Transcript Emergency Management

CSHE Los Angeles Chapter
2013 Annual
Devin J Hugie, SASHE, CHFM, CHSP-FSM, CHEP
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Criticality defined as “the immediacy of risk to patient
safety or quality of care as a result of noncompliance
with a joint commission requirement.”
4 levels of Criticality:
Immediate Threat to Life (ITL) *PDA Until Resolved
Situational Decision Rules * Based on Specific situations
at time of Survey.
Direct Impact Requirements * Noncompliance may
create an immediate risk to patient safety or quality of
care.
Indirect Impact Requirements * Based on planning and
evaluation or care processes
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Significantly compromised fire alarm system
Significantly compromised fire sprinkler
system
Significantly compromised emergency power
supply system
Significantly compromised medical gas master
alarm panel
Significantly compromised exits
Other situations that place patients, staff or
visitors at extreme danger
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The amount of time for submitting the ESC
(Evidence of Standards Compliance) is based
on the criticality of the finding and the
immediacy of risk as follows
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Direct Impact Within 45 Days
Indirect Impact Within 60 Days
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4)
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⑥
7)
8)
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12)
13)
Design/Installs systems that meet pt care / op needs
Written inventory of components
Identifies inspection / maintenance activities
Identifies intervals for inspecting, testing, maintain components
Minimizes pathogenic biological agents in cooling towers, etc
Pressure relationships; air-exchanges, filtration efficiencies (the ventilation
systems provides appropriate pressure relationships, air-exchange rates, and
filtration efficiencies)
The hospital maps distribution of utility systems
The hospital Labels emergency shut downs
The hospital has written procedures for responding to utility system disruptions
The hospitals’ procedures address shutting off the malfunctioning systems and
notifying staff in affected areas.
The hospitals procedures address performing emergency clinical interventions
during utility systems disruptions.
The hospitals procedures addresses the following: How to obtain emergency
repair services.
The hospital responds to utility system disruptions as described in its
procedures
Provides Emergency power for
① Alarm systems per LSC (NFPA 99)
② Exit route and exit sign illumination
③ Emergency communication system
4) Elevators (at least 1 for non-ambulatory pts)
⑤ Equipment that could cause harm if fails
⑥ Areas where loss of power cause result in PT harm
(Or’s)
1)
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④
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Tests components before initial use
Inspects/tests/maintains Life Support Utility
Systems
Inspects/tests/maintains inf Cont utility system
components
Inspects/tests/maintains Non-Life Support
Utility components
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2)
3)
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⑦
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10)
30 day intervals, test battery-powered lights for 30 seconds (if
required for egress)
12 months, tests battery-powered lights for 1.5 HRS or replace all
batteries @ 12 months/random tests 10% (if required for egress)
SEPSS tested for 5 min monthly/annual full load
12/year tests emergency generator for 30 minutes
Emergency generator tested @ 30% or exhaust temp or annual load
bank: 25% for 30 min, 50% for 30 min, 75% 60 min
12/yr tests all automatic transfer switches
36 months, generator tested for 4 continuous hours
36 month test uses 30% nameplate rating or temp
Per Occurrence: If test fails, implements measures to protect pts
until repaired
Perform retest after repairs
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②
3)
Inspects, tests, maintains critical components
per defined timeframes
Tests for purity, correct gas, pressure when
installed, modified, repaired
Shutoff valves accessible and clearly identifies
control areas
EC.02.05.09 Monitors conditions in
environment
11)
Utility systems management problems, failure,
use errors
Emergency Operations Plan identifies alternative means of
providing:
② Electricity
③ Water needed for consumption and essential care
activities
④ Water needed for equipment and sanitary purposes
⑤ Fuel required for building operations or essential
transport activities
⑥ Medical gas/vacuum systems
⑦ Utility systems defined as essential, such as
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Vertical & horizontal transport
Heating & cooling systems
Steam for sterilization
Utility needs identified in the HVA
On the increase are observations related to:
 Electrical Panel Schedules
 Room Pressure relationships
 Fire Sprinkler lines used for support
 Battery back up lighting in Generator rooms
 Eyewash Stations