ENVIRONMENTAL HEALTH & SAFETY ANNUAL REPORT FY2020
1302 Mechanic Street Second Floor Galveston, TX 77555-1111 409.772.1781
Addressing Environmental Health and Safety needs of the UTMB Community
utmb.edu/ehs
ENVIRONMENTAL HEALTH AND SAFETY
EHS coordinated the installation of triage tents at all four campuses. The tents were setup to allow for safe and effective screening of patients suspected of being infected with COVID-19.
Cover photo: Campus Collage of UTMB Facilities by Mark Kinonen
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ENVIRONMENTAL HEALTH AND SAFETY
TABLE OF CONTENTS
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OVERVIEW
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LEADERSHIP
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STATEMENTS
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ORGANIZATION
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MANAGEMENT
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WHAT WE DO
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HOW WE WORK
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YEAR IN REVIEW
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UNPRECEDENTED EVENT
13
PROGRAM AREAS
14
SERVICE HIGHLIGHTS
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ENVIRONMENTAL HEALTH AND SAFETY
OVERVIEW ABOUT US
Environmental Health and Safety works to provide support to the entire UTMB community in fulfiling our “Commitment to Safety”.
Commitment to Safety • UTMB will demonstrate it is a high-reliability organization by providing high-quality education, patient care and research in a manner that provides for the safety of faculty, staff, students, patients and visitors. • UTMB leadership affirms that safety is critical to our mission and is necessary to achieve the UTMB vision and to demonstrate true compassion for all. Safety is never compromised under any circumstances. • UTMB leadership is ultimately accountable for preventing workplace incidents, injuries and illnesses. Leadership will support safety program initiatives, consider employee suggestions for safety improvements and make sure that safety resources are anticipated, addressed and made a priority. • Safety is everyone’s responsibility, and all faculty, staff and students have a responsibility to intervene if they observe unsafe behaviors or environments. All members of the UTMB community are empowered to stop work or take action if they observe something that appears to be an imminent and significant issue regarding safety. • All members of the UTMB community are accountable and expected to report in a timely manner any actual or potential safety concerns, unsafe work practices and safety incidents to their manager, supervisor or faculty advisor, and UTMB will uphold a non-punitive reporting environment. • Any member of the UTMB community who oversees the actions of others is responsible and accountable for ensuring the faculty, staff and/or students under their supervision receive needed safety training and follow necessary safe work practices and policies. • Faculty, staff and students are expected to be alert and aware of their surroundings while maintaining focus on tasks. Everyone is expected and held accountable to complete all safety training and follow safe work practices required to do their jobs, including use of personal protective equipment as appropriate. • UTMB leadership, managers and supervisors will share information through transparent, culturally competent communication in order to drive safety performance and continuous process improvement and to foster a culture of trust. • UTMB leadership affirms that patients, their family members and visitors are responsible for communicating their needs to their care team, treating everyone with respect and not showing disruptive behavior, including physical and verbal abuse of faculty and other care providers, other UTMB employees, students, other patients or visitors.
This commitment extends throughout the university, including all education, research, patient care, administrative and support areas.
Ben G. Raimer, MD, MA, FAAP President ad interim
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ENVIRONMENTAL HEALTH AND SAFETY
LEADERSHIP FROM THE AVP Welcome to the FY2020 Annual Report for Environmental Health and Safety (EHS). This report accounts for the various programs within EHS, our services, and a sample of our accomplishments throughout the year. We have provided facts and information that will provoke some thought about campus safety and hopefully, reflect the contributions of the entire staff. EHS has many programs to help provide a safe and environmentally responsible campus and encourage all at UTMB to embrace the safety culture. We hope you find this information to be both interesting and useful.
Jack
JACK TARPLEY AVP, EHS
SAFETY ISN’T JUST THE RIGHT THING TO DO FOR OUR EMPLOYEES, BUT IT’S ALSO THE RIGHT THING TO DO FOR OUR PATIENTS, STUDENTS, AND VISITORS.
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A strong culture of safety is one where each and every worker integrates safety into the way they do their job.
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ENVIRONMENTAL HEALTH AND SAFETY
STATEMENTS VISION, MISSION & VALUES
VISION
VISION It is our vision to become a recognized national leader and innovator in campus environmental health and safety providing world class services.
MISSION
MISSION The mission of Environmental Health and Safety is to work with our customers to provide a workplace free of recognized hazards in support of the UTMB mission to improve health for the people of Texas and around the world.
VALUES
VALUES
Integrity: Saying what we are going to do, and doing what we say. Accountability: Holding ourselves and each other accountable for our responsibilities and achieving our goals. Commitment: To protect the health and safety of our patients, employees, the public, and the environment. Collaboration: Developing strategic partnerships that foster cooperation and collaboration. Personifying excellence: Providing the highest level of expertise, competence, and professionalism in our staff. Quality: Going beyond regulatory “compliance� and aiming for best-in-class. Environmental Stewardship: Taking the lead to protect the environment and preserve our natural resources.
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ENVIRONMENTAL HEALTH AND SAFETY
ORGANIZATION WHO WE ARE Environmental Health and Safety is a part of Business Operations & Facities (BOF). Units under this group provide institutional support through many business and facilitiesrelated processes. In addition to EHS, BOF includes the areas of Auxiliary Enterprises, Design & Construction, Portfolio Management, Facilities Risk Management, Property Services, and Utilities.
UTMB HEALTH
BEN G. RAIMER, MD, MA, FAAP PRESIDENT AD INTERIM
BUSINESS OPERATIONS & FACILITIES
STEVEN LEBLANC, PE, MBA, CHFM, VICE PRESIDENT
ENVIRONMENTAL HEALTH AND SAFETY JACK TARPLEY, MS, CFI, CHMM, ASSOCIATE VICE PRESIDENT
SOPHIE BROCARD, PHD, RBP, SM(NRCM), CBSP, CHMM, ASP, CSP, PROGRAM DIRECTOR CHARLES CARLISLE, MS, CIH, CSP, CHMM, PROGRAM DIRECTOR DE'ANNE MEEH, MS, REM, CHMM, PROGRAM DIRECTOR WILLIAM PATE, DRPH, MBA, LMP, CHP, CIH, CSP, CPP®, CHFM, CHMM, PROGRAM DIRECTOR
MANAGEMENT
TECHNICAL STAFF
SUPPORT STAFF
Total 54 Employees
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ENVIRONMENTAL HEALTH AND SAFETY
MANAGEMENT THE TEAM
SOPHIE BROCARD PROGRAM DIRECTOR, IBSO, ARO BIOLOGICAL SAFETY PROGRAM
CHARLES CARLISLE PROGRAM DIRECTOR FIRE & LIFE SAFETY PROGRAM
• Fire Protection System Design,
• Biological Safety • Laboratory Inspections • Select Agent Compliance
DE’ANNE MEEH PROGRAM DIRECTOR ENVIRONMENTAL PROTECTION MANAGEMENT
• Hazardous Waste Management • Radioactive Waste Management • Water Quality & Pollution Prevention
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Inspections, & Maintenance
• Fire Safety Training • Life Safety Inspections
WILLIAM PATE PROGRAM DIRECTOR, RSO, LSO RADIATION SAFETY PROGRAM OCCUPATIONAL SAFETY PROGRAM
• • • •
Radiation, Laser, & MRI Safety Industrial Hygiene/IAQ General & Construction Safety Food Safety, Water Quality
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ENVIRONMENTAL HEALTH AND SAFETY
WHAT WE DO OUR PROGRAMS AND SERVICES PROGRAM AREAS BIOLOGICAL SAFETY • IBC Administration & Support • Laboratory Audits • Biological Shipping • Biosafety Training • Select Agent Program Oversight • Biocontainment Unit Support OCCUPATIONAL SAFETY • Chemical Safety • Fall Protection • Hearing Conservation • Aerial Lift and Crane Safety • Respiratory Protection • Construction Safety ENVIRONMENTAL PROTECTION • Regulatory Compliance and Support • Hazardous Waste Management • Stormwater Compliance • Wastewater Compliance • Pollution and Spill Prevention FIRE & LIFE SAFETY • Fire/Life Safety Systems Compliance • Facility Design/Compliance Reviews • Fire Drills and Institutional Response • Life Safety/Joint Commission Compliance • Fire Extinguisher Inspections RADIATION SAFETY • Radioactive Materials Permitting • Radioactive Materials Licensing • X-ray and Laser Registration • Laboratory Evaluations JOINT COMMISSION COMPLIANCE • EOC Tours • Risk Assessments • Committee Support
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SERVICE HIGHLIGHTS FIT TESTING • Performs fit testing for N95, half-face, and •
full-face respirators for health care, research, and support staff Provides training on the proper use of respiratory protection
PPE EVALUATIONS & TRAINING • Evaluation of new models of PAPRs • PAPR and PPE training for healthcare and research staff
N95 REPROCESSING • Supporting healthcare during the pandemic • Tested and validated several different •
decontamination methods for the N95 reprocessing program for all respirator types in use at UTMB BSP coordinates and performs the N95 decontaminations for the reprocessing program for the Healthcare Enterprise
MEDICAL WASTE ASSESSMENT & DISPOSAL • Developed and implemented COVID-19 PPE waste •
acceptance and packaging requirements for the triage tent sites Provided guidance on how to best manage waste generated during the care of patients with COVID-19
BIOLOGICAL SHIPPING • Shipped biological materials worldwide on behalf of the research community
• These biological materials assisted diagnostic •
laboratories with set-up and validation of COVID-19 specific diagnostic testing Research materials shipped assisted the scientific community to study this novel virus
OVERFLOW SPACE ASSESSMENTS • Negotiation with State Fire Marshal for flexible use of additional facilities for COVID-19 treatment
• Modifications of facilities to comply with negotiated conditions for use
• Return to normal service 9
ENVIRONMENTAL HEALTH AND SAFETY
HOW WE WORK BUILDING RELATIONSHIPS
WORKING TOGETHER TO CREATE A CULTURE OF SAFETY
UNIVERSITY PARTNERS EHS works closely with other campus departments such as Facilities Risk Management, Design & Construction, Property Services, Healthcare Quality & Safety, Infection Control & Healthcare Epidemiology, Portfolio Management, Utilities, UT System Police, and the University’s schools.
COMMUNITY PARTNERS EHS serves as a liaison with regulatory and compliance agencies such as: The Joint Commission, EPA, DEA, U.S. DOT, TCEQ, Texas DSHS, FAA, Federal Select Agent Program, Texas State Fire Marshal’s Office, NIH Office of Science Policy, AAALAC, and local municipalities. EHS is charged with certain health and safety inspections and compliance for all applicable federal, state, and local regulations and other EHS requirements intended to protect safety, health, and the environment.
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In FY20 EHS received 246 calls for emergency support ranging from fire alarm activations to hazardous material spills.
CUSTOMERS EHS serves the entire UTMB community. Our customers include patients, faculty, staff, students, campus visitors, and volunteers.
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HOW WE WORK UTMB SUPPORT
UTMB HEALTH EHS provides support on UTMB campuses in ensuring healthy and safe operations, protecting students, faculty, staff, and visitors, and protection of the environment.
TECHNICAL KNOWLEDGE
HEALTHCARE
TRAINING
• Construction plan review • Serving on regulatory committees • Subject matter experts on health and safety issues to ensure safe design, construction and operation of UTMB facilities
• Environment of Care
• Update and maintain online safety courses
• Committee Support • TJC documentation • Survey support • Risk Assessments • Support the Biocontainment Critical Care Unit (BCCU)
COMMUNITY SUPPORT • Support of Regional Ebola Treatment Center Biocontainment Critical Care Unit • SETRAC/IDRU Training • NETEC/SPRN • CLC-monthly meetings • GNL Outreach Team
SAFE WORK ENVIRONMENT • Odor & Indoor Air Quality response • Hazardous materials shipments • Risk assessments • Accident investigations • Emergency incident response • Exposure monitoring • Respirator fit testing • Occupational Health & Medical Surveillance Program Annual Report
SAFE CAMPUS • 24/7 incident response • Food establishment inspections • Drinking water testing • Identification of slip/ trip/fall hazards • Spill cleanup • Facility Safety Audits • Fire System Repairs
• Instructor-led training • Specialized training as requested
RESEARCH • Technical review for renovations • Space evaluations • Fume Hood & Biosafety cabinet certifications • Lab Audits • Controlled substance disposal • Protocol & permit reviews for committees • Consulting on safe lab practices • New PI orientation • Equipment cleanup/ monitoring • Lab setup/closeouts
ENVIRONMENTAL • Storm Water Programs • Title V Permit Management • Chemical & Biological spill cleanup • Hazardous Waste Disposal • Potable Water System Permit 11
ENVIRONMENTAL HEALTH AND SAFETY
FY2020 YEAR IN REVIEW HIGHLIGHTS
377
15,113 N95 REPROCESSING
N95 respirators recycled to support Healthcare Personal Protective Equipment (PPE) needs
BIOLOGICAL SHIPMENTS
246 EMERGENCY RESPONSE
Requests for emergency response including 165 fire alarm responses
249
BIOLOGICAL SAFETY
3,500 HAZARDOUS WASTE
Individual chemical waste items submitted for pickup via 797 chemical pickup requests
RESPIRATOR FIT TESTS
12
Notifications of Use (NOU) of biological and recombinant protocols approved by the IBC in FY20 (98 were COVID19-related protocols)
234 FIRE SYSTEMS
Fire Alarm and Fire Sprinkler Systems tests and repairs
10,776,161
9,827 Fit tests performed (more than FY16, FY17, FY18, and FY19 combined)
Shipments of biological materials sent by Biosafety worldwide
UNIVERSITY SUPPORT
Total gross square footage EHS serviced for FY20
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ENVIRONMENTAL HEALTH AND SAFETY
UNPRECEDENTED EVENT COVID-19 PANDEMIC In late December of 2019, the international community began to hear the rumblings of a novel viral infection cluster in Wuhan, China. Although it was not recognized at the time, this new pneumonia-causing virus would be named COVID-19 and it would soon be spreading across the globe in one of the largest and deadliest pandemics seen since the 1918 Spanish Flu pandemic. As an academic medical center providing high-quality care to our patients as well as a world-renowned infectious disease research organization, it was recognized early on that UTMB would play a vital role in helping to fight and protect against this disease. Beginning in late February, UTMB began to ramp up its preparation plans to ensure the safety of our healthcare workers and researchers on the front line with COVID-19. As alterations to facilities and operations were made, EHS was working hand-in hand with health system and academic enterprise to ensure the safety of our patients, healthcare workers, researchers, students, and staff. Keeping our staff safe meant working in close collaboration with our Supply Chain and Infection Control partners. As a virus which spreads through respirable droplets and aerosols, the primary concern was to ensure that our workers had the necessary respiratory protection to continue to work safely. In the first half of 2020, EHS performed more than 4800 successful respirator fit tests among health care workers and researchers, exceeding the number of successful fit tests in the preceding two fiscal years combined. EHS also increased the frequency of building facility walkthroughs to ensure that alterations to facilities and operations did not create negative impacts to safety. The pandemic has placed a severe strain on the supply chain across the entire health care industry, and many forms of personal protective equipment have been hard to acquire. EHS, working with the Galveston National Lab (GNL), developed and validated N95 reprocessing methodologies that have allowed us to extend how long our supplies of valuable N95 respirators have lasted. EHS has reviewed alternative forms of respiratory protection, such as Powered Air Purifying Respirators (PAPRs), to help ensure even those who cannot be fit tested have the protection they need to work safely. Procedures for patient care and equipment utilized for diagnostic testing of patient specimens had to be evaluated and in some cases procedures modified to ensure staff safety. EHS worked with the different healthcare departments to implement the necessary changes. PAPRs were also a means to alleviate the shortage of PPE on the research side. As a renowned research center and host of the World Reference Center for Emerging Viruses and Arboviruses (WRCEVA) collection, UTMB was a leader in providing critical biological materials to diagnostic reference laboratories and other entities around the world to support the fight against COVID-19. EHS played a critical role in supporting the shipping of all of these materials. Although the pandemic is not yet over, EHS remains committed to supporting the safety of our visitors, patients, employees, and students.
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS BIOLOGICAL SAFETY PROGRAM The Biological Safety Program’s (BSP) mission is to ensure the safe use of recombinant and/or synthetic nucleic acids, infectious agents (including select agents), and potentially infectious materials in research, teaching, and healthcare activities to eliminate or reduce the potential exposure to personnel or the environment.In addition, we achieve this goal through routine inspections of laboratories, providing risk assessments and risk mitigation solutions to all of UTMB enterprises to ensure safety and compliance. Our collaborations across UTMB’s enterprises allows for a rapid response when the need arises in one or more areas .
Accomplishments • • • •
•
•
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Lead the unannounced Federal Select Agent Program inspection with no major findings Lead the annual Federal Select Agent BSL4 inspection with no major findings Modified our Biosafety training courses to a virtual/ hands-on training module to provide critical biosafety training while observing COVID-19 social distancing guidelines Supported Institutional Committees − Developed and implemented an electronic voting process for expedited reviews and approvals of critical COVID-19 related research protocols The IBC was able to review and approve 98 protocols from March 2020 through August 2020. − Enacted an electronic form for the review and approval of human product research with COVID-19 patient samples − Reviewed IACUC protocols for SARs-CoV-2 related animal studies Provided the following services to assist SARs-CoV-2 research efforts at UTMB − Risk assessments, consultations, SOP reviews, and training − Developed solutions to PPE and disinfectant shortages Shipped SARs-CoV-2 virus, its RNA, and infectious clones to assist researches all over the world develop diagnostic tests and assays, and potential therapeutics Maintained BSP Service Level Agreements to ensure compliance with UTMB policies and procedures and regulatory agencies Publication “Multicycle Autoclave Decontamination of N95 Filtering Facepiece Respirators”, N.E. Bopp, D.H. Bouyer, C.M. Gibbs, J.E. Nichols, C. Ntiforo, and M.A. Grimaldo. Applied Biosafety: Journal of ABSA International 1-7. 2020 Belinda Rivera completed a Master’s in Legal Studies and a certificate in Healthcare Compliance
Future •
Continue to spread our “culture of safety” via a biosecurity approach − Stay current with the advancements in research, infectious disease epidemiological trends, regulations, and best practices for working safely with infectious diseases
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ENVIRONMENTAL HEALTH AND SAFETY
Biosafety Training Biosafety offers theoretical and practical training core courses from BSL2 to BSL4, including animal biosafety, and non-human primate training. FY20 totaled 680 training contact hours, which includes trainees across several UTMB departments and enterprises (e.g., research, faculty, graduate and medical school, facilities and maintenance, animal care, and healthcare). In response to the COVID-19 pandemic, we saw an increase in BSL3 and ABSL3 training due to the surge of SARs-CoV-2 research and funding. We trained 327 Healthcare staff on the safe use of Powered Air Purifying Respirators (PAPRs) and PPE.
Institutional Biosafety Committee (IBC) Biosafety manages the IBC and works closely with its members to execute the committees’ mission to ensure research is conducted in a manner compliant with regulations and UTMB policies and procedures. Biosafety provides assistance to investigators with the submission, planning and conducting of research protocols in accordance with the regulations and UTMB policy and procedures. In response to COVID-19, the IBC implemented an expedited approval process to allow research to proceed as quickly as possible.
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS OCCUPATIONAL SAFETY PROGRAM The Occupational Safety Program provides a variety of services to support the safety of patients, employees, students, and visitors across UTMB. Services provided include chemical safety support, accident and near-miss investigations, ladder, forklift, and compressed gas safety, food safety, potable water quality, and construction safety. The Occupational Safety Program also provides industrial hygiene monitoring and indoor air quality evaluations to ensure employees are not overexposed to hazardous chemical or physical agents at UTMB.
Accomplishments
• Publication of two peer-reviewed journal articles in the journal ACS Chemical Health & Safety: − Lessons Learned from Implementation of a Web-Based Environmental Health and Safety Management Database in an Academic Medical Center − Development and implementation of a Clinical Eyewash and Safety Shower Risk Assessment Process in an Academic Medical Center • In response to the COVID-19 pandemic, performed 6643 successful fit tests across UTMB (compared to 2090 in FY19) • Revised & updated the Permit-Required Confined Space Entry permitting process • Successful conversion of SDS management into an online SDS management system • Developed a formalized Job Hazard Analysis and PPE Hazard Assessment template for use internally and by trained customers • Successful implementation of the High-Risk Hazardous Chemical Safety Plan audit program in research • John Sealy Hospital Modernization was awarded a Silver Safety Through Exemplary Performance (STEP) Award by UT System − This award recognizes those projects that demonstrate exceptional leadership that delivers safety excellence and positive changes within the construction industry • Completed Confined Space risk assessment and inventory across Galveston Campus • Purchased and installed 12 new Public Access Automatic External Defibrillators within non-health care (research & support buildings) • Dan Marsh completed an Associate in Applied Sciences degree in Occupational Safety and Health Technology from the College of the Mainland
Future
• Complete a roof fall hazard risk assessment across all UTMB buildings • Continue to support ongoing fit testing needs to ensure safety of UTMB staff involved in the COVID-19 response
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ENVIRONMENTAL HEALTH AND SAFETY
The UTMB Construction Safety Program, supported with a fulltime Construction Safety & Loss Prevention Manager working in close collaboration with Facilities Design & Construction, has seen UTMB achieve consistent safety performance exceeding UT System & industry benchmarks. As measured with the 12 month record-able incident rate (RIR). UTMB ended FY20 with a 12-month rolling RIR of 0.5, which continues to outperform industry’s national average RIR of 3. as well as the UT System average RIR of 0.9.
2500
160
2400
140 120
2300
100
2200
80
2100
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40
1900 1800
20 FY19 Chlorine samples
FY20
0
# of Coliform Samples
# of Chlorine Samples
Water Quality Samples by FY Ensuring a high level of water quality continues to be a top priority in order to ensure the health and safety of patients, employees, students and visitors. As additional facilities are added, or in response to incidents, routine and emergency chlorine and coliform sampling is performed. FY20 saw a significant increase in the number of samples collected, mostly attributed to new facilities that have been activated (Clear Lake Campus & League City Campus Expansion).
Coliform Samples
UTMB continues to show improvement in the rate of severe injuries seen among our staff. UTMB has shown sustained improvement in its Days Away, Restricted, & Transferred (DART) rate over the fiscal years, and continues to outperform those rates seen by other organizations in the industry.
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS ENVIRONMENTAL PROTECTION MANAGEMENT The Environmental Protection Management (EPM) program provides dedicated technical services for protecting UTMB’s environmental liabilities with regulatory oversight for hazardous waste management, hazardous materials spill response and contingency planning, regulatory permitting and reporting, and customer services to include hazardous chemical and radioactive material waste pickup and disposal. Environmental Protection Management also focuses on the sustainable management of the earth’s resources and environmental preservation through federal, state, and local regulations. These programs are designed to protect the University and surrounding communities from the threat of contamination associated with air, water, as well as from hazardous materials or hazardous wastes.
797 Chemical Requests
3500 Chemical Pick-up Requests
TOTAL HAZARDOUS CHEMICAL WASTE 210,878 LBS.
16 Radioactive Pick-up Requests
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ENVIRONMENTAL HEALTH AND SAFETY
REAL PROPERTY ACQUISITIONS This year’s unprecedented times with UTMB Health’s response to the ongoing COVID-19 pandemic has also provided EPM the opportunity to provide value-added services with property acquisitions. Real Estate Operations had prospective interest in two residential properties adjacent to the UTMB Galveston campus. EPM internally performed the environmental site assessments to determine if any potential environmental exposures, spills, or compliance issues occurred with the real estate prior to the acquisition by UTMB. The work was performed according to the UT System Policy 161: Environmental Review for Acquisition of Real 719 Post Office, Galveston, TX. Photo by M. Thibodaux
Property.
AGENCY INTERACTIONS The Environmental Protection Management Team had multiple agency interactions consisting of Comprehensive Compliance Inspections and Regulatory Audits. The Texas Commission on Environmental Quality (TCEQ) performed two inspections on UTMB’s Municipal Separate Storm Sewer System (MS4). The TCEQ, in conjunction with the Galveston County Health District, also performed audits on the Potable Water Program and the Title V Air Permit.
Meagan Thibodaux, Sr. Safety Specialist, bulking waste in the CAF , Galveston Campus
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS FIRE & LIFE SAFETY PROGRAM The Fire and Life Safety Program has a system-wide mission to provide employees, patients, and visitors with a safe physical environment. To do so, we survey the environment, identify potential problems, champion solutions and track them to their resolution. In addition, we achieve this goal through routine inspection and testing of Life Safety features of our facilities to ensure code compliance and that they will function properly in times of an emergency. The Fire and Life Safety group also serves as the liaison to local fire officials, the Joint Commission Life Safety surveyor, and is responsible for fire emergency planning. We help develop departmental plans as well as building-wide and institutional responses to emergencies.
Accomplishments •
•
Provided significant resources into the acceleration and early opening of the League City Hospital South Tower for pandemic response needs through acceleration of construction and commissioning Performed multiple modifications of existing facilities on an emergent basis to ensure code compliance and flexibility of space Completed Clear Lake Hospital extension survey with no above-ceiling findings; due to a new collaboration effort with Property Services and is a very rare achievement for TJC Surveys Participated with Healthcare leadership in the evaluating potential COVID-19 surge space and led negotiations with the Texas State Fire Marshal to obtain concurrence Actively modified surge spaces to meet requirements set out by authorities, then returned to normal service Continued maintenance of fire safety systems (fire extinguishers, sprinkler systems, fire alarm systems, etc.) throughout pandemic, ensuring that the safety of our patients and staff is not compromised Replaced an old diesel fire pump at Primary Care Pavilion with a modern electric one, significantly reducing ongoing
• • • •
maintenance (cut costs by 1/4), improving reliability, and reducing environmental impact due to diesel fume emissions Fully fire sprinkled the Animal Resources building Replaced the obsolete Shope Lab fire alarm system with a modern, integrated system Changed our fire extinguisher maintenance paradigm to significantly improve efficiency and reduce costs Fire and Life Safety is continuing to reduce costs of services on a per square foot basis, while the campus expands efforts
• • • • •
Future • • •
Fire and Life Safety will be improving emergency response and drills by using outdoor, “re-entry” speakers in select areas so that audible mass notification is possible, quicker “All-clears” are possible, and provide for better communication Further improve upon and integrate systems for emergency, mass-notification communications Implement new SharePoint-based document management system for Joint Commission compliance
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ENVIRONMENTAL HEALTH AND SAFETY
As part of the Fire and Life Safety mission, we provide employees, students, patients, and visitors with a safe physical environment to conduct business, study, delivery, and receive care. Our staff efficiently tests and inspects Life Safety features to ensure code compliance and that the Life Safety features function properly during an emergency. As a part of our ongoing efforts to be good stewards of UTMB resources, EHS constantly strives to reduce costs through competitive bidding of services, close attention to work service efficiency and effective maintenance strategies. This has allowed us to do things like reduce the rate of repair costs while the institution has grown.
Emergency cleanup, reactivation and root cause investigation from sprinkler activation; executed solution to prevent another activation
Unintended fire sprinkler activation from steam malfunction
Operating room (OR) fire safety training includes mock fires in the OR and evacuation of a mock patient to an area of refuge Annual Report
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS RADIATION SAFETY The Radiation Safety Program works to ensure UTMB is in compliance with regulations and recommendations for the safe use of radioactive materials, x-rays, lasers, and strong magnetic fields. Services offered include performing leak tests and inventory of sealed sources, receiving & surveying all research radioactive material packages, calibration of radiation survey instruments, bioassays, facility shielding design & verification, as well as administrative oversight of regulatory licenses and registrations.
Radiation Safety’s pumpkin from the EHS Holiday Potluck pumpkin carving contest
Accomplishments
• Managed the successful on-site replacement of GNL radiation equipment (~$1,000,000 project) • Supported the construction and opening of the League City Campus Hospital expansion by validating lead shielding design and performing post-construction surveys to ensure correct standards were met • Implemented formalized MR Safety Audit program across the institution • Completed conversion of all radiation meter calibration records into electronic records maintained in EHS database • Submitted timely renewal of Angleton Danbury mammography registration • Submitted and received approval for new mammography accreditation and registration at the UTMB Clear Lake Campus • Radioactive Material inspection for League City Campus nuclear medicine had no violations • MQSA mammography inspections of Galveston Campus and Angleton Danbury Campus had no violations • X-Ray inspection of Victory Lakes Town Center and Alvin Outpatient Imaging Center had no violations • Successful implementation of new dental x-ray regulations requiring quarterly QA/QC
Future
• Upcoming triennial Joint Commission survey will require Radiation Safety support • Implementation of planned updates to Texas veterinary x-ray rules • Anticipated updates to Texas regulations on the medical use of radioactive materials
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ENVIRONMENTAL HEALTH AND SAFETY
Radiation surveys are required to be performed periodically in areas where radioactive material are used and stored. Radiation Safety provides this service to both research labs and clinical areas using these materials. These surveys are vital to ensure that radioactive contamination is not being spread throughout our facilities and into the public.
Despite reductions in research use of radioactive material, the use of ionizing and non-ionizing radiation in health care continues to increase. The number of x-ray machines and dosimetry program participants has steadily increased over the years, primarily the result of UTMB health care expansion. Regulatory inspections remain steady, indicating continued need for EHS resources to support institutional compliance.
With more than 950 people spread across four regional campuses and 8-offsite x-ray facilities participating in the UTMB radiation dosimetry program, ensuring timely return and actual use of the radiation badges is a struggle. CY20 YTD has seen improvement in late return percentages (17% late) compared to CY19 (24%). Unused dosimeters have improved to 6% unused in CY20 YTD compared to 17% returned unused in CY19..
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ENVIRONMENTAL HEALTH AND SAFETY
PROGRAM AREAS JOINT COMMISSION COMPLIANCE The Joint Commission Compliance Program works to mitigate risks to patients, employees, students, and visitors from known risks that may exist in the physical environment or activities connected to its operations and/or properties. We do this through surveillance, education, data trending, and feedback. The Joint Commission Compliance Program organizes a multidisciplinary team to walk the clinics, provide onsite education, evaluate processes and procedures, provide staff knowledge, and address the specific risks and unique conditions at each site.
Accomplishments •
• • • • •
Shifted from in-person Environment of Care (EOC) tours within hospitals and clinics, to virtual tours in response to COVID-19, with no additional cost incurred to the University Bi-annual inspections for nearly 4 million square footage of healthcare space Conducted a successful Joint Commission Extension Survey of Clear Lake Campus (CLC) and League City Campus (LCC) ICU Reviewed, updated, and distributed the Emergency Procedure Manuals for 2020 Developed a 2020 matrix to display healthcare deficiencies collected each month Effectively transitioned from paper surveys for staff knowledge, to a web-based platform, increasing staff participation from 25% to over 80%
Geraldine Giannotti, Joint Commission Specialist and Billy Martin, EOC Compliance Manager
Future • • • • •
Continue to Correct-Verify-Maintain Preparing for the Joint Commission Tri-annual inspection of UTMB 2020 Preparing for the Joint Commission expansion survey of CLC Pediatrics/Pediatrics ED and LCC South Tower Additional clinics opening and expanding Transition to electronic documentation for Joint Commission
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Sr. Safety Specialists, Jeremy Wilke and Dean Leathers, and Billy Martin, EOC Compliance Manager, at skills fair displaying the controlled substance disposal items currently used and demonstrating proper fire extinguisher use
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ENVIRONMENTAL HEALTH AND SAFETY
The Environment of Care Tours are performed twice a year for both onsite and offsite campuses and clinics. This graph represents an increase in clinics from 2019 to 2020 of the nearly 4 million square feet of healthcare space.
EOC Team participating in Virtual Environment of Care Tours
Nurse Managers and the EOC Team during offsite tours
Geraldine Giannotti participating in an Environment of Care Tour and collecting information on findings
Jeremy Wilke, Sr. Safety Specialist, training UTMB nurses on controlled substance disposal during EOC tour
Total findings discovered during tours, total findings closed, and total findings open for calendar years 2019 and 2020
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ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS SUMMARY FIT TESTING Fit testing is required on an annual basis by the Occupational Safety & Health Administration (OSHA) and is vital to ensuring that respiratory protection is effective. Without a fit test, the employee has no idea whether or not the respirator they are wearing will protect them. Beginning in February of 2020, EHS ramped up its fit testing activities in order to support the anticipated surge of health care workers needing to wear respiratory protection due to COVID-19.
PPE EVALUATIONS & TRAINING During the pandemic, many manufacturers have developed new PPE to meet the critical need of healthcare providers. But not all PPE is created equal, and evaluation of all PPE worn by staff is critical to ensure the appropriate level of protection. Proper use of safety equipment ensures that it provides the protection it was designed for. EHS, in collaboration with Healthcare Leadership, ensured that all new PPE used on campus was evaluated and staff were appropriately trained.
N95 REPROCESSING
The Pandemic has caused severe shortages in respiratory protection for healthcare workers. In order to ensure that UTMB workers could work safely while caring for patients, BSP tested and validated several different decontamination methods for the N95 reprocessing program in coordination with Healthcare leadership. BSP continues to coordinate and perform the N95 decontaminations for the reprocessing program for UTMB.
MEDICAL WASTE ASSESSMENT & DISPOSAL Environmental Protection Management (EPM) provides technical services for protecting UTMB’s environmental liabilities with regulatory oversight for the Institutional medical waste processes. UTMB’s medical waste operations are permitted by the Texas Commission on Environmental Quality (TCEQ) municipal solid waste permitting and must meet regulations for medical waste transport, treatment, and disposal. EPM staff support the Environment of Care Committee with a significant role in monitoring waste trends and Institutional compliance with training for UTMB employees on proper management of pharmaceutical and medical wastes.
BIOLOGICAL SHIPPING BSP supports shipping of biological material for UTMB researchers. BSP played an integral role in shipping SARs-CoV-2 virus and RNA, as well as one of the first infectious clones created in the world to reference laboratories and researchers nationally and worldwide to allow for swift countermeasure development and testing. BSP sent UTMB’s first shipment of SARs-CoV-2 on February 18th, 2020 and continues to ship these critical samples and infectious clones nationally and worldwide.
OVERFLOW SURGE SPACE ASSESSMENTS & MODIFICATIONS Early in the COVID-19 crisis it became clear that our current facility capacity might not meet demand. EHS worked directly with the Texas State Fire Marshal and healthcare leadership to identify potential areas and define changes needed for appropriate levels of safety and maximum utilization. EHS actively modified spaces such as: additional sleep rooms for physicians, gymnasium infirmary, and other spaces by improving life safety systems in preparation for a potential surge. Some spaces, such as the gymnasium, have since been converted back once the initial threat abated.
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Annual Report
ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS FIT TESTING EHS staff put to the side their usual daily activities for several months in order to support the surge in fit testing demand across the entire health system. In addition to the sheer number of people needing to be fit tested, there were also significant challenges associated with N95 supplies, requiring EHS to help evaluate potential new makes and models to be used by our staff. UTMB EHS also supported outside health systems such as Memorial Hermann by providing them with supplies needed to perform qualitative fit testing for their employees.
Jim Stone, EHS Consultant, and Courtney Williams, OSP Technician, providing N95 fit tests to health care workers on the front line with COVID-19
Labor & Delivery night-shift nurses getting fit tested on March 13, 2020
Number of Fit Tests Performed (Pass + Fail) 12000 10000 8000 6000 4000 2000 0
FY16
FY17
FY18
FY19
FY20
In FY20, EHS performed 9,827 fit tests. This is more fit tests than were performed in FY16, FY17, FY18, and FY19 combined (8,375) Annual Report
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ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS PPE EVALUATIONS & TRAINING In response to the shortage of respiratory protection, several manufacturers have developed new models of Powered Air Purifying Respirators (PAPRs). EHS Biosafety and Occupational Health Safety Programs, in collaboration with Infection Control and Healthcare Leadership, evaluated each new model that was obtained for use in the healthcare and research areas to ensure they met safety standards. Biosafety followed up by providing training to all staff that would be using the units. During the pandemic, modifications to the personal protective equipment (PPE) worn by healthcare staff were necessary to ensure staff and patient safety. Procedural evaluations and modifications were necessary in certain areas. Biosafety worked with the different healthcare units and departments to ensure that all staff were properly trained and comfortable in the techniques on proper donning and doffing of the PPE, and that procedures were in place for staff safety.
DOW PAPR training was provided by EHS Consultants, Malissa Mayer-Diaz and Belinda Rivera, and Sr. Safety Specialist, Nikki Ward
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PPE training for Healthcare staff was provided by EHS Consultants, JeT Newton and Belinda Rivera
Annual Report
ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS N95 REPROCESSING
Due to global PPE shortages during the pandemic, UTMB was proactive in working to conserve the supplies on campus to ensure an adequate supply of N95 filtering facepiece respirators (FFRs) were available to Healthcare personnel (HCP). UTMB Healthcare Leadership reached out to the EHS Biosafety Program and Galveston National Laboratory (GNL) to assist with researching potential decontamination methods that would be suitable for the reuse of N95 FFRs for HCP. Collaboratively, the team set out to test and validate two different decontamination methods: moist heat and vapor-phase hydrogen peroxide. The team successfully demonstrated by using stringent testing that, after multiple decontamination cycles, the N95 FFRs met acceptable performance standards. The decontamination Reprocessed 15,113 N95s with current 80% return rate systems were validated using both biological and chemical indicators, filtration efficiency, breathability, form fit testing, and strap integrity testing for each respirator model. The following N95 models were tested separately for each decontamination method: 3M 1805, 3M 1870/1870+, 3M 1860/1860S, Prestige Ameritech RP88020. For each study, the N95 FFRs were subjected to multiple decontamination cycles (of a single method) and then assessed to determine the decontamination point of failure. The validation studies concluded that the folded style FFRs (3M 1805, 3M 1870/1870+) can withstand moist-heat decontamination for several decontamination cycles. Overall, all N95 models tolerated vapor-phase hydrogen peroxide decontamination. The N95 reprocessing program was a collaborative multidisciplinary effort across the UTMB Enterprise. The reprocessing program was a collaborative effort amongst the UTMB Healthcare, Research, Environmental Health and Safety, and support services.
Nikki Ward, Sr. Safety Specialist, and EHS Consultants, Corrie Ntiforo and Malissa Mayer-Diaz, reprocessing used N95 masks Drying reprocessed N95 masks Annual Report
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ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS MEDICAL WASTE ASSESSMENT & DISPOSAL MEDICAL WASTE Anticipating regulatory requirements enhances the quality of facility management decisions. This experience not only had monetary value but affords experience for a more well-rounded professional staff. This value added service incorporated engineering controls, design, and formal DOT destruction testing to reduce the cost of medical waste processing. The Environmental Protection Management Team worked jointly with Healthcare and Research Departments to provide for a safer and more cost-effective method to dispose of medical and red-bag research waste. In partnership with the BOF Utilities and Property Services, EPM developed a medical waste metrics dashboard and wrote a proposal for medical waste improvements for executive leadership.
Meagan Thibodaux Sr. Safety Specialist
Medical Waste Storage
EPM picking up used N95 masks from the campuses/ clinics and transporting to GNL for reprocessing
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Trending of medical waste processed at UTMB Galveston Campus through incineration or autoclaving under the TCEQ Municipal Solid Waste Registration #2232A
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ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS BIOLOGICAL SHIPPING Biological Shipping Trends FY20
BSP oversees packaging, labeling, and documentation for biological materials shipments as well as, all international biological materials and Federally regulated select agents shipped from our campus. BSP works closely with the Office of Technology Transfer to provide support for shipping of biological material to collaborators and institutions around the world. UTMB and the Galveston National Laboratory (GNL) was one of the first laboratories to receive patient sera and to isolate the virus for internal research and subsequent sharing through the World Reference Center for Emerging Viruses and Arboviruses (WRCEVA). As of August 31, 2020, BSP has sent 237 shipments of SARs-CoV-2 virus and RNA, and one of the world’s first infectious clones all over the United States and the world.
Corrie Ntiforo EHS Consultant
Annual Report
Morgan Gerami Systems Analyst I
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ENVIRONMENTAL HEALTH AND SAFETY
SERVICE HIGHLIGHTS OVERFLOW SURGE SPACE ASSESSMENTS & MODICIFATIONS Relationships Count
As the COVID-19 Healthcare Emergency (HCE) developed and UTMB adapted in response, EHS was tasked early on to assist in evaluating which spaces on campus would be both appropriate and safe for patient use. Several strategies were evaluated such as moving existing, non-COVID-19 patients into newly identified surge spaces, modifying larger areas such as the field house gym into an infirmary and also provide for some additional clinician sleep rooms for the extended shifts onsite. EHS met with Healthcare leadership, reviewed proposed changes and then started expedited discussions with the Texas State Fire Marshal. Within hours, we identified reasonable modifications of identified, contiguous spaces for these potential surge spaces. A written memorandum was also obtained to memorialize the discussion and logic behind the effort.
Changing Spaces
Some changes included changing rooms into sleep rooms by a simple addition of smoke detectors and fire alarm strobes, planning for conversion of unused spaces and planning to convert non-healthcare spaces that once were used as healthcare. EHS was able to add several, fully compliant sleep rooms for clinicians in just a day or 2 – the other spaces were never called upon, however a significant pandemic surgeplan is now in-hand. Other areas, that were once used for healthcare but have not been for some time were identified, evaluated for good clinical workflow and support and then reviewed for safety compliance. Plans of action for conversion were developed. Areas identified were/are in various buildings within the Galveston campus Healthcare Core. All areas met Texas State Fire Marshal requirements upon execution of the plan.
League City South Tower
Another repose to the surge demand crisis was the expedited delivery of the League City South Tower project. The expansion of the League City Campus hospital comes at a fortunate time, though the expansion of the pandemic came several months before the projected completion of the South Tower Project. It makes sense to expedite the completion as much as possible. The team was asked to expedite the project by 2 months, which in construction terms is “… not practicable”. The team embraced the challenge and succeeded, however as extraordinary times require extraordinary efforts from extraordinary people. The teams changed work/reporting protocols, put in the extra effort and the longer hours to ensure that work was completed. Other on-going efforts were put on hold and additional personnel resources were devoted to quality inspections, delivery coordination and final inspections. Additionally, old work-flows and protocols were dropped in favor of efficient direct-working relationships. The results were very time effective and ended up in the delivery of a Joint Commission-ready facility. The South Tower was delivered as requested in preparation for surge needs.
Routine Facility Assessments
As facilities were modified in response to the HCE, there was a distinct need to control access into the vulnerable facilities at UTMB. Control of personnel traffic into the facilities was severely curtailed for infection control purposes. These changes can have an effect on proper fire safety exiting from the building, however so EHS once again worked proactively with user groups and the UTMB Campus Police department to develop a safe solution that met the needs of the institution. Additionally, EHS maintained a higher vigil on these spaces, as well as the temporary tents by performing routine safety inspections to ensure conditions did not deteriorate.
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Training on PAPR assembly, donning, and doffing JeT Newton training on PAPR assembly, donning, and doffing Jim Stone training on PAPR assembly, donning, and doffing EPM staff: Jordan Sweet and Meagan Thibodaux EPM bulking hazardous chemical waste EOC tours training nurses on controlled substance disposal EPM preparing medical waste boxes for DOT testing standard Lunch donated to EHS staff re:COVID-19 Triage tents at League City Campus EHS Holiday Potluck & Pumpkin Carving Winners: Fire & Life Safety Team BSP team ready and prepared EPM team at the EHS Retreat at League City Campus (LCC) EHS staff, in groups, working on projects during the EHS Retreat at LCC Jack Tarpley, AVP, judging a team building project, while three (3) of the EHS Program Directors await the winning team entry (De’Anne Meeh, Sophie Brocard, and Chuck Carlisle) during the EHS Retreat at LCC
Annual Report
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Satellite image of Hurricane Laura, category 4, August 26, 2020 Photo: Public Domain - the U.S. National Oceanic and Atmospheric Administration (NOAA)
