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					 UNIVERSITY OF TOLEDO




Regulatory Requirements for all
       Faculty and Staff




                                  1
    Safety and Health Department

• Covers both the Health Science Campus
  (Including Hospital) & Main Campus
• Responsible for maintaining programs
  designed to protect your Safety and Health
• Controlling Exposures, preventing injuries
  and illnesses
• Monitoring Compliance with Regulatory
  Bodies

                                          2
       Safety and Health Education

•   New employee education
•   Departmental In-services
•   Laboratory Safety Training
•   Biological Safety Training
•   Maintenance Training
•   Emergency Preparedness Drills


                                     3
    General Safety, Health and Security

•   Clery Act
•   Joshua’s Law
•   Americans with Disabilities Act (ADA)
•   Public Employees Risk Reduction
    Program (PERRP) OSHA in Ohio
     – State of Ohio adopted OSHA rules into Ohio
       Administrative Code


                                                4
   Chemical-Based Regulations

• EPA--Resource Conservation and Recovery Act (RCRA)
   – Hazardous Waste Rules
      • Proper Handling, Labeling and Disposal
      • Your Role
• PERRP (OSHA) Hazard Communication Standard
   – Proper Labeling of Chemicals
   – Materials Safety Data Sheets (MSDS)
• Safety and Health
• DEA--Controlled Substances (Compliance Office)

                                                  5
     Radiation/Radiologic-Based
             Regulations

• Ohio Department of Health (ODH)
  – Radiation Generating Devices
     • Proper Labeling, Controls and Signage
     • Your Role
  – Radioisotopes
     • Proper Labeling, Controls, Handling and
       Signage
     • Proper Disposal
  – Radiation Safety Office
     • Inspections/Surveys
                                                 6
         Radiation Safety

• Radioactive Materials and radiation
  generating devices are managed by
  Radiation Safety Office

• Look for radiation symbol and stay clear if
  not responsible for patient, or the
  Radioactive Materials

                                           7
       Biological Infectious-Based
               Regulations
• EPA Infectious Waste Tracking Act
   – Manifesting, Tracking and Disposal Infectious Materials
• Toledo-Lucas County Health Department
   – Proxy Agent for EPA in Ohio for Infectious Waste
      • Proper Labeling, Disposal and Signage
      • Your Role
• Ohio Department of Health (ODH) Radioisotopes
      • Proper Labeling, Controls, Handling and Signage
      • Proper Disposal
• Safety and Health

                                                               8
           Exposure Control Plans
            What they are and Why we have them


• Administrative documents, policies
  procedures and protocols written to guide
  employees safely through their workday

• Compliance-OSHA & JCAHO regulations

• Protection from workplace injuries & illness
  and overall risk management

• It’s the right thing to do




                                                 9
               OSHA
        Exposure Control Plan

• Standard Precautions
• Personal Protective Equipment (PPE)
  – Gloves—sterile/non-sterile
  – Face Shields
  – Masks—surgical/N95
  – Gowns—fluid-proof
  – Lab coats--scrubs


                                        10
       Exposure Control Plan
• Based on CDC Guidelines
• Isolation Procedures
  – Airborne
  – Contact
  – Droplet

• To be used in addition to Standard
  Precautions

                                       11
       Blood/Fluid Exposures

• Sharps injuries
  – Needles, scalpel, glass

• Splashes
  – Eyes, mouth, nose

• Non-intact Skin
  – Cuts, skin conditions, hang nail

                                       12
         Exposure Reporting

• Normal Business Hours
  – University Health X5394
• After Hours
  – Administrative Coordinator (Operator)
• Importance of Prompt Reporting




                                            13
    Handwashing Procedures

• Ways to accomplish hand hygiene
  – Traditional Handwash

  – Surgical Scrub

  – Waterless Alcohol-based Products

  – Alcohol-based Towelettes (not the best)

                                              14
 Other Regulations, Standards, and
            Guidelines
•National Fire Protection Administration (NFPA)
  •Life Safety and Fire Prevention
  •Fire Egress Routes
  •Sprinklers and Smoke Detectors
  •Fire Extinguishers
•Department of Transportation (DOT)
  •Shipping of Chemicals, Biologicals etc.
•National Institutes of Health (NIH)
  •Recombinant DNA
  •Grant Requirements
                                                  15
      Proper Waste Disposal

• Solid Waste
• Infectious Waste
  Including Sharps
• Chemotherapeutic
  Waste
• Radioactive Waste
• Chemical Waste

                              16
    Waste Disposal and Recycling

•   Hazardous Drugs
•   Controlled Substances
•   Clean Broken Glass
•   Recyclables
     – Paper
     – Cardboard
     – Batteries
     – Computers
     – Aluminum
     – Bulbs
                               17
    Waste Disposal Procedures

• Five Major Waste Categories at UT
• Wastes Are Separated Due to Their Unique
  Hazards.
• Clean Broken Glass (No Needles or
  contaminated glass)
• Only rechargeable batteries must be collected
  and given to Safety and Health (Alkaline Go to
  Trash)
• Recyclables (Paper, Cardboard, Aluminum
  Cans)

                                               18
     Important Considerations

• Don’t Mix the Waste Streams and
  Remember the Colored Bags Are a Form
  of Labeling.
• Intermingling of Streams Causes the New
  Stream to Take on the Highest Hazard
  Class(I.E. Mixed Solid and Infectious Is
  Now All Infectious)


                                        19
    Important Considerations

• Always Wash Hands After Handling
  Wastes and Don’t Eat Drink or Smoke
  Around Wastes.
• REMEMBER Others on Campus Will Be
  Handling This Materials Based on How
  You Classify Them



                                         20
     Emergency Procedures for
       Hazardous Materials
• Did something spill - Is it a hazardous material?
  Will it affect the environment? (Policy HM-08-
  013)
• Call and Report Any Chemical Spills to Campus
  Police at X77 So That Trained Personnel May
  Be Involved.
• Areas where hazardous materials are stored
     • Institutional contingency plan
     • Spill supplies


                                                 21
UT Emergency Codes
               Infant/Child Abduction
 ADAM                SM-08-02

                   Bomb Threat
 BLACK              EM-08-004

                Medical Emergency
 BLUE              07-45-06,07

             Severe Weather/ Tornado
 GRAY              EP-08-002

                    Evacuation
 GREEN              EP-08-005

          Chem, Bio or Rad Cont. Incident
ORANGE              EP-08-003

             Fire Reported in Building
  RED               SL-08-001

          Snow or Transportation Emerg.
 WHITE             EP-08-008

               Missing Adult Patient
BROWN              SM-08-004

          Disaster Procedure Internal/ Ext.
YELLOW               EP-08-001
                                              22
             CODE ADAM

• Missing Child Reported in Campus
  Building
• Called in conjunction with Campus Police
  over emergency channel on radios
• Assistance from Environmental Services
  and Maintenance



                                         23
              CODE BLACK

• Bomb threat has been
  made by phone or
  other means
• Keep individual on the
  line as long as
  possible
• Use bomb threat
  checklist


                           24
                 CODE BLUE

•   Medical Emergency
•   Dial X77
•   Code team will respond
•   Will call 911 in certain buildings on
    campus




                                            25
             CODE GRAY

• Severe Weather/ Tornado
• Phase 0: Conditions are favorable to
  severe weather (Watch condition)
• Phase 1: Tornado Warning within 25
  miles of UT
• Phase 2: Tornado Warning within 10
  miles of UT

                                         26
               CODE GREEN

• Evacuation of Campus
  Building
• May be called in
  association with another
  code (i.e. red or gray)
• Evacuation can be:
  – Lateral
  – Vertical
  – Complete

                             27
             CODE ORANGE

• Chemical, Biological
  or Radiological
  Contamination
  Incident
• Internal or External
  Incident
  – Spill Situation
  – Weapons of Mass
    Destruction (WMD)

                           28
                     CODE RED

• Fire Reported in Campus Building
• Activated by:
   – Dialing X77
   – Pulling Pull Station
   – Smoke and Heat Detector Response
• Smoking on Campus
   – Only in designated areas
   – Definitely not outside of doors where patients enter the
     institution
   – Effective January 1, 2008 ―No Smoking on HSC‖ this includes on
     grounds/lawn, in parking lots or in your personal vehicles???



                                                               29
R.A.C.E. in Response to a Fire
           Situation
• R escue       anyone in immediate
                danger
• A larm        Sound the alarm that
                there is a fire, pull
                station or X77
• C onfine      the fire by closing doors
                and windows
• E xtinguish   with an extinguisher P.A.S.S.
  or,
• E vacuate     the area either
                Horizontally, Vertical or
                Total                       30
P.A.S.S. to use a
Fire Extinguisher
• P ull       the pin on the
              extinguisher

• A im        at the base of the fire

• S queeze    the handle to expel the
              extinguishing media

• S weep from side to side working
         from the front of the fire
         to the back                    31
            CODE WHITE

• Snow or Transportation Emergency
• Level 3 Snow Emergency called in Lucas
  County
• 4 X 4 Vehicles driven by UT Campus
  Police pick up key employees




                                       32
              CODE BROWN

•   Missing Adult Patient
•   Most likely from Geri-psych (6A)
•   Much like a Code Adam
•   Patient is found by Campus Police,
    Environmental Services and Facilities
    Maintenance


                                            33
            CODE YELLOW

• Disaster Procedure Internal or External in
  Nature
• Phase 0: Potential for multiple victims to
  arrive at UT
• Phase 1: 5 to 15 Patients Expected
• Phase 2: Greater then 15 patients have
  arrived at UT

                                          34
      CODE YELLOW DISASTER

• Hospital Incident Command System (HICS)
  – Disaster management system based on a
    position assignment
  – Individual staff members may be reassigned to
    work in roles outside of their normal job
  – The incident commander is in charge
  – The operation of the hospital will change based
    on the needs of the disaster response

                                               35
Hospital Incident Command System
Incident Management Team Structure
August 2006

                                                                               Incident Commander




         Executive Leadership                                   Public Information                            Safety
     (President, VPs, Deans, etc.)                                   Officer                                  Officer


                                                                                                                             Biological/Infectious Disease
                                                                                                                             Chemical
                                                                                                                             Radiological
                                                                     Liaison                             Medical/Technical   Clinic Administration
                                                                                                                             Hospital Administration
                                                                     Officer                                Specialist       Legal Affairs
                                                                                                                             Risk Management
                                                                                                                             Medical Staff
                                                                                                                             Pediatric Care
                                                                                                                             Medical Ethicist




                                                                                                                                                                  Finance/
  Operations                                           Planning                                       Logistics
                                                                                                                                                                Administration
 Section Chief                                       Section Chief                                  Section Chief
                                                                                                                                                                Section Chief




                                 Personnel Staging Team
                 Staging         Vehicle Staging Team
                                 Equipment/Supply
                 Manager            Staging Team                     Resources        Personnel Tracking           Service               Communications Unit
                                                                                                                                         IT/IS Unit
                                                                                                                                                                              Time
                                 Medication Staging Team                              Materiel Tracking
                                                                     Unit Leader                                Branch Director          Staff Food & Water Unit           Unit Leader




                                                                                                                                         Employee Health &
                            Inpatient Unit                                                                                                 Well-Being Unit
                            Outpatient Unit                                                                                              Family Care Unit
          Medical Care      Casualty Care Unit                        Situation       Patient Tracking              Support              Supply Unit                      Procurement
                            Mental Health Unit                                        Bed Tracking
         Branch Director    Clinical Support Services Unit           Unit Leader                                Branch Director          Facilities Unit
                                                                                                                                         Transportation Unit
                                                                                                                                                                          Unit Leader
                            Patient Registration Unit                                                                                    Labor Pool &
                                                                                                                                           Credentialing Unit




                            Power/Lighting Unit
                            Water/Sewer Unit
                            HVAC Unit                                                                                                                                     Compensation/
          Infrastructure    Building/Grounds                       Documentation
                             Damage Unit                                                                                                                                     Claims
         Branch Director    Medical Gases Unit                      Unit Leader
                            Medical Devices Unit                                                                                                                           Unit Leader
                            Environmental Services Unit
                            Food Services Unit




                            Detection and Monitoring Unit
                            Spill Response Unit
            HazMat          Victim Decontamination Unit             Demobilization                                                                                             Cost
         Branch Director    Facility/Equipment
                              Decontamination Unit
                                                                     Unit Leader                                                                                           Unit Leader




                            Access Control Unit
            Security        Crowd Control Unit
                            Traffic Control Unit
         Branch Director    Search Unit
                            Law Enforcement Interface Unit




            Business        Information Technology Unit
                            Service Continuity Unit
           Continuity       Records Preservation Unit
                            Business Function Relocation Unit
         Branch Director
        WELCOME

THANK YOU FOR YOUR ATTENTION

  ANY QUESTIONS/CONCERNS




                               37

				
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