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Joint Commission (formerly JCAHO) Refresher for the Clinic Environment

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1 Joint Commission (formerly JCAHO) Refresher for the Clinic Environment
ONLINE self-study Joint Commission (formerly JCAHO) Refresher for the Clinic Environment

2 UNC and UNC Hospitals Safety Management Program
The University and UNC Hospitals have a comprehensive Safety Management Program (SMP) to insure the safety of all of its patients, visitors, faculty, and staff. The program is designed primarily as a safety promotion and accident prevention activity. Safety program responsibilities include consultation services, facility inspections, safety training, employee incident/injury investigations, emergency response, hazardous materials waste programs, safety committee activities, and environmental management. The University SMP is overseen by the Safety and Security Committee and UNC-CH Department of Environment, Health and Safety. Any questions you have regarding health and safety issues can be referred to the Department of Environment, Health and Safety at

3 Joint Commission (formerly JCAHO) Environment of Care
Under the Joint Commission Standards there are eight areas of concentration in the Environment of Care. General Safety/Environmental Management Equipment Hazardous Materials Fire/Life Safety Emergency Preparedness Utilities Management Security Each of these elements will be presented in more detail during this course.

4 General Safety/ Environmental Management
All University healthcare workers are expected to conduct their daily activities in such a way that they do not expose themselves or others to potential injury, such as: needlestick or sharp injuries infectious diseases slips and falls back injuries chemical exposures Exposures can be reduced by using appropriate engineering controls, using proper personal protective equipment (PPE), using proper lifting techniques, and following the appropriate procedures to avoid exposures to chemicals and other hazardous substances. Some factors that can contribute to employee incidents include poor work practice habits, fatigue, lack of job knowledge, stress and poor attitude. UNC- CH Department of Environment, Health and Safety, UNC Healthcare Environmental Health and Safety, as well as each department, are responsible for monitoring and trending employee incidents to develop and implement loss prevention activities to reduce the numbers and types of incidents occurring.

5 Environmental Workplace Safety
All employees can assist in ensuring their work areas are free of hazards by: keeping passageways clear of trip hazards ensuring floors are kept free of any debris or moisture reporting unsafe conditions or equipment to the department manager, and/or UNC-CH Department of Environment, Health and Safety storing all equipment and supplies properly keeping file drawers and cabinet doors closed when not in use preventing trash or clutter from accumulating refraining from using space heating devices (i.e. electric space heaters) which are prohibited cleaning up or reporting spills as soon as possible

6 Latex Allergy A recently recognized work place hazard for some healthcare workers is latex exposure. For some individuals exposure to latex products, such as powdered latex exam gloves, can cause a mild to severe allergic reaction. If you believe that you may have a latex allergy, you should notify your supervisor and contact the University Employee Occupational Health Service (UEOHC) for evaluation at Additional information regarding potential hazards associated with latex exposure is also available at the University Employee Occupational Health Clinic.

7 Ergonomics Ergonomics is the science of developing a work site that maximizes the employee's productivity while minimizing their risk of injuries. Simply put, ergonomics helps adapt the job to fit the person. Ergonomics hazards that may exist in the workplace include such things as faulty workstation layout, improper work methods, improper tools, excessive tool vibration, inappropriate workflow or work/rest regimens, and task repetition rates. The UNC Department of Environment, Health and Safety is committed to providing employees with a work site that reduces the chance that an ergonomics illness may occur. If you suspect that there may be an ergonomic hazard in your workplace, you should notify your supervisor and complete an online ergonomic self-evaluation. If you believe that you may be suffering from an ergonomic-related injury, you should complete an incident report, notify your supervisor, and report to the University Employee Occupational Health Clinic (UEOHC) at

8 Hazard Recording Requirements
Patient Incident Reporting:      Any incident involving a patient should be reported to Risk Management as soon as possible after the patient has been provided appropriate care. Incidents can be reported by calling or by completing a patient incident report and forwarding it to the Legal Department. Visitor Incident Reporting:      Incidents occurring at ambulatory care locations should be reported to Ambulatory Care Administration at Incidents occurring on UNC Hospitals property should be reported to Hospital Police ( ). If a visitor needs immediate emergency medical attention call 911 or Property Damage:      Any state or personal property which is damaged as a result of an incident should be reported to UNC Campus Police (911) or Hospital Police ( ).

9 Employee Incident Reporting
If an employee incident occurs, i.e. any accident, incident or near miss situation, the employee is to notify his/her supervisor, complete an Employee Incident Report (available from departmental Human Resource Facilitator) and report to the University Employee Occupational Health Clinic (UEOHC) at during normal working hours or if the injury is serious or life-threatening, the Hospital Emergency Department for treatment. After–Hours Needlestick/Human Blood or body fluid exposures, please call UEOHC at The UEOHC line will automatically forward your call to Healthlink in order to gather the appropriate information and put you in contact with the Family Practice physician covering the needlestick hotline. For all other after-hour work related injuries that requires immediate medical care, go directly to the UNC Emergency Department. If immediate medical care is not needed, then please report to the UEOHC the following day.

10 Suggestions/Concerns About Care and Safety in the Organization
If you have a suggestion or concern related to care and/or safety of patients or staff within your organization and feel that it has not been addressed by in-house administration, you have the right and are encouraged to report these issues to the Joint Commission's Office of Quality Monitoring by either calling or ing

11 Equipment Safety

12 Electrical Safety Electrical Safety is everyone's responsibility in a healthcare setting. Precautions that you can take include the following: obtaining proper instructions before using any electrical equipment not using any electrical equipment or wall receptacle that appears to be damaged or in poor repair reporting all unsafe conditions immediately to the supervisor in charge of the area in question tagging and removing from service immediately any electrical equipment found to present an electrical hazard reporting all shocks immediately pulling the plug, not the cord, to remove the plug from an outlet never using a three-prong grounded plug in a two-slot outlet not overloading adapters or circuits extension cords are not permitted not using a portable electric heater

13 Electrical Safety (continued)
An approved surge protection device may be used to: perform some specific non-permanent (temporary) task provide power to critical areas when the normal electrical supply is out of service energize small office equipment, such as computers and its related equipment

14 Equipment Inspections
All electrical patient care equipment, including equipment used in Ambulatory Care, Student Health Service, and Family Medicine, must be inspected by Medical Engineering. Prior to using any patient care equipment, the user should ensure that the equipment has been inspected and displays a current Medical Engineering sticker. Before using any equipment, the user should be trained in the capabilities, limitations, and applications of the equipment.

15 Privately Owned Patient Care Electrical Equipment
Privately owned electrical equipment such as radios, hair dryers, electric razors, etc. are the responsibility of the patient, visitor, or staff to ensure the equipment is safe and in good working order.

16 Safe Medical Devices Act
Before using any equipment or medical device, the user should be trained in its capabilities, limitations, and applications. Any equipment or device found to be defective or in disrepair should be immediately removed from service and secured to prevent use. If a patient or employee incident occurs, including near miss situations, because of an equipment or product (medical device) malfunction or defect, immediately report the incident to Risk Management ( ) or UNC Healthcare Environmental Health and Safety ( ) respectively to facilitate reporting under the Safe Medical Devices Act. Isolate the equipment to insure it will not be used again until it can be properly repaired by a designated and qualified service representative. Be sure to include with the equipment any attachments, i.e. leads or electrical sources. Do not discard a contaminated device, but properly secure it in a biohazard container. If possible, always retrieve the outer packaging of a product which may provide lot numbers or other identifying information.

17 Electromagnetic Interference with Patient Care Equipment
The use of wireless communications devices (WCDs), such as two-way radios and cellular phones, can result in electromagnetic interference with energized medical equipment. WCDs are defined as devices that transmit and receive a signal. The use of WCDs will be restricted around designated medical devices by employees, faculty, students, and staff. The use of WCDs by patients and visitors will be banned in all areas of the Health Care System except the main lobbies of the Hospitals, the Cafeteria and Food Courts/Snack Bar. Use of such devices must be limited as much as possible in occupied patient rooms. The following guideline, listed in order of preferred compliance, should be adhered to in patient sensitive areas: leave the patient area prior to using the wireless communications device use of the wireless communication device should take place at least 5 feet from any energized medical equipment in areas where patients are dependent on life support equipment. If an employee sees anyone using a WCD in an inappropriate location, the person shall be asked to stop using the WCD immediately and the individual counseled on appropriate use.

18 Equipment Hazard Reporting
If there is an incident involving any type of equipment, you need to report them as soon as possible to Risk Management at If there is an equipment incident involving a patient, visitor, or staff remember to follow the procedures outlined in the Hazard Reporting Requirements under the General Safety section.

19 Hazardous Materials, Waste, and the Environmental Management Program
The Environmental Management Program is managed by the department of Environment, Health and Safety and pertains to the disposal of hazardous waste. If you are responsible for the disposal of hazardous waste, you will receive more in- depth training through your department. Any questions concerning environmental management issues should be reviewed with your departmental safety coordinator, supervisor, or EHS. Hazardous materials are those substances that are potentially hazardous to your safety and health. Employees may encounter many hazardous materials that are classified as health and/or physical hazards. A health hazard is anything that causes acute or chronic health effects. A physical hazard is any chemical that is flammable, an oxidizer, or corrosive. Examples of Hazardous Materials in the Clinic Environment include infectious waste, flammable liquids and gases, toxic chemical, radioactive materials, cancer causing chemicals and drugs, and compressed gas cylinders. All departments using hazardous chemicals are responsible for determining if a less hazardous chemical may be substituted. The unsafe handling of hazardous materials can impact on ambulatory care or hospital operations. Appropriate precautions should always be used in handling hazardous materials.

20 Hazard Communication Background
What is OSHA’s Hazard Communication Standard? OSHA’s Hazard Communication standard (29 CFR ), promulgated 1994, requires that employees be informed of the hazards of chemical(s) that they work with or are present in their work area.

21 OSHA Hazard Communication Standard (continued)
The four elements of the program include: Ensuring chemicals are labeled Maintaining departmental/work unit/laboratory chemical inventories Maintaining Material Safety Data Sheets (MSDS) Training of personnel by Supervisor on the chemicals that are used or in the workplace

22 OSHA collaborates with United Nation
Understanding the need for consistent classifications of hazards chemicals, OSHA decided to better align with the United Nations’ Globally Harmonized System by adopting a common classification and labeling of chemicals. To view details of this report, double click picture.

23 Benefits of Adopting GHS
There are several benefits for OSHA in adopting the Globally Harmonized system. In particular, it will provide a common and coherent approach to classifying chemicals and communicating hazard information on labels and safety data sheets. Thus resulting in: Consistency of information provided Increase comprehension of hazards Help address literacy problems Facilitation of international trade of chemicals

24 OSHA Publishes Revised Standard
In March 2012, the revised Hazard Communication Standard became law and included an established timeframe for implementation. The table below outlines the effective dates, requirements and responsible parties. Effective Completion Date Requirement(s) Who December 1, 2013 Train employees on the new label elements and SDS format. Employers June 1, 2015* December 1, 2015 Comply with all modified provisions of this final rule, except: Distributors may ship products labeled by manufacturers under the old system until December 1, 2015. Chemical manufacturers, importers, distributors and employers June 1, 2016 Update alternative workplace labeling and hazard communication program as necessary, and provide additional employee training for newly identified physical or health hazards. Transition Period Comply with either 29 CFR (this final standard), or the current standard, or both All chemical manufacturers, importers, distributors and employers

25 Benefit of HazCom2012 With the University’s mission to “serve North Carolina, the United States, and the World through teaching, research, and public service,” the new requirements under HazCom 2012 will enhance clarity for University employees positioned on campus as well as abroad.

26 HazCom2012 Requirements By December 2013, all University employees are to have received general training regarding “definitions”, “label” and “Safety Data Sheet” for chemicals under new HazCom 2012 standard. Supervisors are still required to provide job specific training to employees on the chemicals used in their area at least once and every time a new chemical is added. The training must cover proper use, handling, and personal protective equipment required for the safe handling of the hazardous chemicals.

27 Definitions HazCom 2012 will use a “specification” approach rather than a “performance-oriented” approach. Hazards will be classified thus providing a specific criteria for classification of health and physical hazards, as well as classification of mixtures. Specifically: Appendix A defines health and physical hazards Appendix B includes additional parameters to evaluate health hazard data Appendix F pertains to Carcinogens

28 Labels HazCom 2012 requires chemical manufacturers and importers to provide a label that includes a harmonized product identifier, pictogram, signal word, and hazard statement for each hazard class and category. Precautionary statements must also be provided.

29 Labels - Pictograms Pictograms are required on labels to alert users of the chemical hazards to which they may be exposed. Each pictogram consists of a symbol on a white background framed within a red border and represents a distinct hazard(s), such as health, physical, and environmental . The pictogram on the label is determined by the chemical hazard classification. There are nine pictograms with only the environmental pictogram being optional.

30 Labels – Distinct Hazards
As previously stated, “Distinct hazards” are chemicals in which there is scientific evidence that a health, physical, and/or environmental hazards may occur. Health Hazard - acute or chronic health affects may occur if exposed. Physical Hazard - a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive) or water-reactive Environmental Hazard – pose risk or danger to the environment

31 Labels – Pictograms (Health)
Skull and Cross Bones will appear on the most severely toxic chemicals. Depending on the toxicity of the chemical, the skull and crossbones indicates that the chemical may be toxic or fatal. Specifically it can mean: Acute Toxicity (fatal and toxic) Fatal in contact with skin Fatal if inhaled Fatal if swallowed Toxic if swallowed Toxic in contact with skin Examples: Chloroform, Acrylonitrile, Arsenic

32 Labels – Pictograms (Health)
Corrosive will appear on chemicals that have corrosive properties. Depending on the properties of the chemical(s) in the product, the corrosion pictogram can mean: May be corrosive to metals Causes severe skin burns Causes serious eye damage Examples: Sodium Hydroxide (lye) and Sulfuric Acid

33 Labels – Pictograms (Health)
Exclamation Mark will appear on chemicals with less severe toxicity. This symbol will never be used with “skull and crossbones” symbol. Depending on the health hazard, it can mean: Harmful if swallowed Acute Toxicity (harmful) Harmful in contact with skin Skin Sensitizer Harmful if inhaled Respiratory Tract Irritant Causes skin irritation Irritant (skin and eye) Causes serious eye irritation May cause allergic skin reaction Hazardous to Ozone Layer Examples: Isopropyl Alcohol, Acetic Acid, Ammonia

34 Labels – Pictograms (Health)
Health Hazard will appear on chemicals with less severe toxicity. This symbol will never be used with “skull and crossbones” symbol. Depending on the health hazard, it can mean: Carcinogen Mutagenicity Reproductive Toxicity Respiratory Sensitizer Target Organ Toxicity Aspiration Toxicity Examples: Ethyl Alcohol, Carbon Monoxide, Sodium Nitrite, and Hydrogen Sulfide

35 Labels – Pictograms (Health/Physical)
Gas Cylinder can cause fires, explosions, oxygen deficient atmospheres, toxic gas exposures as well as the innate physical hazard associated with cylinders under high pressure Gases under pressure Compressed gases Liquefied gases Refrigerated liquefied gases Dissolved gases Examples: Methane and Propane

36 Labels – Pictograms (Physical)
Exploding Bomb symbol will appear on chemicals that have explosive properties. Unstable Explosives Self-reactive substances and mixtures Organic peroxides Examples: Nitroglycerine and TNT, Gunpowder, Rocket propellants, and Pyrotechnic mixtures (fireworks).

37 Labels – Pictograms (Physical)
Flame symbol will appear on chemicals that are flammable. Depending on the properties of the chemical(s) and the product, the flame can mean: Extremely flammable gas Extremely flammable aerosol Self-Heating Flammable aerosol Extremely flammable liquid and vapor Highly flammable liquid and vapor Flammable liquid and vapor Flammable solid Examples: Methane and Butane, Pyrophorics, Organic Peroxides

38 Labels – Pictograms (Physical)
Flame over circle symbol will appear on chemicals that are: Oxidizers Oxidizing gases, liquids, and solids Examples: Hydrogen Peroxide and Nitrous Oxide

39 Labels – Pictograms (Environment)
Environment symbol will appear on chemicals which are acutely hazardous to fish, crustacean, or aquatic plants. This is the only symbol that is not mandatory. Aquatic Toxicity Acute hazards to the aquatic environment Chronic hazards to the aquatic environment

40 Label – Signal Word A Signal Word is used to indicate the relative level of severity of hazard and alert the reader to a potential hazard on the label. The signal words used are: "Danger" - used for the more severe hazards “Warning" - used for less severe hazards.

41 Labels- Hazard Statement
A Hazard Statement describes the nature of the hazard(s) of a chemical, including where appropriate the degree of hazard. All of the applicable hazard statements must appear on the label.

42 Labels – Precautionary Statement
A Precautionary Statement is a statement that describes recommended measures that should be taken to minimize or prevent adverse effects.

43 Label – What do UNC Employees need to do?
Effective June , all chemicals received at the University should have the required label. Any material transferred to another container must also have the same label versus just chemical/product name.

44 Safety Data Sheets HazCom 2012 requires Safety Data Sheets - SDS (formerly known as Material Safety Data Sheets – MSDS) to use a specified 16-section standardized format. Under the new format, employees wanting information regarding Exposure Controls/Personal Protection will always refer to Section 8 of the Safety Data Sheets.

45 Safety Data Sheets To improve employee understanding, information listed on the label, like Precautionary Statement, will be same information the employee will find on the Safety Data Sheet. The standardize 16 sections is broken down as follows:

46 Safety Data Sheet – 16 Sections
Identification of the substance or mixture and of the supplier Toxicological Ecological information (non mandatory) Hazards identification Composition/information on ingredients Substance/Mixture Disposal considerations (non mandatory) First aid measures Transport information (non mandatory) Firefighting measures Regulatory information (non mandatory) Accidental release measures Handling and storage Other information including information on preparation and revision of the SDS Exposure controls/personal protection Physical and chemical properties Stability and reactivity

47 Safety Data Sheets – What do UNC Employees need to do?
By December 2015, distributors must provide the new format of Safety Data Sheets. Supervisors need to update the Safety Data Sheet notebooks and/or computer links in their job specific area to the newly format sheets. Remember SDS(s) must be accessible to employees at all times.

48 NC OSHA– Enforcement By June 2016, NC OSHA will begin to enforce compliance with HazCom 2012 by conducting site evaluations. Environment, Health and Safety will continue to assist University departments with the implementation of the specific requirements covered in this training.

49 Resources - OSHA’s HazCom2012 Web Page
OSHA has developed an extensive web page to provide additional resources for employees at

50 Resources - Guidance & Outreach
Supervisors can find printable guidance material that can be utilized when training employees. Guidance OSHA Briefs Fact Sheet Quick Cards

51 Major Chemical Spill Plan
The Major Chemical Spill Plan is activated by the Director On-call when notified that a spill has occurred that poses an immediate threat of fire, explosion, personnel exposure or pollution of the general environment. A major spill will necessitate the response of Chapel Hill Fire Department and the Regional Hazardous Material Emergency Response Team. The immediate evacuation of personnel from the spill area should occur if the spill poses a clear and present danger and is not readily confinable. Individuals should call 911 and explain the scenario to the best of their ability to the operator. The operator will immediately notify UNC-CH Department of Environment, Health and Safety ( ) or UNC Healthcare Environmental Health and Safety ( ).

52 Fire/Life Safety Fire Safety education is essential for the protection of everyone should a fire occur. In the event of a fire, the following steps should be taken: R - Remove or rescue individuals in immediate danger A - Activate the alarm by pulling the fire pull station located in the corridors and calling 911. C - Confine the fire by closing windows, vents and doors E - Evacuate to safe area - Know the evacuation routes for your areas. Extinguish the fire with the proper extinguisher located in all hallways, if you can do so safely.

53 Fire Signal System at UNC Hospitals
Fire strobe lights, tone signals, and overhead paging are located in corridors throughout all hospital buildings. Receipt of an alarm signal is automatically broadcast throughout the Hospitals via the Fire Alarm Public Address System. Activation of one of the alarm system at UNC Hospitals will result in the following announcements or alarms/signals. Overhead Tones and Lights Only (No announcement is made) - Fire detection device other than a fire pull station has been activated by zone. Immediately following activation of a smoke detector, the telephone operators will notify all persons responsible for checking fire alarms. Employees are to stand by for further instruction. Attention Please: Location - Smoke or fire has been reported by either a pull station or a 911 call Attention Please: All Clear - Emergency has been corrected. Resume normal activities. Attention Please : This is a Hospital wide Fire Drill. Location - A hospital wide fire drill is being held and all employees, faculty and staff are expected to participate.

54 Fire Signal System at Ambulatory Care Center
Fire strobe lights and audible alarms are located throughout the ACC. Activation of the alarm system at the Ambulatory Care Center will result in the following announcements: Attention Please: Location - A fire alarm device has been activated. When only one alarm device is activated, the audible alarm will be silenced and strobe lights will continue during the alert. If the audible building alarm sounds for more than one minute, staff members are to instruct all able persons to leave the center, with the exception of the Day-Op Surgery which will be monitored separately for the need to evacuate. Patients and the physically challenged who are unable to leave the building will be reassured and safeguarded in place. If there is an immediate threat to safety, assistance should be obtained and patients relocated. Attention Please: All Clear - Emergency has been corrected. Resume normal activities. Attention Please: This is a facility-wide fire drill. Location - A facility-wide fire drill is being held for all employees, faculty and staff are expected to participate.

55 Fire Signal System at Family Practice Center
Fire strobe lights and audible alarms are located throughout the building. No overhead announcements are made. Patients not in immediate danger should remain in the clinic until notified by emergency responders to evacuate. Administrative staff and all other personnel should evacuate until given permission to enter the building.

56 Fire Signal System at Student Health Service
Fire strobe lights and audible alarms are located throughout the building. When an alarm is activated, all ambulatory patients and staff will be instructed to leave the building. Acute Care/Extended Services Fire Marshal will announce the alarm information on the overhead paging system three times. Once cleared, an overhead announcement will be made stating "all clear".

57 Fire Drills All staff members are expected to respond to fires/drills as outlined in their departmental unit site specific fire plan and to assist visitors, volunteers, or other persons who may not be accustomed to emergency procedures in that area. Staff should discuss evacuation routes and techniques and ensure that emergency exits are kept clear and unobstructed. The departmental representative shall complete a fire drill evaluation form after each facility-wide fire drill. During a drill only the person who identifies the fire at the fire's point of origin will actually pull the fire pull station and call 911. Other locations will conduct all other aspects of a drill including discussing the RACE response, evacuation routes, area of refuge/safe zones and the location of fire extinguishers and pull stations. Participation by patients is not required during the drills.

58 Fire Detection Systems
Fire strobe lights and audible alarms are located throughout the ACC. Activation of the alarm system at the Ambulatory Care Center will result in the following announcements: Smoke Detector- A device that senses visible or invisible particles of combustion (smoke) Heat Detector- A device that senses a change in temperature above a fixed setting. Manual Pull Station- A device that personnel use to activate the fire alarm system typically located in corridors near exits and stairwell doors. Water Flow Alarm- A device used to detect any flow of water from a sprinkler system. Smoke Damper- An automatically closing device used to stop the movement of smoke through an air duct penetration of a required smoke wall. Duct detector- A smoke detector located in air ducts for the purpose of fan shutdown in the presence of smoke.

59 Fire/Life Safety It is essential that each employee be familiar with the information contained on their departmental site-specific fire/emergency plan information sheet for their area. Within UNC Hospitals, activation of any of these devices in any part of the building sends a signal to the Fire Alarm Public Address System. Immediately following a smoke detector alarm (tone sound), the telephone operators will notify all persons responsible for checking smoke alarms of the activation of the system by smoke detector alarm, indicating the building, floor, and zone. The persons responsible will then immediately check the area to confirm the existence of a fire. If a fire is located, an announcement is made indicating the location by building, floor, and zone. A tone will sound also if a pull station has been activated. When a fire pull station is activated the telephone operator will announce over the Fire Alarm Public Address System the location of the fire pull station including the building, floor, and zone, repeating the announcement three (3) times. When an alarm is received, all magnetically locked exit doors in the affected zone will automatically unlock; all corridor doors will automatically close, but not lock; and smoke control systems will be activated.

60 Personnel Must Follow these Procedures to Contain Smoke and Fire within Building Compartments
Doors are instrumental in the containment of smoke or fire. ALL doors must be closed and any equipment in the corridors must be cleared. Some buildings, such as UNC Hospitals and Ambulatory Care Center, are designed and constructed using fire compartments. Fire compartments are formed with firewalls that are continuous from outside wall to outside wall or from one firewall to another, including continuity through all concealed spaces, such as those found above a ceiling. Firewalls, fire doors and vertical openings such as stairwells are designed and constructed with a specific fire resistance rating to limit the spread of fire and restrict the spread of smoke. These structures, including ceiling tiles, cannot be interrupted or removed without the knowledge and approval of Plant Engineering/ACC Admin. Holes in walls and ceilings must be patched with the proper fire chalking. Smoke walls and smoke doors are designed and constructed to restrict the movement of smoke. Smoke walls and smoke doors may or may not have a fire resistance rating. The locations for the nearest area of refuge/safe zone and fire exit stairwells for your department are listed on your site-specific fire/emergency plan. Every department should have a site-specific fire/emergency plan posted.

61 Evacuation Procedures
To understand the evacuation procedure, it is important to be familiar with the fire safety characteristics in the building within which you work. Each building is divided into compartments to limit the spread of fire and restrict the movement of smoke. Fire walls, doors, and vertical openings, such as stairwells are designed to prevent the spread of smoke and fire. Doors are instrumental in the containment of smoke or fire. All doors must be closed and any equipment in the corridors must be cleared. These structures, including ceiling tiles, cannot be removed or interrupted. Holes in the walls and ceilings must be patched with the proper fire chalking. Exits are marked by an approved sign that is readily visible from any direction of exit access. In such buildings, individuals can be moved horizontally or downward (vertical) to an area clear of heat and smoke and kept there until the danger is over.

62 Evacuation Procedures, con’t.
Evacuation will usually refer to movement away from the danger zone. The primary responsibility for patient evacuation will rest with the healthcare providers. In rare cases, general evacuation would involve clearing the entire building. Following emergency evacuation, all persons should be accounted for to ensure the evacuation of all individuals. The order of evacuation is determined according to the patient's physical condition. Whenever possible, the patient's medical chart should be taken with the patient upon relocation.

63 The Roles and Responsibilities in Transferring Patients to Areas of Refuge/Safe Zones or Building Evacuation Evacuation of the Hospitals is determined by the Director on Call, Director of Plant Engineering or Senior Member of the Fire Response Team, Director of Environmental Health and Safety or designee, the Senior Nurse Manager of the area in question or the Chapel Hill Fire Department. Internal evacuation will depend on the extent of the fire and how well it is confined. In a fire resistive structure such as UNC Hospitals, patients or other individuals may be moved horizontally or downward to an area clear of heat and smoke and kept there until the danger is over. "Evacuation" will usually refer to movement away from the danger zone. General evacuation of UNC Hospitals will be required in rare cases resulting in the need for the entire building to be evacuated. All personnel should know all exits that can be used for evacuation.

64 If evacuation is necessary, personnel should follow these guidelines
Evacuation plans should be consulted to pre-determine the best route to be used considering the location of the fire. An approved exit sign that is readily visible from any direction will designate the proper exit. Horizontal evacuation on the same floor is the preferred method. If this is not possible, the stairwells (vertical) will be utilized to descend. Elevators should never be used for evacuation, unless directed by the Chapel Hill Fire Department. Personnel in the area are responsible for clearing the exit/egress corridor of any carts or wheelchairs, which may be in the corridor at the time of the fire/drill. The primary responsibility for patient evacuation will rest with healthcare providers, unless conditions are too severe for staff, then the responsibility will fall on the Chapel Hill Fire Department. Specific duties should be assigned to personnel in the department/unit. For example, clerical staff can assist in clearing the corridor of code or isolation carts and transporting patient medical records and other pertinent clinical information, which should be taken with the patient upon relocation. Respiratory Care personnel can provide oxygen as needed to transport patients. All other personnel can assist in moving patients to an area of refuge or in other ways as may be needed under the circumstances. To ensure all rooms have been empties, doors should be marked to indicate they have been checked, such as placing a pillow outside the door.

65 Evacuation Procedures
Following emergency evacuation, all persons should be accounted for to ensure the evacuation of all individuals at risk. The predetermined area(s) of refuge/safe zone for your department, both internally and externally, are located on the site-specific fire/emergency plan information sheet for your department/location. Order of Evacuation The order in which persons are evacuated will be determined according to the individual's physical condition. Medically and physically challenged patients, visitors, employees, volunteers, and guests must be evacuated as needed to a safe zone. Ambulatory persons: Form a group of ambulatory patients/individuals and appoint a helper to lead them to safety and to remain with them until the all-clear announcement is made. Wheelchair persons: Move these patients to safety on the same floor level if possible. Take chairs back for additional patients. Others may help by taking this category of patients downward later, if necessary. Stretcher or helpless persons: If the patient cannot walk with support or sit upright in a wheelchair, then they should be transported using a stretcher, rolled in their beds, dragged on the floor on mattresses or blankets, or carried. These persons should also be moved to safety on the same floor level, if possible. Others may help by taking these patients downward later, if necessary. Wheelchairs, stretchers and bottled oxygen may be necessary in order to transport patients and certain phone numbers should be readily available. For additional information specific to your department, refer to your site-specific fire/emergency plan information sheet.

66 Fire Extinguishers Fire Extinguishers - To effectively fight a fire, you must understand what causes a fire to burn. There are three basic elements of fire: fuel, heat, and oxygen. Removing any one of these elements will cause the fire to cease to burn. The first step of extinguishing a fire is to identify the type of fire and choose the right extinguisher to use. There are three major classes of fire and three types of extinguishers:

67 Fire Extinguishers, con’t.
Class A: Contains only water and should be used on class A fires only (ordinary combustible products such as paper, cloth or wood). NEVER use this type of fire extinguisher on an electrical fire. Class BC: Contains carbon dioxide and should be used on class B fires (flammable liquid fires) or Class C fires (electrical fires). Class ABC: Contains a white powder and can be used on class C fires (electrical fires) or class A or B fires.

68 Using the Fire Extinguisher
In the event a fire occurs in your area, you should assist in securing persons to a safe area as needed. In the event a fire occurs in another area, you should remain available and provide assistance as needed. To properly use a fire extinguisher, you only have to remember to PASS. P – Pull the pin between the handles A – Aim the nozzle at the base of the fire S – Squeeze the handles together S – Sweep the extinguisher from side to side

69 Using the Fire Extinguisher, con’t.
Discharge the fire extinguisher as you approach the fire to ensure its operation. The extinguishing agent should be applied even after the flames are extinguished. Never leave an extinguished fire unattended. Always, extinguish the fire with your back to an exit door, in case you have to leave the area. If safe, you should remain in the area until the fire department arrives on the scene.

70 Fire Safety Tips Prior to opening any door during a fire emergency, feel the door and the doorknob. If either are hot, do not open the door. If the door and knob are cool, stand to the side of the door and open the door slowly. If you must enter a fire scene, stay low. Remember that smoke and heat rise to the ceiling and you must crawl beneath them.

71 Fire Safety Reminders DO’s
Keep hallways clear of furniture, surplus, and equipment Know the location of all fire alarm pull stations, fire extinguishers, and fire exits in your work area Know evacuation routes for your work area and what to do in case of a fire Smoke only in designated outdoor smoking areas Keep your work area clean and free of clutter Learn patient transportation and evacuation techniques DO NOT’s Leave equipment standing in traffic lanes or hallways since this could obstruct the evacuation of patients and personnel Obstruct fire equipment or fire doors so they do not open/close properly Place anything within 18” of a sprinkler head Smoke in stairwells Prop open emergency exit or stairwell doors for any reason Tamper with electrical wiring, equipment, or fuses.

72 Interim Life Safety Measures (ILSM)
Interim life safety measures are a series of actions required during construction to provide the level of life safety that existed prior to construction startup. If applicable, interim life safety measures, which apply to all personnel (including construction workers), must be implemented upon project startup and must be continuously enforced through project completion. Each interim life safety measure action must be documented through written policies and procedures. For additional information on ILSM, please refer to the policy located in the Health Care Systems' Safety Policy Manual.

73 Medical Gasses Shut-Off Procedure
In the event of the need to discontinue the flow of medical gases, physicians, registered nurses, and respiratory therapists will assess and assign clinical priorities to patients receiving medical gases based on the critical need for continued gases. Clinic personnel will inform the Fire Marshal and Director on Call of the number of patients on medical gases and the number in critical need. Respiratory Care will provide sufficient portable oxygen to provide continued flow of medical gases to patients with critical needs. On order of the Fire Marshal and/or the Director On Call, the controlling valve for medical gases in the area will be shut off by Plant Engineering personnel or the nurse in charge of the area. Patients on medical gases will be transported immediately to the nearest safe area. In the Ambulatory Care Center, the medical gases will only be shut off by Chapel Hill Fire Department or UNC Facilities Services. This is done only at the discretion of the Fire Chief, after provisions are in place for the planned interruption.

74 Emergency Preparedness Introduction
Disaster events are those events that stress the medical system by exceeding its capacity to deliver services in the usual manner. Disaster events could include natural disasters as well as internal events. Regardless of whether a disaster is internal or external, the key to effective management is an orderly mobilization of personnel and supplies. The UNC Department of Environment, Health and Safety, UNC-Hospitals and some specific departments have Disaster Plan Manuals that provide all employees with a written resource to accomplish an effective response to disaster events. The Director on Call and the Disaster Commander will assess the need for personnel, supplies, and equipment. In addition, all departments need to have an internal plan on what to do during a disaster. If an event occurs, the following announcements will be heard over the public address system:

75 External Disaster/Code Triage-External
This is a disaster which occurs outside of the medical facility in which the Hospitals will be involved in the care of a large number of new patients presented over a relatively short period of time. All physicians not involved in urgent patient care and all recalled to the hospital are to report to the medical labor pool area, located in the gymnasium of the second floor of the Neuroscience's Hospital. If at the ACC report to the second floor, Administrative Office.

76 Internal Disaster/Code Triage-Internal
This is an emergency event that arises within the Hospitals which may or may not generate victims requiring mobilization of patient care resources. Even if there are no victims, your assistance may be required in case the Hospitals need to be evacuated. Physicians should report to the medical labor pool as indicated above.

77 Medical Emergency/"code blue - "(Location)"
Cardiac Arrest - Only assigned personnel are to respond. To report a medical emergency, call 911 or

78 Code Yellow/Code Triage Internal
Code Yellow indicates a Bomb Threat has been received. Everyone is to check for unusual or suspicious packages or articles and notify 911 if anything unusual is found. Once the area has been checked and everything is found to be in order, call the internal command center at to notify that the area is all clear. Should you be the recipient of the actual bomb threat, follow the telephone guidelines located in the Hospitals Disaster Plans Manual.

79 Code Green Code Green indicates that an act of Bioterrorism is suspected. Bioterrorism is the use of a biological agent (e.g., smallpox, botulism toxin, plague, anthrax) that is employed in a biological attack. Bioterrorism may occur as covert events (persons are unknowingly exposed) or as announced events (persons are warned that an exposure has occurred).

80 Code Orange Code orange indicates that a major chemical spill has occurred either internally to the Hospitals or at an external location. A major chemical spill is defined as a release or spill of a large quantity of a chemical agent (solid, liquid, gas) in an uncontrolled state posing an immediate threat of fire, explosion, personnel exposure, or pollution of the general environment. An immediate threat spill is a spill that poses a clear and present danger to personnel in the general area.

81 Code White Code White indicates that a radiation incident has occurred either internally to the hospitals or at an external location. A radiation incident is defined as a situation when an individual sustains an acute high- level exposure to penetration radiation, possible internal deposition of radioactive material, or when ordinary trauma or illness occurs in combination with external or internal contamination and/or exposure.

82 Code Black Code Black would indicate the activation of the Utility Management Plan. Suspected events involving cyberterrorism should be reported to Hospital Police at For additional information on utility management, please see the Utility Management Section.

83 Code Grey Code Grey could indicate the activation of one of three weather-related situations: snow and/or ice, hurricane, or tornado. Winter weather can pose significant challenges for the UNC Health Care System. The primary objective of the Snow Operations Command Center is to coordinate pickup of staff members necessary to continue operations of the hospitals and to ensure adequate supplies and materials are available for operating the Hospitals during a snow emergency. Hurricanes can and do affect areas as far in shore as UNC Health Care locations. During the hurricane season, it is important to be aware of the weather conditions and take appropriate actions in planning for and minimizing the effects of tropical storms and hurricane force winds. This far inland, the most likely affects of hurricanes or tropical storms would be flooding or wind damage. However, hurricane force winds and tornadoes are possible during tropical storm season. The National Weather Service issues a tornado watch when tornadoes are possible in the area. Staff should remain alert for approaching storms. This is time for staff members to review where the safest places in their work area are located and be alert for additional information from the paging system. A tornado warning is issued when a tornado has been sighted or indicated by weather radar.

84 Code Pink/Code Triage Internal
Code pink means an infant has been abducted. Upon notification of a Code Pink, all staff members should monitor their area and report suspicious behavior to Hospital Police. People carrying infants or containers potentially carrying an infant should be approached and identified.

85 Code Red Code Red will be activated by the Director on Call once notified that a fire has progressed to the extent necessary to require activation of the plan. The Director on Call will determine if the Plan should be activated after assessing the situation and discussing the nature of the incident with the Facility Director, Hospital Police, and the CHFD Captain.

86 Code Silver/Code Triage Internal
Code Silver indicates that a hostage situation is occurring within UNC Hospitals. In the event of a hostage situation, Hospital Police should be notified immediately.

87 Utilities Management Program
Healthcare Systems and UNC Hospitals have a comprehensive utility management program to ensure the appropriate utilities are available to support patients and personnel. A grid has been developed to assist in what to expect, whom to contact, and responsibility of the user, when a system fails. Most instances should be reported to Facilities Services Division ( ) in University buildings and Plant Engineering ( ) in Hospital buildings.

88 Security Management Most hospitals and healthcare systems are no longer immune to serious crime and it is everyone's responsibility to take precautions to protect our community. There is a delicate balance between providing open public access and reasonable safety and security. Of all the technology, hardware, and policies in place, the most important element of our security system is you. Ambulatory Care Center, Family Practice, Student Health Service, University buildings, and the employee parking areas are in the UNC Campus Police Department jurisdiction. UNC Healthcare jurisdiction primarily includes the main hospital, the Hedrick building, and all property owned and operated by the Hospitals. All criminal incidents or suspicious activities within University facilities should be reported to UNC Campus Police at 911. All incidents that occur within the Hospital must be reported to the Hospital Police Department at Healthcare Photo Identification Badge: The photo identification (ID) badge is an important part of the Hospitals' security program. All employees and staff members must wear their badge with the photo clearly visible when entering and while within the medical complex. The photo ID badge contains a magnetic stripe that allows access to certain entrances during the evening hours. University employees who have been issued a Healthcare photo ID badge are subject to Occupational Health Requirements for University Employees located in Healthcare Facilities. This policy is located in the University Health and Safety Manual, Chapter 5.

89 Consultation If you have any questions regarding any of the above information, please contact the UNC Department of Environment, Health and Safety at Additional information is also available in several reference manuals including the UNC-CH Health and Safety Manual, UNC Healthcare Safety Policy Manual, the Infection Control Manual, and the Disaster Plans Manual. REMINDER: University employees with duties in Health Care Facility or UNC Hospitals are required to complete annual Tuberculosis and Infection Control training. In addition, if duties involve exposure to blood or other potentially infectious materials. University employees are required to complete annual Bloodborne Pathogen training, Both courses are available on-line. For more details, return to the training page at You have completed this self-study unit. In order to receive credit for this course, please complete the short multiple choice test. To take this test, you may click on the highlighted Post-test now.

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