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By Kelly M. Pyrek
Infection control practitioners (ICPs)have 11 months to help their facility put a little more muscle into its effortsto prevent hospital-acquired infections (HAIs) before it is expected to complywith stringent new infection control (IC) standards that take effect in January2005 for healthcare facilities seeking accreditation.
In November 2003, the infection control expert panel assembledby the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)approved revised standards to help prevent the occurrence of 2 million-plusinfections annually in the United States. More than 20 experts in infectioncontrol, infectious diseases, epidemiology and public health were convened toassist JCAHO in exploring the issues that are critical to an effective ICprogram, as well as identify priority areas for infection control and developrecommendations that revised current IC standards within all accreditedprograms.
The revised standards are designed to raise awareness thatHAIs are a national concern that can be acquired within any healthcare,treatment or service setting, and transferred between settings, or brought infrom the community. Therefore, prevention represents one of the major safetyinitiatives that a healthcare organization can undertake. The revised standardsfocus on the development and implementation of plans to prevent and controlinfections, with organizations expected to:
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 butnot scored. The surveyors will offer consultation to healthcare facilitiesabout how their program would have been viewed if they had been scored, aspreparation for the real thing.
Patricia S. Grant, RN, BSN, MS, CIC, director of infectioncontrol for RHD Memorial Medical Center and Trinity Medical Center in Dallas,confirms that the final standards are more reflective of what an ICP does inhealthcare facilities, however, she expresses concern that some of theexpansions will be burdensome without being fully reflective of improvement tothe prevention of nosocomial infections.
Grant says she suspects the strengthened guidelines may be aresponse to the intensified media coverage of public interest in infectionrates, but says that overall and in the long run, I believe JCAHO motivationswere pure and not a knee-jerk reaction to bad press. There is a strong effortfor JCAHO surveyors to be knowledgeable about the standards so thatinterpretation of compliance is uniform.
The Road to Consensus
Creating a unified front wasnt a quick process. Early lastyear, JCAHO sent to members of the panel a questionnaire that asked them totarget the most important components of an IC program. According to GeorgiaDash, RN, MS, CIC, immediate past president of the Association for Professionalsin Infection Control and Epidemiology (APIC), six key areas were targeted fordiscussion: staffing and personnel; incorporation of adherence to nationalguidelines; data collection and analysis; employee health; care of theenvironment; and appropriate evaluation of IC programs. Several weeks later, theexpert panel convened to discuss these areas of concern, and as a result, sixprinciples were created as the foundation of the revision of JCAHOs ICstandards:
A Little Respect
A recurring theme of the expert panels discussions and thesix 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, butthey felt isolated from leadership, Wise says. They felt the leadership oftheir organization was not aware of how serious of an issue HAIs are, andwithout their awareness, they are not being resourced adequately.
It becomes more of an issue because a lot of leaders dontunderstand how a good IC program helps save money. The new standards make itclear 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 safetyissue.
Being adequately resourced is a matter of interpretation inmany regards. Early in the expert panels discussion, there arose dialogueabout ICPs increasing workloads, dwindling resources, and the constant threatto their very existence in so many organizations.
The expectation is that the organization will look at itsinternal risks and produce a plan outlining their ability to do things liketargeted surveillance and implementing solutions, Wise says. Its fromthat plan that the IC program must be appropriately managed. JCAHO looks to seeif 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 ICprogram was that organizations didnt have a system-wide view of what wasgoing on, Wise says. We frequently heard that data collection was poor andthat information systems were inadequate. If you dont have your eyes,you cant see where you should be going. We also heard there are not enoughICPs to go around, so organizations must make sure the people they put in thosepositions are adequately trained. They must make an effort to ensure that personcould actually do the job expected of them. Obviously we are talking about somesignificant monetary expenditures for these efforts.
The expert panel identified two particular areas of concern bioterrorim and antibiotic resistance that will have lasting impact oninfection control.
As we were going through the revisions, SARS ripped throughthe world, Wise explains. IC has traditionally been reviewed as dealing withwhat happens inside the four walls of the organization how to deal with anoutbreak and prevent its spread after it happens. But say you have a potentialepidemic 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 toentire communities, we realized we needed to expand the issue of IC andbioterrorism to include natural epidemics, whether they are SARS or pandemicflu. Healthcare facilities must protect themselves from being disabled by anexternal epidemic.
Wise also addresses the current debate over facilitiesability to differentiate between something like the flu, and SARS. The new ICstandards are designed to make healthcare workers more aware of pathogens cominginto the facility from the community.
If you have a fever and a cough and you present yourself toa crowded ER, theres a good chance you are infectious be it a cold, theflu, of the measles. The ER staff says, Take a seat and we will see you in afew hours. You may be sitting in the ER and theres some guy who isfebrile, 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 todo basic droplet precautions, and that has led to some healthcare workers andpatients 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 whilethey are waiting three hours for their turn, the guy next to him will say, Wheresmy mask and why is he sitting here? Everyone who has a cough and a rash or afever should be put in their own environment. Its a major change in how afacility must think about how to handle these situations.
Regarding antibiotic resistance, Wise advocates some kind ofcentralized control and responsibility about what antibiotics the clinician isprescribing for treatment. Its a touchy issue but it needs to be looked atbecause of its serious impact.
In addressing resistance issues, the standards also addresshand hygiene in more ways than one.
Bacteria like MRSA are going to be spread because of poorhand hygiene, Wise says, even though its been more than 150 years sincepeople first learned you had to wash your hands to prevent the transmission ofdisease. Look at every handwashing study in the past 20 years, and youll seethat compliance is horrible, even among clinicians. We have felt that in manycases, there was not a strong culture of safety in hospitals. In the OR, if youtore a glove, everybody would notice and say You need to deal with thatproblem. Thats part of the departments culture. But when you go out on the general unit, its a differentstory. If you just examined a patient and went on to another patient withoutwashing 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 aleadership concern.
Wise says including infection control in JCAHOs NationalPatient Safety Goals (NPSG) was a way to address the common attitude thatinfection control is not connected to patient safety issues and healthcareerrors.
If a practitioner examines one patient and forgets to washhis or her hands, its cross contamination; that is a patient safety issue anda breach of very common protocol, Wise says. By putting it in the NPSG, weare trying to highlight IC measures as a patient safety issue; it should bethought of in the same way as a wrong-site surgery or giving the wrong medicineto 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 millioninfections that are preventable. Unless you think of it in that way, you willnever direct action to reducing these infections.
Says Grant, Making infection control a patient safety goalfor 2004 is an excellent idea. It will help many ICPs get the supplies they needthat hospitals may not have been willing to implement because of costconstraints and perceived expense. At my two hospitals I didnt need to haveJCAHO make this an NPSG, because Ive educated administration about what aCategory 1A and 1B recommendation means in a CDC-published guidance document; Imalso fortunate to work in an institute where infection control is a valuedparticipant in the overall hospital process.
In addition to evaluating compliance with infection controlstandards during triennial surveys, JCAHO has included infection control as aspecial focus area during random, unannounced surveys for hospitals in 2003.Furthermore, JCAHO has advised accredited organizations that HAIs resulting indeath or serious injury should also be voluntarily reported to the SentinelEvent database. The 2004 NPSG require organizations to manage as sentinel eventsall HAIs that result in death or major permanent loss of function.
In 2002, JCAHO distributed a special letter to accreditedhealthcare organizations which urged them to manage and report unanticipateddeaths associated with HAIs as sentinel events, which was followed in January2003 by a separate Sentinel Event Alert on deaths associated with HAIs.
JCAHOs position that deaths and disabilities associatedwith HAIs were sentinel events that they required analysis and intervention,even for individual cases did not go down well with many healthcareorganizations 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 inthe delivery of care. But the Joint Commission respectfully disagreed, and westill do.
The seventh NPSG has two requirements: as of Jan. 1, 2004, allaccredited organizations must be in compliance with the CDCs handwashingguidelines, and all unanticipated deaths associated with organization- acquiredinfections must be managed as sentinel events. One root cause of these sentinelevents is clearly inattention to handwashing. That simply must change.
Many hope that JCAHOs new scrutiny of infection controlissues in accredited institutions will help raise the rate of hospitalsvoluntarily reporting HAIs.
I believe that 99.9 percent of hospitals report thevoluntary sentinel events that are strictly related to a nosocomial eventresulting in death or loss of permanent function/limb that is the sole cause ofthat outcome, Grant says. There seems to be a large misperception thatthese are under-reported, mostly because when a solid infection control programis in place and implemented, these are very rare occurrences indeed. In my 13years of experience as an ICP, spanning five hospitals, I can honestly say therehas been only one case that comes to mind that meets the JCAHO definition of asentinel event ... and even then, Id have to go back and review that chartbecause it happened more than seven years ago.
The second part of NPSG No. 7 says that when there is asentinel event and there is an HAI, a root cause analysis (RCA) is done, Wisesays. One of the issues that came up is that some people in the community seethat there is little to be learned from doing a RCA of an infection associatedwith a sentinel event, that these should only be looked at in cohorts. Clearlyyou need to look at this from an epidemiological point of view. But there aresituations where a patient is not expected to die but does, and somewhere inthat event there may be an HAI; that situation deserves the same type ofscrutiny. It should not be glossed over or something that is ignored in the RCA.
Wise says there was widespread confusion over the sentinelevent alert issued by JCAHO. People thought we were saying that every personwho dies who has an HAI was a sentinel event, and thats not true.
So they were saying, The number of people with HAI doesnttell us anything, and you are going to run us ragged over data with littlevalue. It was a misunderstanding. First of all, it must be a sentinel event.So the first task is determining which patients had an unexpected outcomeassociated with some kind of severe physiological condition; look at thosepeople 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 onelook at that event? Were there potential flaws in the process that made it morelikely that the person got an SSI? Maybe it had to do with a staffing issue. TheRCA may lead to causative issues that are very different or are upstream fromthe actual infection. It may be that there was a huge rush to get the personinto surgery and there were less experienced people in the OR and that is morelikely to cause an SSI. Or the patient didnt get pre-surgery antibiotics.They must look for the systems-derived issues that predispose the creation ofthis infection.
Which leads back to having in place a solid infection controlprogram, Grant says. She believes the most important elements are customizationof 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 theroadmap 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 howthe surveillance/rates were accomplished. If you try to put an IC program into asimple document, much will get lost, and whats worse, you have no way ofproving your rationale and actions.
Grant says some facilities will be challenged byimplementation of the standards. I started doing infection control in January1990 during the initial Agenda for Change and Saint Paul Medical Centerwas one of the first hospitals in the area to be surveyed, Grant adds. Witheach subsequent update to the standards there is confusion regardingimplementation and interpretation of compliance it is the nature of thething we call change.
Go to www.jcaho.org toread the pre-publication version of the 2005 Infection Control Standards.