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The Joint Commission Update for Infection Control
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Joint Commission ups the ante on infection prevention
Sweeping 2009 patient safety goals could have major impact
The Joint Commission has broadly expanded its emphasis on infection prevention in proposed 2009 patient safety goals that recommend specific strategies to fight a veritable "murderers' row" of health care-associated infections (HAIs). Moving boldly beyond a comparatively general emphasis on hand hygiene and sentinel event reporting in longstanding patient safety goals, The Joint Commission is establishing what are essentially "best practices" to prevent the following infections:
Goals could affect surveys
Though The Joint Commission will consider all comments compiled in a field review that ran through the end of February, the final goals will be enforceable in 2009 accreditation surveys.
"Health care organizations will need to demonstrate their attempts at complying with these goals," says Peter B. Angood, MD, vice president and chief patient safety officer for joint commission. "The goals are surveyed and scored in similar fashion to all of the standards. It does affect the overall scoring as part of the accreditation review process."
The move comes as HAIs gain increasing notoriety among the public, consumer groups, and state and federal lawmakers. Though this recent attention is driving the new patient safety goals, it follows a growing emphasis on infection prevention within The Joint Commission. In a continuing effort to bring patients into the safety loop, the goals call for organizations to provide patients with information regarding infection control measures for hand hygiene practices, respiratory hygiene practices and contact precautions as appropriate to the patient's condition. The information is to be discussed with the patient and family members on the day the patient enters the organization. (The information may be written or recorded.)
"Health care-associated infections have really become very topical in the last three to five years," Angood says. "There have been national as well as international efforts to standardize the approaches in managing HAIs. We felt that it would be important to focus on this issue through the national patient safety goals."
Indeed, The Joint Commission goals could generate additional resources for infection control programs as administrators realize accreditation hangs in the balance. That said, there are always concerns that such a comprehensive list of infection prevention activities could result in the proverbial unfunded mandate for ICPs. "We recognize that in order to comply with many of these patient safety goals it does require institutions to sometimes add resources," Angood tells The Joint Commission Update for Infection Control. "But these are important [infections] and they need to be addressed."
However, the specificity of the goals could box in ICPs who prefer to style their programs to their institutional needs and problems. "They're very specific and there doesn't seem to be a lot of leeway for ICPs to do their internal assessments and determine the path that's correct for their organization," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN.
The Joint Commission should provide more "punch" for infection control resources while leaving ICPs the flexibility to target their programs, she says. "Prevention strategies should be focused on all aspects," she adds. "Keying in on one or two organisms is micromanaging infection prevention and control programs. I hope the Joint Commission will ask [hospitals] to support national patient safety goals, but be less specific."
Asked whether the goals were prescriptive to a fault, Angood says a balancing act is always part of the process. "If we are too general, then we have noted over time that the variety of approaches are way too diffuse and we wind up not creating a positive impact," he says. "If we get too prescriptive then we end up having to manage all the concerns that individual organizations have we have to address their own particular nuances. We are always trying to hit a balance."
Feedback from the field could influence the process, he adds. "It gives us an opportunity to revise and edit the goals and better hit the balance prior to their formal release," he says.
Active surveillance for MRSA
Though some ICPs have raised concerns about the cost-effectiveness and the potential unintended consequences of active surveillance cultures (ASC) for MRSA, The Joint Commission calls for hospitals to adopt the practice in the proposed 2009 patient safety goals. The specific goal calls for "clinical or active surveillance culture/testing" as part of MRSA surveillance programs.
"We are putting it on the table," Angood says. "We had a lot of deliberation on this particular issue of surveillance and we [decided] to get some feedback from our field review and make a final decision. Depending how the feedback comes back in the field review, we will make a final choice on whether it is going to be a goal or whether it is perceived as way too onerous."
ASC has been successfully used in some institutions to detect the reservoir of MRSA, place colonized patients in contact isolation, and ultimately lower infection rates. However, there is considerable controversy about the practice within the infection control community. Some ICPs see ASC as an essential prevention measure, while others argue that it is expensive and unnecessary if other infection prevention measures, such as standard precautions, are practiced with high compliance by health care workers. Critics of the practice cite unintended consequences such as a rise in other pathogens and ambulance diversions as demand for isolation rooms exceeds bed capacity.1,2 Many favor the approach recommended by the Centers for Disease Control and Prevention, which calls for active surveillance cultures only if rates continue to go up after all basic measures have been implemented.3
"I continue to be convinced that is the best approach for the most hospitals, says William Scheckler, MD, who has previously served on advisory boards for both the CDC and The Joint Commission. "The concern I have [about the patient safety goals] is that they focus a bit much on MRSA and C. diff. That's not in and of itself a bad thing, but those are not the only organisms of interest."
That said, The Joint Commission's increasing interest in infection prevention is good news, he emphasizes. "The increased emphasis and interest in infection control is very welcome for us that have dedicated a good share of our professional lives to preventing these infections," says Scheckler, a health care epidemiologist at St. Mary's Hospital in Madison, WI.
The Joint Commission goals also include establishing surveillance systems for Clostridium difficile-associated disease (CDAD). As an epidemic strain of C. diff continues to emerge in many U.S. hospitals, a Centers for Disease Control and Prevention working group has issued clinical definitions and is urging ICPs to increase surveillance for the pathogen.4 However, the general consensus is that formal C. diff surveillance systems are more the exception than the rule, in part because the pathogen was so named because it is 'difficult' to grow out in lab cultures. "We recognize that surveillance will be a stretch for many organizations, but if we don't prompt them to pay attention to it then the problem is going to continue to evolve and potentially get worse," Angood says.
Research or quality improvement?
In another interesting aspect of The Joint Commission goals, the practices outlined to prevent CA-BSIs are almost identical to the program developed at Johns Hopkins Hospital in Baltimore and implemented by 108 intensive care units in the Michigan Keystone project. One problem: That highly successful program was recently shut down by the federal Office for Human Research Protections because it appeared to be involved in human research rather than quality improvement.
"It is very similar," Angood concedes. "But this is oriented toward improving the quality and safety of health care. Some of the topics we wind up addressing are important for improving quality and safety, but we recognize occasionally there [are research questions raised]."
In addition, CA-BSIs are one of the infections targeted for reduced reimbursement by the Centers for Medicare & Medicaid Services (CMS). Effective this October, the new CMS rules cut payments for the additional costs of CA-BSIs and other "preventable conditions," including infectious complications of mediastinitis and catheter-related urinary tract infections. The latter two were not included in The Joint Commission's proposed patient safety goals. "We chose not to specifically mirror those efforts by CMS," Angood says. "This is independent and specifically focused on trying to improve the management of HAIs overall. "
SSIs after discharge
One of the HAIs The Joint Commission is trying to manage are SSIs, but the proposed goals do not address the troublesome issue of post-discharge surveillance. "We certainly discussed it and chose not to keep it in there at this stage," he says. "If the feedback comes in that's an obvious gap then we will make efforts to put it into place." According to the CDC, between 12% and 84% of SSIs are detected after patients are discharged from the hospital.5 However, many hospitals do not do sufficient post-discharge follow-up on patients to record subsequent infections. Such programs can be labor-intensive to say the least, so some epidemiologists and surgeons have suggested targeting SSIs that require additional hospitalization or antibiotic prescriptions. The Joint Commission SSI goal calls for rate compilation and reporting, but does not specify feedback of surgeon-specific rates. "The intent is that reporting [occurs], and all levels of the organization that need to know the results are informed so, if needed, there can be further quality initiatives," he says.
The 2009 proposed patient safety goals were created as a part of a multiorganization collaboration that included The Joint Commission, the Centers for Disease Control and Prevention, the Society for Healthcare Epidemiology of America and the Association for Professionals in Infection Control and Epidemiology. Guidelines to assist in adopting the goals are expected to be issued soon.
1. Kirkland KB, Ptak JA, Dugan EA, et al. A voice crying out in the wilderness? Sustained control of healthcare-associated MRSA infection without screening or organism-based isolation. Abstract 23. Presented at the Society for Healthcare Epidemiology of America. Baltimore; April 14-17, 2007.
2. Edmond MB, Ober JF, Bearman G. Active surveillance cultures are NOT required to control MRSA infections in the critical care setting. Abstract 23. Presented at the Society for Healthcare Epidemiology of America. Baltimore; April 14-17, 2007.
3. Centers for Disease Control and Prevention. Siegal JD, Rhinehart E, Jackson L, et al. The Healthcare Infection Control Practices Advisory Committee Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. On the web at: cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.
4. McDonald LC, Coignard B, Dubberke E, et al. The Ad Hoc Clostridium difficile Surveillance Working Group. Recom-mendations for surveillance of Clostridium difficile-associated disease Infect Control Hosp Epidemiol 2007; 28:140-145.
5. Mangram AJ, Horan TC, Pearson ML, et al. Centers for Disease Control and Prevention, The Hospital Infection Control Practices Advisory Committee Guideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol 1999; 20:247-278.