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Patient Safety and Quality Healthcare
Posted June 20, 2007

Patient Safety and Quality Healthcare: Feature Article

Footwear & Safety
A Safety Bulletin from the Partnership for Health and Accountability
Spring 2007

Situation
A Georgia Hospital Association (GHA) member recently pointed out the dilemma hospitals are facing regarding balancing the safety needs of patients, protecting employees, and maintaining staff morale and comfort. The issue concerns the appropriateness of popular and comfortable footwear in the hospital environment, which make some question their ability to comply with OSHA regulations.

The Shoes Known As Crocs

  • Are very popular footwear known for their comfort and functionality. They are made of a plastic resin — CrosliteTM, a material that enables production of a soft and lightweight, non-marking, slip and odor-resistant shoe.

  • Were originally designed for boating for their slip resistant soles and holes on top and vents on the side for drainage, conforming to the ASTM slip-resistance standard.1

  • Receive hospital staff testimonials for their ergonomic design and shock absorbing properties that are a benefit for employees who are on their feet for long hours.

The American Nurses Association (ANA) has partnered with Crocs, Inc. to offer ANA members a special member benefit program for Crocs "Work" shoes. This program offers 4 models, 3 totally closed and one with side holes and can be accessed by ANA members at this link: http://nursingworld.org/MALL/crocsANA.htm.2

     

Specific Issues

  • Hospital members have raised concerns that the Crocs with holes may not comply with the following OSHA regulations:

    1. Protective Footwear — Standard 29 CFR 1910.132 and 1910.136 29 CFR 1910.136(a) requires the use of protective footwear when employees are working in areas where there is a danger of foot injuries due to falling or rolling objects, or objects piercing the sole, ...3

    2. Bloodborne Standard, 1910.1030, section (d)(3)(i) requiring that employers ensure protective foot gear is worn to provide protection from potential needle sticks, splashing from blood or OPIM (Other Potentially Infectious Materials) spills:4


  • A posting to Joint Commission Watch reported that hospital staff wearing Crocs may have produced static electricity that caused equipment malfunctions5
    - A Swedish hospital wants to ban its staff from wearing Crocs plastic clogs, saying they generate static electricity that can knock out medical equipment, a spokesman said. Blekinge hospital in southern Sweden suspects the slip-on shoes made by U.S.-based Crocs Inc. are to blame for at least three incidents in which respirators and other machines malfunctioned. The mishaps caused no injuries.

Follow Up

  • PHA staff contacted the manufacturer of Crocs, the American Nurses Association, and OSHA to review our member concerns. In addition, at the request of Vickie Stuckey, director of Patient Safety at the Medical Center of Central Georgia (MCCG), a short survey was sent to PHA member hospitals and reviewed by PHA staff.

  • The Crocs, Inc. Response: PHA staff spoke with Anton Albrand, Vertical Business manager, and Jeff Tolaio, National Accounts, Crocs, Inc. Their response was positive and indicated their willingness to work with hospitals. They provided the following information for us to share with member hospitals:

    1. Regarding the OSHA Bloodborne Standard:
      We have communicated with OSHA (Pam Baptiste, OSHA Blood Borne Pathogen coordinator) to determine if Crocs meets OSHA criteria for the Healthcare environment. We were informed that there is only one standard which needs to be met. This is OSHA's Bloodborne Standard, 1910.1030, section (d)(3)(i). OSHA does not qualify specific shoes or brands, but indicates that employees should wear shoes that protect from potential blood or OPIM splashing. According to OSHA, each hospital or healthcare facility should review the standard recommendation and decide if they will restrict brands or models. If shoes with ports or holes are allowed, shoe coverings are recommended. (Note: If shoes with holes are allowed, it is the employer's responsibility to provide these shoe coverings at no cost.)
    2. Current Models and Future Plans:
      Crocs, Inc. notes that in response to healthcare community concerns there are currently two models that we are specifically marketing for the healthcare environment. The Endeavor model is a fully enclosed design. The Professional has a closed top with ventilation ports that are ribbed to channel liquids away from the feet. These models can be viewed on our Web site, www.crocs.com.

    Two new Crocs model shoes are expected to be launched in June. The "Specialist" is designed to provide a higher level of compliance to meet workplace standards, and has a covered heel, solid construction, and no holes or vents. A second model has vents. These shoes are expected to retail at $34.99, and Crocs, Inc. reports that:

    ....these were specifically developed to meet the requests / requirements that we received from the healthcare community. Both have the same slip-resistance, non-marking soles, anti-microbial and odor resistant properties, patented closed cell Croslite material and phenomenal comfort of all of our Crocs models. The specifications are being finalized.6

    Employees who wish to purchase the Crocs Specialist shoes that meet employer workplace requirements are advised to check with their professional associations regarding member benefits for Crocs Work Products special offers.

  • The American Nurses Association responded to the issue of static electricity noting:
    There are a number of factors that contribute to the build-up of static electricity including temperature, humidity, flooring applications, types of material, and the nature of the contact. It is unlikely that any one factor is the sole cause of any static electricity problems. We know of no reason that Crocs would be any more susceptible to static electricity than shoes such as sneakers and other types of footwear worn by medical professionals. Medical employees are one of many valued constituencies at Crocs and we will continue to ensure that we are fully addressing the needs of our customers and the environments in which they wear our products.7
  • PHA Footwear Survey: A three-question voluntary survey was sent to PHA Peer Review Contacts in April 2007 in response to a member's concern about the safety of hospital employees wearing shoes with openings. Management was considering a policy change and wanted to know how other Georgia hospitals were handling this issue. The questions asked if hospitals permitted staff to wear Crocs either with holes or no holes. A third question asked if nurses were required to wear white.

  • Footwear Survey Results: More than 50 hospitals responded to the survey, and many respondents indicated that footwear and employee safety were concerns. These hospitals are in the process of evaluating their policies on footwear and dress requirements and planning to require closed shoes for staff protection. 13% of the hospitals responding indicated that Crocs with holes are not permitted to be worn on duty at this time.

    A number of hospitals had policies requiring that shoes be closed at the top and sides. A few did not specify the type of shoe that could be worn such as clogs or Crocs, just that the shoe be closed. Analysis of the results further indicated that 7% of the hospitals that did not allow the original Crocs (with holes and vents) would permit the closed shoes.

    Finally, 8% of the hospitals responding required nurses to wear whites, and several used different colors to represent staff disciplines. More respondents indicated they would like to require nursing staff to wear either all white uniforms or white lab coats or vests.

Summary
This Safety Bulletin is intended to provide information to members to help them make informed decisions on patient safety issues related to employee footwear. The Crocs Corporation is working with heathcare associations and organizations and has partnerships with several.

Many healthcare workers including nurses and physicians rely on their Crocs for comfort and relief of foot and back problems. New footwear designed to meet the OSHA standards for footwear protection will be available shortly from Crocs, Inc. You may want to discuss these issues with the appropriate decision makers, legal counsel, and frontline staff in your organization to have polices that can balance employee safety with the need to meet their comfort and satisfaction.

Questions can be addressed to Anne Grabois-Davis at adavis@gha.org.

PHA would like to thank all of our members who took the time to complete the Crocs Footwear survey. Together we are improving care.

About the Partnership for Health and Accountability (PHA)
PHA, formed in January 2000 and sponsored by the Georgia Hospital Association, is a voluntary statewide patient safety program that brings together health care providers with community agencies and individuals to increase accountability and to achieve safer care and healthier communities. PHA is a national model for statewide patient safety programs and includes representation from hospitals, physicians, state health officials, legislators and businesses. For more information about PHA, please visit its Web site at: www.gha.org/pha.

About Georgia Hospital Association (GHA)
Established in 1929, GHA is the state's largest trade organization of hospitals and health systems providing education, research and risk management services to its 174 hospital and health system members. Additionally, it represents and advocates health policy issues benefiting Georgia's citizens before the state legislature and U.S. Congress as well as before regulatory bodies. Please visit the association's Web site at www.gha.org.

This Rapid Response Survey (RRS) uncovered the issues and solutions regarding wearing of Crocs in the hospital setting. PHA initiated Rapid Response Surveys to help members learn how other hospitals are responding to new Joint Commission standards, regulations and critical issues.

Members can send an e-mail to their peers on an issue that includes a link to a short web based survey created by PHA staff. Up to 3 questions are included and the anonymous answers are received at GHA and analyzed by PHA staff. This Safety Alert Bulletin on Crocs was written to summarize the responses from the RRS and the issues it raised.

The "successful strategies" discussed in this Safety Bulletin do not represent a standard of care. They are merely a compilation of certain methods or procedures which were found to be effective when implemented by some hospitals. The legal standard of care applicable to each hospital and patient will vary depending on the circumstances.


GHAREF 2007

References

1. ANA Press Release of March 8, 2007, accessed on 4/30/07 at http://nursingworld.org/pressrel/2007/PR030807-CROCS.htm

2. ANA Press Release of March 8, 2007, accessed on 4/30/07 at http://nursingworld.org/pressrel/2007/PR030807-CROCS.htm

3. Letter posted from Richard E. Fairfax, Director, Directorate of Enforcement Programs, OSHA, accessed on 5/3/07 at http://www.osha.gov/pls/oshaweb/
owadisp.show_document?p_table=INTERPRETATIONS&p_id=25439

4. OSHA Standard accessed on 5/3/07 at http://www.osha.gov/pls/oshaweb/
owalink.query_links?src_doc_type=STANDARDS
&src_unique_file=1910_1030&src_anchor_name=1910.1030

5. April 23, 2007 posting to the JCAHO-WATCH list serve from Christopher Burney

6. Draft product specifications sent by Anton Albrand in an e-mail dated 4/27/07

7. Response in an e-mail on 4/30/07 from Mary Stewart, Senior Public Relations Specialist, American Nurses Association

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