Joint Commission Feels Infection Preventionists’ Pain

September 22, 2020

Sylvia Garcia-Houchins, MBA, RN, CIC: “I think initially, everybody said: ‘Oh, my gosh, we have a pandemic happening.’ It’s sort of a dead stop everywhere. And we’ve got to get ready. We’ve got to be prepared…. In many organizations at that point, the infection preventionist was really put into a position: Put my resources here? Put my resources there? I need to get a plan.”

There was life before coronavirus disease 2019 (COVID-19). And there was a busy work life, as well, for infection preventionists (IPs) that had nothing to do with the Johnny-come-lately SARS-CoV-2. The work of the infection preventionists stretches far beyond the current pandemic and should continue because that work is important. For instance, about 72,000 Americans die of healthcare-acquired infections (HAIs) each year. Sylvia Garcia-Houchins, MBA, RN, CIC, the director of infection prevention and control at the Joint Commission, recently sat down with Infection Control Today® to discuss how IPs need to say on top of HAIs, the Joint Commission’s approach to accrediting healthcare organizations, and how the pandemic slowed the Commission down for a bit, but it’s now ready to restart the accreditation process. “We had been surveying less for a while,” says Garcia-Houchins. “We had to put a stop on on-site surveys. While this was all sorting out, many of our organizations just couldn’t handle being ready for the for the pandemic. Their emergency response plans were being activated.”

Infection Control Today®: One of the key functions of infection prevention and control programs is overseeing and following up on healthcare-acquired infections. But with the COVID-19 pandemic going on for months, and knowing that it might be some time before we get a vaccine, some are concerned about how it has affected the day-to-day operations, and resources, so infection control programs. How are infection preventionists managing the oversight and prevention of healthcare-acquired infections these days?

Sylvia Garcia-Houchins, MBA, RN, CIC: It’s really interesting, we’ve been hearing a lot of different things depending on where in the country the person is, what’s the level of transmission that’s happening. I think initially, everybody said: “Oh, my gosh, we have a pandemic happening.” It’s sort of a dead stop everywhere. And we’ve got to get ready. We’ve got to be prepared. We need to get everything lined up. And so, I started thinking about what was going to happen. Many organizations at that point, the infection preventionist was really put into a position: Put my resources here? Put my resources there? I need to get a plan. I need to make sure we’re ready. So that initial part, some people didn’t have the backups on wards to just do the routine stuff that we would normally do to manage healthcare-acquired infections. As this pandemic has played out, some areas have now gone pretty much low-level transmission. Things are operating well. Sort of on the back burner. We’re ready. PPE is stabilizing. We’ve got a process to make sure that it’s still there. And it’s coming regularly. And anticipating right? Other organizations still are in that flight or fright part; that adrenaline rush is still on. They’re seeing cases. They’re seeing increases. What’s happening today? And those are really the organizations that are struggling. Day-to-day operations is not happening. And so, they may not have the resources to look at those other healthcare-associated infections. And we’re hearing reports of this in our office of patient quality and patient safety. You know, we’re starting to hear: “I don’t have the right gown to go into an isolation room.” Or, “This isn’t a COVID patient. It’s a patient with an MDRO. And they’re asking me to put on gloves, but we don’t have gowns. They’ve asked me to preserve the gowns for something else.” It’s really a struggle. Infection preventionists need to have good resources, and good references to make those judgment calls on what it is they’re doing day to day. I mean, that really has changed with the CDC stuff.

ICT®: But the reality is they haven’t had the resources they need. In the meantime, healthcare-acquired infections continue. And they continue sometimes with COVID, right?

Garcia-Houchins: We actually heard of little clusters of outbreaks that were happening in organizations where they had set up cohort units for COVID. It put all the COVID patients together, and wear the same PPE the same way. And the same gown and gloves because you don’t have enough between multiple patients where normally we would have someone with Candida auris or resistant acetobacter. And we were being very careful as IPs to make sure our staff knew to take off the PPE, do hand hygiene, put on new PPE for the next patient in the cohort. That wasn’t possible. So, we were hearing about clusters of infection. The other thing that happened is, you know, initially, staff was scared. Priorities may have changed a little bit. We need to save this person’s life. We need to protect our staff from being exposed. And so some of those routine things that we would have probably done for a patient, for example, on a ventilator, routine oral care, keeping the head of the bed up, right? Pulmonary toileting for someone who’s starting to walk and get better, may not have been done because of limited PPE, or just overwhelming number of patients. Those routine practices may not have been possible for a time and still may not be possible in some organizations. That’s the real hard part is keeping a handle on that. Making sure that people know, yeah COVID’s important, but if they end up with a ventilator-associated pneumonia, that could kill them too.

ICT®: It didn’t help that regulations and requirements kept changing.

Garcia-Houchins: As we talk about regulation and requirements, we need to think about what’s a requirement, meaning there’s legislation that says you must do; versus a recommendation or guidance. CMS is an example of an organization that puts out regulations. Right? And so, if they say this is a regulation, and it is a requirement—keyword, requirement—then organizations have to do it. If they put out information that says this is guidance or recommendation, then there’s that gray area. Do I have to do it? Or do I not have to do it? That’s caused some real issues here during this pandemic, because some things that everybody thought were requirements aren’t actually requirements. And some of the things that people thought were recommendations that they could have some leeway on are now coming to light. People are saying: “Well, depending on what state you’re in, it’s not a requirement.”

ICT®: What’s the Joint Commission’s mission?

Garcia-Houchins: We don’t actually grade hospital performance. We’re an accrediting organization. As an accrediting organization, we go into organizations who may be deemed. Meaning that we are serving for compliance on behalf of CMS. Or they may not be deemed, which means they’ve invited us in to help them to ensure they’re providing the best quality of care for their patients. We’re not a regulatory agency. That’s an important part to start with. We are an accrediting organization.

ICT®: But didn’t the Joint Commission make healthcare-acquired infections a priority around the same time as CMS did?

Garcia-Houchins: Yes, we did. And, and we actually this year have changed. It used to be a national patient safety goal to reduce certain particular healthcare-acquired infections. But we weren’t prescriptive. We said you need to look at the guidance. And we need to put in processes in place to implement those best practices and recommendations that are applicable to your care and services and settings. We don’t do a one-size-fits-all.

ICT®:Has the Joint Commission, in light of COVID, altered or adjusted their approach to accreditation regarding healthcare-acquired infections?

Garcia-Houchins: Nope. We’re still doing the same things. We’re still expecting organizations to continue to follow those practices to reduce healthcare-associated infections that have remained throughout this pandemic. Now, how organizations do that…. For example, if we go into an organization and the organization’s policy and procedures say that the nurse should perform oral care every four hours, and we go and we see they’re not doing it, right? So, they’re not in compliance with their own policy and best practices to reduce ventilator-associated pneumonia. We’re going to start pulling that thread. “Why aren’t you doing this?” Now, there are a lot of reasons today why they might not be doing it. One of the key reasons may be because they can’t get the supplies. If they can show us, “Look, we’re trying but we can’t get the supplies and instead we're doing X to try to mitigate that risk,” we would consider them in compliance. Now, if they’ve got a policy in place they’re supposed to be doing every four hours oral care and the person just says, “Well, I don’t have time to do this.” We’re going to start pulling that thread. What’s the issue here? We really do survey to what practices have they put in place. What practices have organizations put in place to reduce the risk of healthcare-associated infection? And are they implementing them? Regardless of the pandemic? Are they implementing them? If they can’t implement them, that’s one thing. If they don’t have the supplies or the equipment, how would they modify those practices to try to reduce that risk versus they’re just not doing it? Remember, if we’re going out to survey, that organization has told us they are ready for survey.

ICT®: Have you been surveying less since the pandemic struck?

Garcia-Houchins: We have been. We had been surveying less for a while. We had to put a stop on on-site surveys. While this was all sorting out, many of our organizations just couldn’t handle being ready for the for the pandemic. Their emergency response plans were being activated. We could not risk distracting them from that important task. As things have leveled out, and we’re seeing decreased outbreaks or clusters of COVID and prevalence is going down in some areas, we’ve now got criteria for when we will have our surveyors go out. We work with those organizations to say, “Are you still operating under your emergency management plan?” “Are you ready for a survey?” “Can we come out?” We don’t want to distract from their ability to care for patients. If they say, “Yep, were ready.” And they’re considered, we have criteria for what level of transmission there can be in the community. You want to protect our surveyors, too. If they meet certain criteria, then we can schedule a survey. They are still unannounced surveys. But we’re proactively going through what’s on our list in the next three months, who’s up for survey. We were trying to get rid of the backlog and look at as areas get safer, and I know that’s a relative term, but if they have less COVID. We’re looking at that, but we did stop surveys for a while. We are now back up and surveying. We’re doing a lot fewer surveys right now, just because people aren’t ready. Or there’s significant transmission occurring in the community. What might work in my organization from an evidence-based guideline, may be different in another person’s organization. It may not work. So that’s the part that organizations get to choose. We look at that. We say what are you doing? That looks like you made some good choices. Show us how you’ve implemented it? Show us how it’s impacted your infection rates. Right? Your CLABSI rate: Was it 2 and it’s now at 0.5? Wow, you’re doing well. Or you were at 0.5 and now you’re at 3. What are you doing about it? It’s not supposed to be confrontational. We’re not inspectors.

ICT®: Any final words for your fellow infection preventionists who are dealing with healthcare-acquired infections and COVID-19?

Garcia-Houchins: Yes, don’t lose sight of the overarching point, which is all healthcare-associated infections are important. We want to prevent morbidity and mortality of all of our patients. We need to make sure that we’ve got processes in place that look at everything. Sometimes we get focused on one thing and making it perfect and we don’t look at everything else. We need to have that eye on the ball. The goal is to decrease all healthcare-associated infections, not just one.

This interview has been edited for clarity and length.