The Joint Commission Update for Infection Control
The Joint Commission drops MRSA active surveillance in 2009 patient safety goals
Resistant bugs, surgical and bloodstream infections make final list
Conceding that there is too much debate and controversy about the practice, the Joint Commission has dropped a proposed requirement in its 2009 patient safety goals to conduct active surveillance cultures (ASC) for methicillin-resistant Staphylococcus aureus (MRSA). The Joint Commission called for the practice in proposed 2009 patient safety goals, but dropped the requirement in recently finalizing the goals after a field review that included feedback from infection preventionists (IPs).
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 IPs 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
"We recognized that there is a debate," says Nancy Kuzmich, RN, MSN, education program manager at Joint Commission Resources. "Active surveillance cultures are not specifically required under this national patient safety goal, but we would encourage organizations to follow the [CDC] guidelines. We specify the CDC guidelines in the standard."
However, the Joint Commission defers to legislative requirements for MRSA active surveillance in those states that have enacted laws requiring the practice. "There is no [Joint Commission] requirement for ACS, but we do say in the performance elements that 'the hospital implements policies and procedures aimed at reducing the risk of transmitting MDROs that meet regulatory requirements.' And now some states are requiring [ACS]," she says.
As originally proposed, the Joint Commission goal called for "clinical or active surveillance culture/testing" as part of MRSA surveillance programs. However, there was concern expressed in the comment period that the specificity of the 2009 goals could be prescriptive to a fault, and ASC was one the apparent causalities of that mindset. Now MRSA falls under a general patient safety goal to "prevent health care-associated infections due to multiple drug-resistant organisms in acute care hospitals." The goal has a phase-in period for 2009 with expectation of full implementation by Jan 1, 2010. The Joint Commission set up a similar phase-in for two other new 2009 patient safety goals to reduce surgical-site infections (SSIs) and catheter-associated bloodstream infections (CA-BSIs).
"We went for the three issues that contribute most to morbidity and mortality in health care organizations," Kuzmich says.. "These national patient safety goals are kind of like a subset of standards that we are putting a spotlight on. There are a number of recommendations for each of them, but there are some commonalities."
Common factors for each of the three new goals include a risk assessment, staff and patient education, and surveillance specifically designed for MDROs, SSIs, and CA-BSIs. For the MDROs, for example, the hospital must implement a laboratory-based alert system that identifies new [MDRO-positive] patients," she says. "[They must] also implement an alert system that identifies readmitted or transferred MDRO-positive patients."
Clostridium difficile — a formidable pathogen that is technically not considered an MDRO — was also included under that section. The goals include establishing surveillance systems for C. diff-associated disease (CDAD). As an epidemic strain of C. diff continues to emerge in many U.S. hospitals, a CDC workgroup has issued clinical definitions and is urging IPs to increase surveillance for the pathogen.4 However, the consensus is that formal C. diff surveillance systems are more the exception than the rule. "We do realize that C. diff is not officially an MDRO but it is managed in the same way in terms of isolation and treatment — [with] just two antibiotics to treat it," Kuzmich says. "Because treatment and isolation are similar, [we included] that as well."
Key points in MDRO goal
National patient safety goal (NPSG) 07.03.01 is to "prevent health care-associated infections due to multiple drug-resistant organisms in acute care hospitals." As with the other new goals, hospitals will have to meet benchmark progress measures throughout the year to show they are serious about preventing MDRO infections, hospitals will be expected to meet the following timeline:
- As of April 1, 2009, the hospital's leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG.07.03.01.
- As of July 1, 2009, an implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a timeline for full implementation of NPSG.07.03.01 by Jan. 1, 2010.
- As of Oct. 1, 2009, pilot testing in at least one clinical unit is under way, for the requirements in NPSG.07.03.01.
- As of Jan. 1, 2010, the elements of performance in NPSG.07.03.01 are fully implemented across the hospital.
One of the key performance elements beginning in 2010 will be to conduct periodic risk assessments for multidrug-resistant organism acquisition and transmission. Some of the key features of that requirement, effective Jan. 1, 2010, are:
- Based on the results of the risk assessment, the hospital educates staff and licensed independent practitioners about health care-associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter. The education provided should recognize the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the hospital.
- The hospital implements a surveillance program for multidrug-resistant organisms based on the risk assessment.
- The hospital measures and monitors multidrug-resistant organism prevention processes and outcomes including the following:
— Multidrug-resistant organism infection rates using evidence-based metrics.
— Compliance with evidence-based guidelines or best practices.
— Evaluation of the education program provided to staff and licensed independent practitioners.
- 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.
- 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.
- 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: www.cdc.gov.
- McDonald LC, Coignard B, Dubberke E, et al. The Ad Hoc Clostridium difficile Surveillance Working Group. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007; 28:140-145.