On-line CEUs

TIP OF THE MONTH: September/October 2005
Patient and Technologist Safety in the Cast Room & Clinic
Tom Byrne, OTC, OPA-C

“The Cast Room” is a treatment area, a place were procedures from wound care to pin removal to fracture reduction take place. The direct responsibility for establishment and maintenance of a safe environment in the Cast Room is that of the Orthopaedic Technologist.  Both patient and technologist safety are the subject of this article. The specifics are not as important as the concept that we, the Orthopaedic Technologists, must engage in the “active process” of preventing problems. This means we must look at all procedures that take place in our areas and set up controls and actions that deal with possible safety issues. We must develop protocol for any actions within our area of control, and we must correct problems if they do occur.

This major concern over patient and staff safety is reflected in the data from the New England Journal of Medicine, dated December 12, 2002 that stated: “40% of patients have experienced a medical error, whether themselves directly or with a family member …In addition, one third of doctors reported seeing a medical error.” Further evidence that safety is becoming a point of strong concern is the establishment of the Patient Safety Coalition formed in November of 2002. This group consists of the AAOS, NAON, and Orthopaedic Corporate Advisory Council, & Orthopaedic Military Physicians. These, normally very independent, groups actually formed an alliance to deal with safety issues!

HAND WASHING AND SANITIZING

Washing your hands is the single most effective contamination control according to the Joint Commission on Accreditation of Healthcare Organizations (JACHO). Does your cast room have foot controls for the sink, does the soap dispenser have foot controls, and is the soap an appropriate type that destroys the types of pathogens we deal with, if not, you have a great source of contamination right on the handles of the water supply.

Did you know that while hand washing is a good mechanical (rubbing, rinsing) means of removing bacteria, according to the CDC, the aqueous alcohol (62% Ethyl Alcohol) based hand cleaners now used are actually more powerful at the elimination of microbes. Therefore, it would be a very good policy to follow every hand wash with a “Hand Sanitizer.” In addition, there should be one dispenser at each hand washing location. Strict aseptic technique should always be followed. This is a method where the basic idea is to isolate contamination. 

Do you clean your hands before answering the cast room phone? Just taking off the gloves is not enough. This is another great place to put a Hand Sanitizer dispenser. You still need to wash your hands, however this might cut down on the phone “bugs”.

When washing your hands, the towel used to dry them and the disposal of it should be a concern. Hand washing and sanitizing should be done between each and every glove change. If you dress a wound, change gloves before you role the cast on the same patient. The contaminants from your gloves will end up in the cast bucket and are passed on to you. Therefore, hand washing, sanitizing, and glove changing should take place any time there is a possibility that we might come in contact with contaminants.

GLOVES

Single use, disposable gloves “shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, or other infectious materials.”  In my opinion, I put on gloves to do anything and everything. I do not wash my gloves; I change them, every time. They are our best barrier from the patient’s fluids and they are also a barrier that keeps the normal bacteria that live on our hands from getting in the patient’s wound. Dispose of gloves after each exposure, possibly several times on the same patient.

BANDAGE SCISSORS

Who cleaned the scissors after cutting off the draining wound dressing? No one, that’s who. Yes, your hands are clean; your gloves were clean, until you picked up the bandage scissors, that is. Or maybe you just pulled them from your pocket, where you put them after the last cast. In my opinion, one great source of pathogen spread is the bandage scissor. Please think about that when you go from patient to patient.

Do not use "instrument milk" to soak scissors or instruments as a disinfectant. Instrument milk is not the solution. It has been basically outlawed and if JACHO finds the practice in use, it is a major infraction. Substantial colonies of bacteria and virus live just fine in this “milk”. One possible solution to eliminate the problem is the use of alcohol swabs after every procedure to wipe down the scissors. Then use an external holder for the scissors, not your pocket. Think and visualize what has made contact with these instruments after each use.

EYE PROTECTION/MASK

“Mask and eye protection or a combination face shield shall be worn whenever splashes, sprays, spatters, or droplets of blood may be generated and contamination can be reasonably anticipated.” Your eyes are the “window to the rest of your body”. Consider the dust from a cast saw, consider that the cast covered a post-op wound, think about the airborne nature of the dust. Consider the airborne particles that end up on your arm just proximal to the end of your gloves. Think about wiping that sweat from your brow with the back of your gloved arm, you know the place where the particles of contaminants are. Eye infection and exposure to pathogens can occur so wear eye protection whenever you put on gloves and every time you treat patients.

REGULATIONS (STANDARDS -29CFR)

“The employer shall provide, at no cost, to the employee, appropriate, personal, and protective equipment. This equipment includes, but is not limited to: gloves, gowns, lab coats, face shields, masks, and/or other ventilation devices.” Also, an “Employer shall clean, launder, and dispose of personal protective equipment at no cost to the employee.”

THE SAW

This device is, once again, one of the most overlooked sources of contaminants in the cast room. Think about it-- we wash our hands, wear eye and mask protection, and we wear lab coats, yet, no one wipes the saw or the saw’s blade clean! That blade that passed through the draining, purulent, diabetic ulcer is now to be used on a three year old’s SAC! This three year old will pull away and who you will then, ever so slightly, scratch?

Please respect the fact that it is a saw and think about the contamination of the grip on it. Not to worry, those gloves you changed were great protection for you. But now you’re just changing the blade of the saw, so you don’t wear gloves to change the blade? That’s why we need to wipe down with alcohol the handle and grip of the saw on a regular basis. What about the switch?

Did you remember to unplug the saw before doing any service or cleaning? Does anyone know who emptied the cast saw vacuum bag last? Has anyone ever emptied the bag in the O.R.? Airborne pathogens are a major risk. Deep within the dark reaches of that filthy, unchanged vacuum bag the bacteria have a nice, warm place to live and thrive. Both the Occupational Safety and Health Administration directive, (CPL 2-0.120) and 29CFR 1910.134 (Respiratory Protection Standard) deal with the airborne contaminants and the filters and systems required to make the air we breathe safe. Make sure you and your employer are aware of these.

What do you mean you don’t have a vacuum? “It’s too hard to use” or “It’s too expensive.” Your health and that of the staff and patients in your office are at risk from airborne pathogens. Always remembers to wear a mask and gloves to change the bag on the vacuum. These precautions are both cheaper than treating you for systemic infections.

WATER BOTTLES

Water bottles or any other food or beverage items are not to be in clinical treatment areas. While proper hydration is important, you can become exposed to contaminants and spread them to others. Keep your supplies isolated from the cast room. Also, makeup, lip balm, or any thing you “apply” to yourself is absolutely forbidden in the clinical area. Like food, the application of these materials can contaminate you. Never have food, beverages, or anything you ingest or apply to yourself around patient areas.

SHARPS

“Engineering controls (sharps containers, needless systems, self-sheathing, etc.) shall be examined and replaced on a regular schedule to ensure their effectiveness.” Sharps’ containers must be highly visible, and puncture proof. Containers with “Biohazard” labels as well as labels to designate the clinic or hospital source of the container, should also be highly visible and puncture proof. The device must allow easy sharps entry without risk of stick. It must also be locked to the wall or cart. They must be disposed of in an approved manner. When the sharps’ container is half full, it’s full. This is very hazardous waste and objects sticking out of the container can kill you, literally. Saw blades are considered sharps. Therefore, they are disposed of in a sharps’ container!

PREVENTING SLIP & FALLS

The cast room is, by it’s very nature, a place where water will inevitably end up on the floor.  Where there is water on the floor, there will eventually be people laying in it. Accidents can be prevented. Safety is no accident. We need to recognize the existing environmental problem of wet surfaces and patients who are on crutches or who are incapacitated from injury or orthopaedic condition. These patients might fall just walking on a clean dry surface, but they most assuredly will fall if there is a loss of traction or an obstacle they can’t see because they are supporting their fractured arm in front of them as they walk.

You and I need to make the cast room environment one that makes patients aware of the hazards. This can be done through the use of signs and posters in the waiting room. Then, to lessen the risks that are present, we need to look at the way we do things and look at the ways we can change those actions to lessen the possible harm they can cause.

A spot of water on the floor is a disaster waiting to happen. How can we address this, the simplest of hazards? Prevention. We must deal with the fact that the floor will get wet in a cast room. The Orthopaedic Technologist must make sure appropriate signs in the lobby and the cast room let patients, staff, and visitors know that the risk does exist. This disclaimer does not free the technologist from responsibility; it does demonstrate a sense of concern for patient and staff safety.

What about those little plastic cores in the center of fiberglass cast tape? These cores like to travel and are hard to keep track of. They seem to enjoy reappearing under patient and staff feet, who then take on gravity games sort of “360” and occasionally “wipe out”.

Solution to material on the floor—well, a helpful hint anyway. Use two paper cast buckets, because you should dispose of them as often as several times a day. One bucket is for the clean, cool water for the cast. The other is a trash bucket for dressings, padding ends, those plastic cores, and any other disposable material. This helps to isolate such things and then, if they are contaminated with body fluid, dispose of them. Cast Buckets are great for temporarily keeping isolation materials in a controlled space until they can be placed in the proper receptacle. Again, the waxed paper buckets help to keep down cross contamination.

INJURED OR EXPOSED TO PATHOGENS

If you are injured, exposed to pathogens, or hazards, immediately, not later or the next day, report to your supervisor in a formal written manner exactly what happened and the effect it had on you. The “Source Individual” (patient or person who is the source of the contamination) must be documented. This is critical for your proper care and follow up. Workers’ Compensation has many rules and regulations, but the above protocol will insure that there is a proper documentation from the beginning. Talk to your supervisor regarding specific protocols. Do that now, before an incident.

DISASTER PLAN

Your clinic, hospital, or treatment area must have a well-conceived plan to deal with fire, electrical, or natural emergencies. How would you evacuate your staff and patients if there were to be a sudden emergency? Right now, what would you do if one of your chosen exits were blocked? Do you have and are you up to date on emergency protocols. Can you hear alarms in the cast room?

Once again, safety is an active process that systematically employs preventative and corrective actions to avoid injury. We, as Orthopaedic Technologists, are experts in our field. We must take a leadership role when it comes to our own health and that of our patients. Think, anticipate problems, and solve them in advance. Educate your staff and administrators. Educate the patients in your waiting room with storyboards or cautions regarding cast care, or just slippery floors.

PATIENT SAFETY

Is the person you are treating the right person?  How many times have you called out a name to a row of patients and had someone respond to “Tom Byrne” when their actual name was Joel Smith?  It really does happen! Folks are anxious to get out of that waiting room, they’ll answer to anything just to get behind that door! 

A strong emphasis has been placed on the accuracy of patient information. Patient labels, I.D. arm bands, date of birth and verbal identification of patients are all critical points when identifying a patient. Surgeons are now required to “Sign The Site”, that is they must put their written initials on the patients affected limb prior to going in for surgery. In the O.R. a “Time Out” is taken to verify that this is the right patient and the appropriate limb has been designated.

How do you identify a patient who is confused, or non-responsive? Was it the left or right side for the splint or was the cast on the left? You, the Orthopaedic Technologist, the one treating the patient, must know definitively and exactly whom you are treating, what you’re treating them for, who the ordering physician is and which limb and in what position the device or cast is to be applied. That’s a lot of information. Is it on the written order? Is it written down, word for word, as a verbal order? If not then you are going to assume you know what your doing. There is an attorney waiting for you as well as a patient who has a left SAC as treatment for her right navicular (tarsal) fx. Oops!

Date of birth and first name are great ways of differentiating patients who have similar names or speak another language. Also, write “RIGHT” or “LEFT”. How many times have you changed the R to an L?

CONCLUSION

Is this all you need to know about cast room safety; No, you must use common sense, logic, and observation to “see” problems before they happen. Or, if they do happen, you need to know what to do to correct what caused them. We are professionals. We must accept the responsibility for proper use of equipment, personal protection, proper technique, and awareness of the sources of risk. THINK.

EMAIL THE NAOT OFFICE TO REQUEST THE QUESTIONS FOR ON-LINE CEUS
(period to obtain CEUs on-line for this article expired January 6, 2006).