Download CDC Proposes Updated Guidance For Seasonal and H1N1

Health Care Series
August 2010 | Vol. 17, No. 1
CDC Proposes Updated Guidance
For Seasonal and H1N1 Influenza
Also In This Issue
The U.S. Centers for Disease Control and Prevention (CDC) proposed updated guidance on prevention strategies for seasonal influenza
in health care settings, replacing both the current seasonal guidance
and last year’s interim infection control guidance for the novel H1N1
virus. The new guidance continues to emphasize the importance of
influenza vaccination, management of ill health care workers, droplet
and aerosol-generating procedure precautions, surveillance, and environmental and engineering controls. It also now reflects the availability of a safe and effective vaccine for H1N1, which is being included
in the 2010-2011 seasonal flu vaccine, CDC said. The prevention strategies can be applied across the entire spectrum of health care settings,
including hospitals, nursing homes, physicians’ offices, urgent-care
centers and home health care. Page 2
Safe patient handling programs can be adapted
for use in home health and other settings . ........ 5
HazCom Expert Advises Safety
Professionals on GHS, ‘Gray Areas’
While most of the work needed to achieve compliance with a new
globally harmonized system (GHS) of hazard communication will
fall on chemical manufacturers and distributors, employers should
keep an eye on key dates and determine how the proposed changes
will impact their hazard communication programs, says Glenn
Trout, president of MSDSonline, a provider of on-demand material safety data sheets. Speaking to the American Society of Safety
Engineers (ASSE) at their annual meeting in Baltimore, Trout also
offered tips for complying with current HazCom requirements, particularly those “gray areas” intentionally left vague in the standard
so employers could tailor their compliance to the specific situations
in their workplaces. Page 3
Workers’ Comp Insurer Says Safe
Lift Programs Can Reduce Injuries
Safe patient handling (SPH) programs can reduce both the number
and cost of injuries to direct care providers in nursing homes and other
health care settings, a workers’ compensation insurance specialist
said at the ASSE annual meeting in Baltimore. Jason Schaufenbuel,
MPH, CSP, a regional manager for United Heartland (UH), told ASSE
members in Baltimore that UH requires its nursing home and hospital clients to implement SPH programs as a condition of maintaining
coverage. One key element in the program is a requirement that supervisors regularly perform one unannounced observation of a patient
transfer by each direct care giver every quarter. Page 6
Safe Patient Handling
Practice Tools
Hazard Communication
A safety consultant offers best practice
takeaways at the ASSE annual meeting in
Baltimore . ......................................................... 4
Infection Prevention
CDC includes 13 specific prevention strategies
in its proposed updated guidance on seasonal
influenza in health care settings ........................ 5
Update Pages
This month’s update includes:
 a clarification of OSHA’s policy on backup
systems for online access to MSDSs; and
 a note on OSHA’s decision to drop a reexamination of the standard on ionizing
radiation.
Draft Norovirus Guideline
CDC on June 16 requested comment on a new
Draft Guideline on the Prevention and Control
of Norovirus Gastroenteritis Outbreaks in
Healthcare Settings.
Proposed recommendations cover topics that
include: sick leave policies for symptomatic
staff, hand hygiene, environmental cleaning, use
of personal protective equipment and special
considerations for food handlers and other
indirect patient care staff.
The draft guideline and submitted comments
can be viewed online at http://www.cdc.gov/
publiccomments.
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CDC Proposes to Update Guidance for Seasonal
Flu, Replacing Interim Recommendations for H1N1
The U.S. Centers for Disease Control and Prevention
(CDC) proposed updated guidance on prevention strategies for seasonal influenza in health care settings, replacing both the current seasonal guidance and last year’s
interim infection control guidance for the novel H1N1
virus.
The new guidance, proposed June 22 (75 Fed. Reg.
35497), continues to emphasize the importance of
influenza vaccination, management of ill health care
workers, droplet and aerosol-generating procedure
precautions, surveillance, and environmental and engineering controls; however, it also now reflects the
availability of a safe and effective vaccine for H1N1,
which is being included in the 2010-2011 seasonal flu
vaccine, CDC said.
The prevention strategies outlined in the guidance can
be applied across the entire spectrum of health care settings — including hospitals, nursing homes, physicians’
offices, urgent-care centers and home health care — but
are not intended to apply to settings whose primary purpose is not health care.
Fundamental Elements
Preventing transmission of influenza virus and other
infectious agents among patients, visitors and health care
personnel (HCP) within health care settings requires a
OSHA Guide for
Health Care Facilities
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multifaceted approach, according to the proposed guidance. The core prevention strategies include:
•• administration of influenza vaccine;
•• implementation of respiratory hygiene and cough
etiquette;
•• appropriate management of ill HCP;
•• adherence to infection control precautions for all
patient-care activities and aerosol-generating procedures; and
•• implementing environmental and engineering infection control measures.
HCP should don a facemask when
entering the room of a patient with
suspected or confirmed influenza, remove
the facemask when leaving the patient’s
room, dispose of the facemask in a waste
container and perform hand hygiene.
“Successful implementation of many if not all of
these strategies is dependent on the presence of clear
administrative policies and organizational leadership
that promote and facilitate adherence to these recommendations among the various people within the health
care setting, including patients, visitors and HCP,”
CDC said.
The guidance should be implemented in the context
of a comprehensive infection prevention program to prevent transmission of all infectious agents among patients
and HCP.
Droplet Precautions, N95s and Special
Considerations
The guidance includes specific action recommendations focusing on familiar strategies, such as vaccination, surveillance and management of ill HCP, with
an emphasis on screening and triage of symptomatic
patients, adherence to respiratory hygiene and cough
etiquette, and use of standard and droplet precautions
(see Proposed Recommendations Summarized, Page 5).
Regarding droplet precautions, the guidance states
that HCP should don a facemask when entering the
room of a patient with suspected or confirmed influenza,
remove the facemask when leaving the patient’s room,
See Flu Guidance, p. 5
2
August 2010 | OSHA Guide for Health Care Facilities
Keep an Eye on Key GHS Dates, Update Labels On
Secondary Containers, HazCom Expert Advises
While most of the work needed to achieve compliance with a new globally harmonized system (GHS) of
hazard communication will fall on chemical manufacturers and distributors, employers should keep an eye
on key dates and determine how the proposed changes
will impact their hazard communication (HazCom) programs, an expert advised safety engineers at their annual
meeting in Baltimore.
Glenn Trout, president of MSDSonline, a provider
of on-demand material safety data sheets (MSDSs) and
other safety resources, offered members of the American
Society of Safety Engineers tips for complying with current HazCom requirements and preparing for proposed
changes that could take effect as soon as 2011.
Adopted in 1983, the hazard communication standard
covers 100 million workers in 7 million U.S. workplaces, Trout said. Its purpose is to ensure that hazards of
chemical substances are evaluated and that details about
potential hazards and safe work practices are transmitted
to employees. To comply with the standard, Trout said,
all employers need to know what hazardous chemicals
they have “on the floor” and communicate those hazards
to employees.
Navigating the Gray Areas
HazCom is sometimes referred to as the “common
sense regulation” because employers must apply its
provisions to the unique circumstances of their own
workplaces, Trout said. The U.S. Occupational Safety
and Health Administration (OSHA) purposely wrote the
standard to include “gray areas,” he explained. For example, the standard requires employers to keep MSDSs
in a location “readily accessible” to employees, but it
does not define what that term means.
For guidance on compliance with gray areas, Trout
advised, employers should look to the standard interpretation letters (SILs) that OSHA issues in response
to situation-specific questions submitted by safety professionals and others. Employers who have a question
about how to comply with the standard can check the
OSHA website for relevant SILs.
Readily accessible, for example, has been interpreted by OSHA to mean accessible within 20 minutes
for some work environments. Trout recalled one SIL
in which OSHA told a hospital that had 16 floors in its
main building and numerous small outlying building to
keep one set of MSDSs on each floor of the main building and one set in each of the outlying buildings.
For many employers today, Trout said, providing
workers with online access to MSDSs makes the most
sense because it eliminates the need to constantly update
and file paper copies in binders. Online access is considered permissible by OSHA as long as an employer has a
backup system in place for use if the company intranet
goes down (see ¶242 in the Guide). This backup can be
electronic, such as a phone-and-fax-back system, or it
can be paper copies in binders, he said. A rule of thumb,
he said, is that if the employer retains MSDSs for more
than 30 chemicals, it should go with an online system;
for fewer substances, paper copies should suffice.
A substance is removed from its labeled
product packaging and put into a spray
bottle ‘and nobody knows what it is.’
— Glenn Trout, president, MSDSonline
Consumer Use
Trout said he sometimes hears questions from employers such as whether a four-gallon drum of Windex
is covered by HazCom or exempt as a consumer product
(see ¶233). Employers seeking to avoid HazCom compliance in this way are “pushing into the gray area” he
said. His advice is that it will be easier for them to get
the MSDS for a substance than to argue the point with
OSHA.
If a housekeeper or laundry workers uses a substance
normally covered by the exemption for consumer products in an industrial setting, the substance no longer
qualifies for consumer use, Trout said. “Now, it’s covered by the standard.”
Similarly, employers sometimes ask whether they
need an MSDS for items that in most workplaces would
not be covered by the HazCom standard, such as copy
paper or even water. MSDSs for these products often are
available, he explained, not because they are hazardous
See HazCom Gray Areas, p. 4
Editorial Advisory Board
Thomas H. Wilson, Esq.
Chairman
Vinson & Elkins, LLP
Houston, Texas
Fran Slater Feltovich, R.N.
Methodist Hospital
Houston, Texas
August 2010 | OSHA Guide for Health Care Facilities
Roger S. Kaplan
Jackson Lewis
Woodbury, N.Y.
James W. Stanley
FDRSafety LLC
Nashville, Tennessee
3
HazCom Gray Areas (continued from p. 3)
chemicals covered by the standard but because, from the
vendor’s perspective, it is easier to provide the MSDS
than to reassure a customer who fears that not having it
could lead to an OSHA citation.
The real compliance problems tend to arise around
the use of unlabeled secondary containers in the workplace.
A substance is removed from its labeled product packaging and put into a spray bottle, Trout said, “and nobody
knows what it is.” This can lead to hazardous exposures.
One oft-cited incident, he said, occurred in a school
where someone put a blue liquid into an unlabeled
container, then placed that container in the refrigerator
— where staff mistook it for Kool-Aid and served it to
children.
The HazCom standard requires employers to ensure
that secondary containers of hazardous chemicals are appropriately labeled to prevent such accidents from happening (see Best Practice Takeaways).
Transition to GHS
Trout advises employers to “keep an eye on GHS
milestones,” as OSHA proceeds with its plan to amend
the HazCom standard to align with the Globally Harmonized System of Classification and Labeling of
Chemicals (GHS), a system approved by the United Nations and intended to facilitate international trade in and
reduce unnecessary and duplicative testing of hazardous
chemicals (see Tab 200 in the Guide). OSHA published
its proposed rule changes in September 2009, held informal public hearings in March and April, and could issue
a final rule before the end of the year (see April 2010
newsletter, Page 2).
The major compliance burden of the rule changes
will fall on chemical manufacturers and distributors,
who will have to revise chemical product labels to incorporate new standardized pictograms and warnings
and also provide customers with the revised, standardized safety data sheets (SDSs) that will replace the old
MSDSs.
Employers, Trout said, will have to make sure that
they have the latest SDSs from suppliers and also
train employees on their use. Again, he added, the real
problem for many employers will be ensuring that the
secondary labels they have placed on containers of
chemicals transferred from their original container at the
work site are updated when the revised standard goes
into effect.
It also would be “prudent,” he advised, for employers
to ensure that those containers are labeled in additional
languages, such as Spanish, if any of their potentially exposed employees have limited proficiency in English.
For More Information
For more on HazCom compliance and changes expected under GHS, see Tab 200 in the Guide.
Hazard Communication: Best Practice Takeaways
Be prepared to show OSHA your written plan. “It’s not good enough to have your HazCom plan in your head,”
Glenn Trout of MSDSonline says. It must be written, and “it’s the first thing OSHA will ask for when they walk in the
door.” Employers can buy written plans, “but they must be tailored to your workplace,” he advises. The plan must reference your list of chemicals and describe how you train your employees and where you keep your MSDSs.
Overlabel. Overlabeling is a good practice in most environments, Trout says, not just to ensure HazCom compliance
but because it helps to avoid mistakes that could result in exposures, such as a new employee putting refrigerant into a
container that should hold oil. When performing the HazCom chemical inventory, identify chemicals in pipes that have
an outlet to which an employee could be exposed, he advises. If a pipe holds only water, label it as water to avoid any
confusion.
Provide blended HazCom training. Provide blended training — some in the classroom and some at the worksite —
that is specific to your work environment. Generic training will not meet OSHA’s standards.
Consider language needs. OSHA does not require employers to maintain MSDSs in a language other than English.
However, Trout says, it is a best practice to make this information available in other languages for employees who have
limited English proficiency. Regular HazCom training should be provided in employees’ native languages to ensure that
all employees are fully aware of hazards and safe handling procedures.
Get MSDSs in advance. Try to make sure that you have MSDSs in hand before you receive the first shipment of a new
chemical in case you do not have a place to store it before it is used for the first time by employees.
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August 2010 | OSHA Guide for Health Care Facilities
Flu Guidance (continued from p. 2)
dispose of the facemask in a waste container and perform hand hygiene. Based on local needs, facilities and
organizations “may opt to provide employees with alternative personal protective equipment as long as it offers
the same protection of the nose and mouth from splashes
and sprays provided by facemasks (e.g., face shields
and N95 respirators or powered air purifying respirators
which would also protect against inhaling airborne particles),” the guidance states.
The use of N95 filtering facepiece respirators is
recommended for HCP involved in aerosol-generating
procedures. Respirators must be provided in the context
of a respiratory protection program that includes fit testing and training as required under the U.S. Occupational
Safety and Health Administration’s respiratory protection standard (see ¶540 in the Guide).
In addition, the guidance discusses special considerations for HCP who are at higher risk for complications
from influenza, such as pregnant women, HCP age 65
and older, and HCP with chronic diseases such as asthma, heart disease and diabetes. For example, employers
should consider offering work accommodations to avoid
potentially high-risk exposure scenarios, the guidance
states.
Vaccination Recommendations
Despite the recommendation to promote and administer seasonal influenza vaccine, the proposed guidance
does not recommend mandatory flu vaccination for
health care workers.
“While some have mandated influenza vaccination
for all HCP who do not have a contraindication, it
should be noted that mandatory vaccination of HCP
remains a controversial issue,” CDC said. However,
the guidance states that tracking influenza vaccination
coverage among HCP “can be an important component of a systematic approach to protecting patients
and staff.”
It also suggests strategies for improving HCP vaccination rates, including:
Sick Leave
The proposed guidance includes specific recommendations for managing HCP who show symptoms of the
flu and states that facilities should develop sick leave
policies that are non-punitive, flexible and consistent
with public health guidance to allow HCP with confirmed or suspected influenza to stay home. Facilities
also should ensure that all HCP, including those not directly employed by the facility, are aware of the policies.
Written comments on the proposed guidance are due
July 22; however, the notice states that comments received after that date “will be considered to the extent
possible.” Comments may be submitted via e-mail to
[email protected].
For More Information
The Federal Register notice is available online at
http://www.access.gpo.gov/su_docs/fedreg/a100622c.
html.
Proposed Recommendations
Summarized
CDC’s proposed updated guidance on prevention strategies for seasonal influenza advises health care facilities to:
• promote and administer seasonal influenza vaccine
to health care personnel (HCP);
• take steps to minimize potential exposures;
• monitor and manage ill HCP;
• adhere to standard precautions;
• adhere to droplet precautions;
• use caution when performing aerosol-generating
procedures;
• manage visitor access and movement within the
facility;
• monitor influenza activity;
• implement environmental infection control;
•• providing incentives;
• implement engineering controls;
•• providing vaccine at no cost to HCP;
• train and educate HCP;
•• improving access, for example, by offering vaccination at work and during work hours; and
• administer antiviral treatment and chemoprophylaxis of patients and HCP when appropriate; and
•• requiring personnel to sign declination forms to acknowledge that they have been educated about the
benefits and risks of vaccination.
• take extra considerations for HCP at higher risk for
complication of influenza.
August 2010 | OSHA Guide for Health Care Facilities
5
Workers’ Comp Insurer Requires Clients To
Implement Safe Patient Handling Programs
Safe patient handling (SPH) programs can reduce
both the number and cost of injuries to direct care providers in nursing homes and other health care settings,
a workers’ compensation insurance specialist told a
group of safety engineers at their annual meeting in
Baltimore.
Jason Schaufenbuel, MPH, CSP, a regional manager
for United Heartland (UH), told the American Society
of Safety Engineers (ASSE) June 15 that UH requires
its nursing home and hospital clients to implement SPH
programs as a condition of maintaining coverage.
While researching the problem, the UH loss control
team found that the nursing home losses were driven
primarily by manual lifting and transferring of residents,
repositioning in beds or chairs, residents going to nonweight-bearing status, assisting or transporting, and
moving residents’ limbs. Tasks most often associated
with injuries included:
•• moving residents to and from wheelchairs and toilets, beds and bathtubs;
•• lifting residents in bed;
•• weighing residents;
“What is your process for getting a fallen
resident up off the floor? It better not be
manual.”
— Jason Schaufenbuel,
regional manager, United Heartland
•• changing residents’ thrombo embolic deterrent
(TED) stockings;
•• repositioning residents; and
•• making beds.
No Safe Method of Manual Lifting
Moreover, he said, the program has reduced both the
number and cost of claims. Studying 57 client accounts
held for at least two years before and after implementing SPH, UH found a 37 percent reduction in the number of SPH-related claims. Moreover, claim costs for
those SPH accounts dropped 39 percent compared with
a 19 percent increase across all accounts.
As a mono-line workers’ compensation carrier, the
Milwaukee-based firm insures about 400 hospitals and
nursing homes. Its website attributes its “rapid growth
and success” to customized loss control services and
managed claims handling and emphasizes the firm’s role
in helping clients improve workplace safety.
Carrier Notices Losses
According to Schaufenbuel, UH’s interest in SPH
programs began in 2002, when it noticed significant
losses accumulating across its nursing home accounts,
an industry sector long known for reporting significantly
higher-than-average rates of back injuries and other musculoskeletal disorders (MSDs) caused by patient lifting.
Rather than exiting the nursing home market, UH’s
corporate leaders challenged the loss control staff to try
to solve the problem. The solution they came up with
was to require most health care clients, as a condition of
maintaining coverage, to implement a comprehensive
SPH program designed by UH based on a program developed by the Department of Veterans Affairs (VA).
6
After researching ways to make manual lifting tasks
safer for nursing home workers, the loss control team
concluded that although there are many ways to perform
a manual lift, there is no safe way. No single method
studied has proven to be effective, and regardless of how
well workers are trained, all of the methods produce large
forces on the spine and other joints, Schaufenbuel said.
Eventually, UH adopted, with some minor changes,
an approach put forth by the VA’s Veterans Integrated
Service Network (VISN) 8 Patient Safety Center of
Inquiry (PSCI) in Tampa, Fla., whose mission is to promote safe patient handling. The VISN approach relies on
the use of mechanical lift equipment and other patient
handling aids, program elements that support use of that
equipment, employee training and a “culture of safety”
in the work environment.
The main elements of the SPH program that UH clients adopt are:
•• written program;
•• use of objective transfer criteria;
•• quality assurance activities and reporting;
•• initial and ongoing education and training;
•• progressive disciplinary program; and
•• equipment inspection and maintenance.
August 2010 | OSHA Guide for Health Care Facilities
See Safe Patient Handling, p. 7
Safe Patient Handling (continued from p. 6)
The written program is an important element of SPH,
Schaufenbuel emphasized. “Organizations need to document their commitment and expectations,” he said. The
written program should describe:
•• roles and responsibilities of all staff, including leadership, the director of nursing and
maintenance;
•• specific processes to be followed by staff when
lifting or moving residents;
•• equipment used in the facility, such as gait/walking belts, total body lifts, sit-to-stand devices and
lateral transfer devices; and
•• all other program elements.
Any special circumstances that may arise in the facility also should be addressed in the written program,
Schaufenbuel said. “What is your process for getting a fallen resident up off the floor? It better not be
manual,” he said. The program also should state how
staff will handle bariatric patients and residents who
are combative.
Using Transfer Criteria
The use of objective criteria in determining how to
safely transfer residents is a cornerstone of an effective
SPH program, Schaufenbuel said. Often, he said, UH
finds that caregiving staff in facilities do not understand
why a resident needs a total body lift or a sit-to-stand as
specified in the care plan. Yet these workers are often
in the best position to determine how much assistance a
resident needs over the course of a day, when physical
fatigue may become a factor, he said.
Accordingly, UH requires that direct care workers
have the authority to make a transfer more assistive if
they determine that the resident needs it. Institutions often resist this, he said, but the key is that caregivers have
authority only to make a transfer more assistive, not less
assistive, than what is specified in the care plan.
When training staff in use of objective criteria, there
are various systems to choose from, Schaufenbuel said.
To provide an example, he said, if a resident is:
•• unable to stand up from seated three times or stand
in one place for 30 seconds, use a total body lift;
•• able to do the above, but not march in place six
steps at bedside, use a sit/stand device;
•• able to stand and march, but not able to take step
forward and back with each foot, use sit/stand device or wheelchair;
•• able to do all of the above but with difficulty understanding and following directions, use a gait
belt; and
•• if able to complete all of the above, considered
independent.
Another useful and easy-to-remember system, he
said, is the “4-second rule.” If a resident:
•• can stand unassisted for four seconds, use a walking belt;
•• can stand for 4 or less seconds with assistance, use
a sit-to-stand device; or
•• is unable to stand, use a total body lift.
Checking Up on Training
All new hires must undergo SPH training regardless
of where they worked previously, Schaufenbuel said.
Training must be provided:
•• prior to assignment;
•• whenever a staff member returns from a period of
extended leave; and
•• whenever needed based on direct observation of
the employee or any incident that indicates the person is lacking in knowledge.
Training must be hands on, and employees must
demonstrate their competency. Both the trainer and the
See Safe Patient Handling, p. 8
Applying SPH to Home
Health and Other Settings
Although most of UH’s health care clients are nursing
homes and hospitals, Schaufenbuel said, the basic program elements can be applied to any setting.
For home health providers, he said, the key is whether
the employer is willing to invest in training employees
and purchasing equipment that is suitable for use in
patients’ homes. Such equipment is available on the
market.
Schaufenbuel acknowledged, however, that some
health care settings present a greater challenge. Hospital emergency departments, in particular, have a
higher incidence of staff injuries because of the need to
transfer patients very quickly, for example, to obtain a
radiograph or an MRI. UH is continuing to experience
losses in that area and is trying to determine the best
approach to solving the problem, he said.
August 2010 | OSHA Guide for Health Care Facilities
7
Safe Patient Handling (continued from p. 7)
UH staff will go into a facility to perform the observations if they believe management is not doing so.
supervisor must “sign off” in written documentation
that the employee has satisfactorily completed training.
Training topics must cover:
Maintaining and Inspecting Equipment
•• use of mechanical lifts;
•• use of lateral transfer devices;
•• repositioning residents;
•• pre-use visual inspection of equipment; and
•• an explanation of the objective transfer criteria and
how it is used.
It is critical that facilities implement a quality assurance program for monitoring compliance with the SPH
program policies and fostering continuous improvement,
Schaufenbuel said. UH requires clients to have a quality
assurance program that includes:
•• unannounced observations by supervisors of staff
making transfers, with at least one observation per
staff member per quarter;
•• evaluations of transfer incidents to determine what
went wrong and why;
•• monitoring of residents’ transfer needs; and
•• annual evaluation of the program’s effectiveness.
Following up on training with unannounced observations of staff is critical, Schaufenbuel said, adding that
8
All staff must be trained to visually inspect equipment
before use, and the facility must set up an inspection
program consistent with the manufacturer’s requirements, under the UH program. Maintenance staff in
particular must be trained in how to inspect and maintain
equipment, and they must understand that this is their
responsibility to do so.
One problem that sometimes arises is that facilities
will invest in lift equipment, and train staff in its use,
but the equipment ends up getting pushed aside or even
locked away, Schaufenbuel said. This is not acceptable
to UH, he said, and clients that do not use the equipment
cannot remain insured.
Involving direct care staff in the selection of equipment
before it is purchased is one way to avoid ending up with
equipment that they do not want to use, he suggested.
Sometimes nursing facilities fear that patient-handling
equipment kept on stand-by in hallways will cause them
to fail a fire inspection. In such cases, he suggests that administrators make the effort to meet with the fire marshal
to explain the situation and find an agreeable solution.
For More Information
The VISN 8 Patient Safety Center can be accessed
online at http://www.visn8.va.gov/patientsafetycenter.
August 2010 | OSHA Guide for Health Care Facilities