Infection Control Today - 02/2004: JCAHO Helps Facilities

JCAHO Helps Facilities Put More Muscle Into IC Programs

By Kelly M. Pyrek

Infection control practitioners (ICPs) have 11 months to help their facility put a little more muscle into its efforts to prevent hospital-acquired infections (HAIs) before it is expected to comply with stringent new infection control (IC) standards that take effect in January 2005 for healthcare facilities seeking accreditation.

In November 2003, the infection control expert panel assembled by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) approved revised standards to help prevent the occurrence of 2 million-plus infections annually in the United States. More than 20 experts in infection control, infectious diseases, epidemiology and public health were convened to assist JCAHO in exploring the issues that are critical to an effective IC program, as well as identify priority areas for infection control and develop recommendations that revised current IC standards within all accredited programs.

The revised standards are designed to raise awareness that HAIs are a national concern that can be acquired within any healthcare, treatment or service setting, and transferred between settings, or brought in from the community. Therefore, prevention represents one of the major safety initiatives that a healthcare organization can undertake. The revised standards focus on the development and implementation of plans to prevent and control infections, with organizations expected to:

  • Incorporate an infection control program as a major component of safety and performance improvement programs
  • Perform an ongoing assessment to identify its risks for the acquisition and transmission of infectious agents
  • Use an epidemiological approach which includes conducting surveillance, collecting data, and interpreting the data Implement infection prevention and control processes
  • Educate and collaborate with leaders across the organization to effectively participate in the design and implementation of the infection control program
  • Integrate efforts with healthcare and community leaders to effectively participate in a communitywide effort
  • Remain a viable community resource and plan for responding to infections that potentially overwhelm its resources

The new standards will definitely go into the scored Joint Commission survey for January 2005, says Robert Wise, MD, vice president of the Division of Standards and Survey Methods for JCAHO. Hopefully by July 2004, they will be part of the survey but not scored. The surveyors will offer consultation to healthcare facilities about how their program would have been viewed if they had been scored, as preparation for the real thing.

Patricia S. Grant, RN, BSN, MS, CIC, director of infection control for RHD Memorial Medical Center and Trinity Medical Center in Dallas, confirms that the final standards are more reflective of what an ICP does in healthcare facilities, however, she expresses concern that some of the expansions will be burdensome without being fully reflective of improvement to the prevention of nosocomial infections.

Grant says she suspects the strengthened guidelines may be a response to the intensified media coverage of public interest in infection rates, but says that overall and in the long run, I believe JCAHO motivations were pure and not a knee-jerk reaction to bad press. There is a strong effort for JCAHO surveyors to be knowledgeable about the standards so that interpretation of compliance is uniform.

The Road to Consensus

Creating a unified front wasnt a quick process. Early last year, JCAHO sent to members of the panel a questionnaire that asked them to target the most important components of an IC program. According to Georgia Dash, RN, MS, CIC, immediate past president of the Association for Professionals in Infection Control and Epidemiology (APIC), six key areas were targeted for discussion: staffing and personnel; incorporation of adherence to national guidelines; data collection and analysis; employee health; care of the environment; and appropriate evaluation of IC programs. Several weeks later, the expert panel convened to discuss these areas of concern, and as a result, six principles were created as the foundation of the revision of JCAHOs IC standards:

  • Principle 1: The organization must have a structured process for organization- wide collaboration in the development, implementation, oversight and evaluation of infection control and control processes. Collaboration should include: IC professionals, patient-care staff, other ancillary services, licensed independent practitioners, non-clinical staff, sterile processing, housekeeping, building maintenance/ engineering, equipment management and food service
  • Principle 2: The infection prevention program is well planned and focused based on the type of organization, demographics of the organization and population served, the services provided, current scientific research, and peer-reviewed or national guidelines on IC and the organizations IC data
  • Principle 3: Designated management of the infection prevention and control program is the responsibility of an individuals with appropriate education, training and experience, and who are given appropriate authority
  • Principle 4: Sufficient staff and resources are available to support the IC program
  • Principle 5: The IC program adheres to the principles of epidemiology and incorporates concepts of performance improvement demonstrated by documented integration with the organizations overall performance initiatives
  • Principle 6: The organizations IC program is responsive to the changing environment and is redesigned as necessary to meet IC outcome objectives

A Little Respect

A recurring theme of the expert panels discussions and the six principles is the empowerment of the ICP a tall order these days.

When we talked to people in the field and the expert panel, what we heard over and over from ICPs was that they were doing their jobs, but they felt isolated from leadership, Wise says. They felt the leadership of their organization was not aware of how serious of an issue HAIs are, and without their awareness, they are not being resourced adequately.

It becomes more of an issue because a lot of leaders dont understand how a good IC program helps save money. The new standards make it clear that IC issues are organization-wide, they must be viewed as a priority, and they must be adequately resourced because they are a major patient safety issue.

Being adequately resourced is a matter of interpretation in many regards. Early in the expert panels discussion, there arose dialogue about ICPs increasing workloads, dwindling resources, and the constant threat to their very existence in so many organizations.

The expectation is that the organization will look at its internal risks and produce a plan outlining their ability to do things like targeted surveillance and implementing solutions, Wise says. Its from that plan that the IC program must be appropriately managed. JCAHO looks to see if the organization has the right type of manager generally an ICP or more who has what it takes to get things done.

The expert panel agreed that the weakest part of an IC program was that organizations didnt have a system-wide view of what was going on, Wise says. We frequently heard that data collection was poor and that information systems were inadequate. If you dont have your eyes, you cant see where you should be going. We also heard there are not enough ICPs to go around, so organizations must make sure the people they put in those positions are adequately trained. They must make an effort to ensure that person could actually do the job expected of them. Obviously we are talking about some significant monetary expenditures for these efforts.

The expert panel identified two particular areas of concern bioterrorim and antibiotic resistance that will have lasting impact on infection control.

As we were going through the revisions, SARS ripped through the world, Wise explains. IC has traditionally been reviewed as dealing with what happens inside the four walls of the organization how to deal with an outbreak and prevent its spread after it happens. But say you have a potential epidemic outside your four walls; how do you make sure it doesnt come inside? And if it does, are you able to contain it? When we saw how damaging SARS was to entire communities, we realized we needed to expand the issue of IC and bioterrorism to include natural epidemics, whether they are SARS or pandemic flu. Healthcare facilities must protect themselves from being disabled by an external epidemic.

Wise also addresses the current debate over facilities ability to differentiate between something like the flu, and SARS. The new IC standards are designed to make healthcare workers more aware of pathogens coming into the facility from the community.

If you have a fever and a cough and you present yourself to a crowded ER, theres a good chance you are infectious be it a cold, the flu, of the measles. The ER staff says, Take a seat and we will see you in a few hours. You may be sitting in the ER and theres some guy who is febrile, is coughing, and has been waiting to be seen for hours. Guess what ... these people are going to infect others. Many ERs are currently not prepared to do basic droplet precautions, and that has led to some healthcare workers and patients getting sick with the potential for devastation.

Wise adds that new IC standards may force a change in culture. Going back to the ER ... if I put a mask on someone while they are waiting three hours for their turn, the guy next to him will say, Wheres my mask and why is he sitting here? Everyone who has a cough and a rash or a fever should be put in their own environment. Its a major change in how a facility must think about how to handle these situations.

Regarding antibiotic resistance, Wise advocates some kind of centralized control and responsibility about what antibiotics the clinician is prescribing for treatment. Its a touchy issue but it needs to be looked at because of its serious impact.

In addressing resistance issues, the standards also address hand hygiene in more ways than one.

Bacteria like MRSA are going to be spread because of poor hand hygiene, Wise says, even though its been more than 150 years since people first learned you had to wash your hands to prevent the transmission of disease. Look at every handwashing study in the past 20 years, and youll see that compliance is horrible, even among clinicians. We have felt that in many cases, there was not a strong culture of safety in hospitals. In the OR, if you tore a glove, everybody would notice and say You need to deal with that problem. Thats part of the departments culture. But when you go out on the general unit, its a different story. If you just examined a patient and went on to another patient without washing your hands, it would be unheard of for a nurse to stop a doctor and say, You didnt wash your hands, and the doctor thanks her for the reminder. That culture of concern does not exist at so many facilities, and we see it as a leadership concern.

Wise says including infection control in JCAHOs National Patient Safety Goals (NPSG) was a way to address the common attitude that infection control is not connected to patient safety issues and healthcare errors.

If a practitioner examines one patient and forgets to wash his or her hands, its cross contamination; that is a patient safety issue and a breach of very common protocol, Wise says. By putting it in the NPSG, we are trying to highlight IC measures as a patient safety issue; it should be thought of in the same way as a wrong-site surgery or giving the wrong medicine to the wrong patient. But not every healthcare-associated infection is an error. We know thats not true but there is a significant percentage of the 2 million infections that are preventable. Unless you think of it in that way, you will never direct action to reducing these infections.

Says Grant, Making infection control a patient safety goal for 2004 is an excellent idea. It will help many ICPs get the supplies they need that hospitals may not have been willing to implement because of cost constraints and perceived expense. At my two hospitals I didnt need to have JCAHO make this an NPSG, because Ive educated administration about what a Category 1A and 1B recommendation means in a CDC-published guidance document; Im also fortunate to work in an institute where infection control is a valued participant in the overall hospital process.

 In addition to evaluating compliance with infection control standards during triennial surveys, JCAHO has included infection control as a special focus area during random, unannounced surveys for hospitals in 2003. Furthermore, JCAHO has advised accredited organizations that HAIs resulting in death or serious injury should also be voluntarily reported to the Sentinel Event database. The 2004 NPSG require organizations to manage as sentinel events all HAIs that result in death or major permanent loss of function.

In 2002, JCAHO distributed a special letter to accredited healthcare organizations which urged them to manage and report unanticipated deaths associated with HAIs as sentinel events, which was followed in January 2003 by a separate Sentinel Event Alert on deaths associated with HAIs.

JCAHOs position that deaths and disabilities associated with HAIs were sentinel events that they required analysis and intervention, even for individual cases did not go down well with many healthcare organizations and practitioners, stated Dennis OLeary, president of JCAHO, in a 2003 speech. They argued that the required root cause analyses (RCAs) were a labor-intensive exercise in futility for a problem that is inherent in the delivery of care. But the Joint Commission respectfully disagreed, and we still do.

The seventh NPSG has two requirements: as of Jan. 1, 2004, all accredited organizations must be in compliance with the CDCs handwashing guidelines, and all unanticipated deaths associated with organization- acquired infections must be managed as sentinel events. One root cause of these sentinel events is clearly inattention to handwashing. That simply must change.

Many hope that JCAHOs new scrutiny of infection control issues in accredited institutions will help raise the rate of hospitals voluntarily reporting HAIs.

I believe that 99.9 percent of hospitals report the voluntary sentinel events that are strictly related to a nosocomial event resulting in death or loss of permanent function/limb that is the sole cause of that outcome, Grant says. There seems to be a large misperception that these are under-reported, mostly because when a solid infection control program is in place and implemented, these are very rare occurrences indeed. In my 13 years of experience as an ICP, spanning five hospitals, I can honestly say there has been only one case that comes to mind that meets the JCAHO definition of a sentinel event ... and even then, Id have to go back and review that chart because it happened more than seven years ago.

The second part of NPSG No. 7 says that when there is a sentinel event and there is an HAI, a root cause analysis (RCA) is done, Wise says. One of the issues that came up is that some people in the community see that there is little to be learned from doing a RCA of an infection associated with a sentinel event, that these should only be looked at in cohorts. Clearly you need to look at this from an epidemiological point of view. But there are situations where a patient is not expected to die but does, and somewhere in that event there may be an HAI; that situation deserves the same type of scrutiny. It should not be glossed over or something that is ignored in the RCA.

Wise says there was widespread confusion over the sentinel event alert issued by JCAHO. People thought we were saying that every person who dies who has an HAI was a sentinel event, and thats not true.

So they were saying, The number of people with HAI doesnt tell us anything, and you are going to run us ragged over data with little value. It was a misunderstanding. First of all, it must be a sentinel event. So the first task is determining which patients had an unexpected outcome associated with some kind of severe physiological condition; look at those people first and then if they had an HAI, that should still be part of the RCA. Say a healthy person got an antibiotic-resistant surgical site infection (SSI) and then died; that would be a sentinel event, but the question is, how does one look at that event? Were there potential flaws in the process that made it more likely that the person got an SSI? Maybe it had to do with a staffing issue. The RCA may lead to causative issues that are very different or are upstream from the actual infection. It may be that there was a huge rush to get the person into surgery and there were less experienced people in the OR and that is more likely to cause an SSI. Or the patient didnt get pre-surgery antibiotics. They must look for the systems-derived issues that predispose the creation of this infection.

Which leads back to having in place a solid infection control program, Grant says. She believes the most important elements are customization of the program to meet the services, geographic elements, and patient population all grounded in the historical surveillance data/trends of that facility. She adds, My IC program is divided into three polices: The Program, Definitions of Infection, and Surveillance Activities. These policies are the roadmap for RHD and TMC, so that if Im suddenly gone from my position, the next experienced ICP could tell exactly what I was doing, why, when, and how the surveillance/rates were accomplished. If you try to put an IC program into a simple document, much will get lost, and whats worse, you have no way of proving your rationale and actions.

Grant says some facilities will be challenged by implementation of the standards. I started doing infection control in January 1990 during the initial Agenda for Change and Saint Paul Medical Center was one of the first hospitals in the area to be surveyed, Grant adds. With each subsequent update to the standards there is confusion regarding implementation and interpretation of compliance it is the nature of the thing we call change.

Go to to read the pre-publication version of the 2005 Infection Control Standards.

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