National Patient Safety Goal 7: Recommendations for Compliance

Editor's note: This article is part two of a two-part series. To access part one, CLICK HERE.

Note: The Joint Commission is revising the 2009 National Patient Safety Goals (NPSGs) and the 2009 Universal Protocol to clarify language and make sure that they are relevant to the settings in which they apply. This initiative to review and revise the 2009 NPSGs and the 2009 Universal Protocol is a first step in the Joint Commission’s efforts to focus on those issues that are of highest priority to safety and quality. Proposed revisions for 2010 can be found, by program, at: http://www.jointcommission.org/Standards/FieldReviews/. In these documents, the current (2009) requirement is listed in regular type and the proposed revision follows it in bold type.

The Joint Commission (JC)’s National Patient Safety Goals (NPSGs) are a specific set of initiatives designed to promote improvements in patient safety by providing healthcare organizations with proven solutions to persistent patient safety problems. NPSG 7: “Reduce the risk of healthcare associated infections” contains requirements for appropriate hand hygiene and the management of sentinel events. In 2009, three new hospital and critical-access hospital requirements were added. These requirements are related to preventing deadly healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDROs), central line-associated bloodstream infections (CLABSIs), and surgical site infections (SSIs).¹

The new requirements related to CLABSIs also apply to ambulatory care facilities and office-based surgery practices, home care organizations, and long-term care organizations. In addition, prevention of SSIs is a new requirement for ambulatory care facilities and office-based surgery practices.¹

These new infection-related requirements have a one-year phase-in period that includes defined milestones, with full implementation expected by Jan. 1, 2010.^2-3

This article, the second of a two-part series, reviews the three new requirements for NPSG 7 along with their elements of performance and recommendations for compliance.

New Requirements and Elements of Performance for NPSG 7

1. MDROs: Implement evidence-based practices to prevent HAIs due to MDROs in acute-care hospitals.²

Elements of performance for the hospital:

• Conduct periodic risk assessments for MDRO acquisition and transmission

• Based on the results of the risk assessment, educate staff and licensed independent practitioners about HAIs, MDROs, and prevention strategies at hire and annually thereafter

• Educate patients, and their families as needed, who are infected or colonized with a MDRO about HAI prevention strategies

• Implement a surveillance program for MDROs based on the risk assessment

• Measure and monitor MDRO prevention processes and outcomes

• Provide MDRO surveillance data to key stakeholders (e.g., leaders, licensed independent practitioners, nursing staff, other clinicians)

• Implement policies and practices aimed at reducing the risk of transmitting MDROs that meet regulatory requirements and are aligned with evidence-based standards

• Implement a laboratory-based alert system (manual and/or electronic) that identifies new patients with MDROs, especially when indicated by risk assessment

2. CLABSIs: Implement best practices or evidence-based guidelines to prevent CLABSIs.^2-3

Elements of performance for the organization (hospital, ambulatory healthcare):

• Educate healthcare workers who are involved in these procedures about HAIs, CLABSIs, and the importance of prevention upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities

• Prior to insertion of a central venous catheter, educate patients and, as needed, their families about CLABSI prevention

• Implement policies and practices aimed at reducing the risk of CLABSIs that meet regulatory requirements and are aligned with evidence-based standards

• Conduct periodic risk assessments for SSIs, measure CLABSI infection rates, monitor compliance with best practices or evidence-based guidelines, and evaluate the effectiveness of prevention efforts

• Provide CLABSI rate data and prevention outcome measures to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other clinicians

• Perform hand hygiene prior to catheter insertion or manipulation

• For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable

• Use an all inclusive standardized supply cart or kit for the insertion of central venous catheter (CVC)

• Use a catheter checklist and a standardized protocol for CVC insertion

• Use a chlorhexidine-based antiseptic for skin preparation during CVC insertion in patients over two months of age, unless contraindicated

• Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports

• Evaluate all CVCs routinely and remove nonessential catheters

3. SSIs :Implement best practices for preventing SSIs.^2-3

Elements of Performance for the organization (hospital, ambulatory healthcare):

• Educate healthcare workers who are involved in surgical procedures about HAIs, SSIs, and the importance of prevention upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities

• Prior to all surgical procedures, educate patients and, their families as needed, who are undergoing a surgical procedure about SSI prevention

• Implement policies and practices aimed at reducing the risk of SSIs that are aligned with evidence-based standards and meet regulatory requirements

• Conduct periodic risk assessments for SSIs, select SSI measures using best practices or evidence-based guidelines, monitor compliance with best practices or evidence-based guidelines, and evaluate the effectiveness of prevention efforts

• Measurement strategies follow evidence-based guidelines, and SSI rates are measured for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices

• Provide SSI rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians

• Antimicrobial agents for prophylaxis used for a particular procedure or disease are administered according to evidence-based standards and guidelines for best practices

• When hair removal is necessary, use clippers or depilatories

Recommendations for Compliance

“The main challenge to prevention has not been the lack of guidelines but rather a dearth of methods for efficient and consistent implementation of recommended practices”⁴

A culture of safety is central to complying with the HAI elements of performance as detailed in NPSG 7. Given this culture within the healthcare facility, accountability, infrastructure and performance measures are effective tools to achieve and maintain compliance.

Patient Safety Culture

• Active executive leadership: An effective patient safety culture must come from the top to attain and maintain the level of infection prevention required

• Of paramount importance is a verbal, mental and emotional mindset that rejects the statement: “it is acceptable to be at or below national infection rate averages,” and instead marches to a “zero tolerance of avoidable HAIs”

• Accept “reminders” from monitors, colleagues, patients and patient advocates who identify potential errors or oversights in the spirit of HAI prevention

Infrastructure Requirements

• Active, effective, dedicated infection prevention and control program

• User-friendly information technology (IT) systems must be in place and capable of providing necessary records maintenance, patient surveillance activities, infection rate calculations, trending analysis, correlation comparisons and required alerts

• When multiple facilities are affiliated, IT systems should be integrated and compatible; or at a minimum produce comparable outputs based on standardized definitions and means of classification

• Personnel must be adequately trained for effective use of applicable IT programs

• Sufficient quantities of appropriate, quality supplies and devices strategically placed to ensure convenient compliance to best practices (e.g., “line carts” with all appropriate supplies and a procedure checklist increases compliance with best practices for aseptic central line placement; supplies readily available for donning prior to entering MRSA, VRE, C. difficile or any other contact isolation patient room increase PPE compliance)

• Resources available for providing documented education and training to healthcare personnel – addressing HAI-specific risk factors, frequent pathogens, consequences, means of transmission and prevention strategies are essential

• Educate at-risk patients, their families and visitors on their role in prevention and detection of HAIs presented at the right level in an understandable format including the appropriate language and font size for written materials (e.g. elderly patients in stressful situations need written instructions in large print as verbal explanations are often forgotten or remembered incorrectly)

• Adequate laboratory capability, and support with alert-communications systems are essential

• Best practice strategies have been most successful when incorporated into a bundled approach incorporating zero tolerance for failure to meet 100 percent compliance with each bundle component

• Conduct risk assessments to determine most vulnerable areas to be addressed and rank in priority order

• Run pilot protocols to identify gaps and correct problems

Performance Measures

• Document adherence to relevant guidelines and best practices (e.g. CDC guidelines, SHEA and APIC best practices) either by automated means, or on frequent unscheduled audits

• Internal reporting: Provide unit staff, clinicians, and hospital administrators an accounting of:

- Process measures: staff adherence to standardized protocols developed in compliance with guidelines or best practices — such as rates of adherence to recommended practices

- Outcome measures: HAI incidence rate trending — such as CLABSI or SSI rates — adjusted for patient risk factors as appropriate

- Correlation of outcome measures with process measures provide a useful means of identifying areas for improvement

- Patient risk factors as indicated

• External reporting requirements for state and federal agencies should be clearly spelled out in readily accessible procedures with all contact information and definitions as appropriate for consistent, comparable reporting

Accountability

• Facility’s chief executive officer and senior management are responsible for:

- Providing resources necessary to maintain adequate personnel, training, equipment

- Ensuring sufficient, supplies are in place to enable compliance

- Assigning responsibility for each component to competent individuals

• Administrative strategies include standing orders and admittance based alert systems

• All facility personnel must recognize they are an integral part of the infection prevention team and that they share responsibility for patient infections and for ensuring that appropriate infection prevention practices are used at all times

• Each employee and contracted professional should know their facility’s major HAI rates and the specific HAI rates and causative pathogens in their own area of responsibility

• Each employee and contracted professional must be able to describe how performance of their responsibilities impact HAI risk

• Hospital and unit leaders are responsible for holding personnel accountable for their actions and informed of potential and actual consequences of non-compliance to facility protocols

Summary

The focus of National Patient Safety Goal 7, emphasizing the three new requirements that address MDROs, CLABSIs and SSIs, is to reduce HAIs by implementing performance elements. Implementation of the specified elements of performance enables healthcare facilities to achieve these essential mandates. The incorporation of a facility-wide patient safety culture along with an appropriate infrastructure, performance measures with assigned accountability are necessary for successful implementation. This focus, along with its aggressive timeline, places great responsibility on the shoulders of the entire healthcare team with special emphasis for executive leadership and infection preventionists.

Kathleen Stoessel, RN, MS, is senior manager of clinical education for Kimberly-Clark Health Care.

Wava Truscott, PhD, is director of scientific affairs and clinical education for Kimberly-Clark Health Care.

References:

1. The Joint Commission. The Joint Commission Announces 2009 National Patient Safety Goals. Available at: http://capan.homestead.com/NEWS_RELEASE.scapan.pdf. Accessed May 5, 2009.

2. The Joint Commission. Accreditation Program: Hospital.  2009 National Patient Safety Goals. Available at: http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf. Ac-cessed May 5, 2009.

3. The Joint Commission. Accreditation Program: Ambulatory Health Care.  2009 National Patient Safety Goals. Avail-able at: http://www.jointcommission.org/NR/rdonlyres/979098FA-74FD-4F25-AF41-EDD48FBD300E/0/AHC_NPSG.pdf.  Accessed May 5, 2009.

4. Singh NS, et al., Primum Non Nocere. Infect Control Hosp Epidem. 2008; 29:S1-2.

Resources:

• Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in healthcare settings. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Accessed May 9, 2009.

• Marschall J, Mermel LA, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S22-S30.

• Anderson DJ, Kaye KS, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008; 29:S51-S61.

• Patient education resources: Journal of the American Medical Association Patient Page (http://jama.ama-assn.org/cgi/reprint/294/16/2122); Surgical Care Improvement Project consumer information sheet (http://www.ofmq.com/Websites/ofrnq/Images/FINALconsurmer_tips2.pdf).