusion on your hospital specific list of hazardous medications. That third publication mentioned above may be helpful in screening which drugs you use that should be added to your list. As a reminder USP Chapter <800> does include a ”must” requirement to have a facility specific list of hazardous medications. TJC’s MM.01.01.03 also requires a hospital to identify the high alert and hazardous medications that are used.

After you have solidified your hospitals list of hazardous medications in use, you will want to re-review the 2023 NIOSH publication on Managing Hazardous Drug Exposures. This document suggests an “exposure assessment”, followed by a “risk assessment” evaluating the different hazards, the probability of exposure and the severity of health effects. The next step is then a risk management plan to protect workers  from the effects of hazardous medications.

While this may seem like a huge new burden, to some extent the work you were already doing to implement USP Chapter <800> is helpful because you were doing that analysis, knowing that the 2016 NIOSH Hazardous Drug List was out of date, and therefore evaluating other products you were already using for potential hazard identification. But, to the extent that the analysis for USP Chapter <800> was lagging, you will want to finalize your analysis, as this may be on more surveyors’ radar than previously.

NCC Restraints and Psychotropic Medications:

On March 10, 2025, CMS posted QSO 25-14-NH. This is for the nursing home industry and had been initially posted 1/16/25 as QSO-25-12 NH as an advanced copy. It appears the key modification is to minimally delay the implementation from March 24, 2025, to April 28, 2025. This regulatory memo only affects the long-term care industry, but as we suggested in January, if time permits hospitals readers may want to read the memo’s guidance on restraints and psychotropic medications as they reflect current CMS thinking that may be incorporated into hospital guidance at a later time.