The Joint Commission Update for Infection Control

MDRO goal starts with risk assessment

The Joint Commission's 2010 patient safety goal to prevent multidrug-resistant infections (NPSG.07.03.01) includes the following key aspects and elements of performance:

• Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals.

Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria.

Rationale for NPSG.07.03.01

Patients continue to acquire health care-associated infections at an alarming rate. Risks and patient populations, however, differ between hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment. The elements of performance for this requirement are designed to help reduce or prevent health care-associated infections from epidemiologically important multidrug-resistant organisms (MDROs).

Note: Hand hygiene, contact precautions, as well as cleaning and disinfecting patient care equipment and the patient's environment are essential strategies for preventing the spread of health care-associated infections. Hand hygiene is addressed in NPSG.07.01.01. Contact precautions for patients with epidemiologically significant multidrug-resistant organisms (MDROs) are covered in IC.02.01.01, EP 3. Cleaning and disinfecting patient care equipment are addressed in IC.02.02.01.

Elements of Performance for NPSG.07.03.01

1. Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug- resistant organism acquisition and transmission.

2. Based on the results of the risk assessment, educate staff and licensed independent practitioners about health care-associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter.

Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the hospital.

3. Educate patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care-associated infection strategies.

4. Implement a surveillance program for multidrug-resistant organisms based on the risk assessment. Note: Surveillance may be targeted rather than hospitalwide.

5. Measure and monitor 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

Note: Surveillance may be targeted rather than hospitalwide.

6. Provide multidrug-resistant organism process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

7. Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

8. When indicated by the risk assessment, implement a laboratory-based alert system that identifies new patients with multidrug-resistant organisms.

Note: The alert system may use telephones, faxes, pagers, automated and secure electronic alerts, or a combination of these methods.

9. When indicated by the risk assessment, implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms.

Notes: The alert system information may exist in a separate electronic database or may be integrated into the admission system.

The alert system may be either manual or electronic or a combination of both.

Each hospital may define its own parameters in terms of time and clinical manifestation to determine which readmitted patients require isolation.