Joint Commission Update for Infection Control

Keys to compliance with the new 2010 MDRO goal

Include C. diff, gram negatives

Given that some trace the very founding of hospital infection prevention programs back to the first volleys in the longstanding battle with multidrug-resistant organisms (MDROs), it comes as little surprise that The Joint Commission has made these bugs the focus of a National Patient Goal for 2010. At the same time, it signals that the threat posed to increasingly frail patients by methicillin-resistant Staphylococcus aureus (MRSA) and other MDROs may actually be on the rise.

The price of keeping so many patients alive through cutting-edge interventions and transplants is that there are ever more targets for these resourceful, ever-evolving pathogens. But dramatic reductions in infection rates in recent years also signal that infection prevention has devised a few tricks of its own, and some of these hard-earned strategies coupled with ongoing vigilance may yet turn the tide toward patient safety.

"Patient safety goals are kind of a subset of our standards," explained Louise M. Kuhny, RN, MPH, MBA, CIC, senior associate director of standards interpretation at The Joint Commission. "The purpose of them is to put a spotlight on critical issues in patient safety and patient quality. Obviously, health care-associated infections have risen to the level of national concern, and therefore we are putting out some more requirements to help focus energy and efforts on preventing HAIs."

The Joint Commission's 2010 patient safety goal (NPSG.07.03.01) calls for hospitals to implement evidence-based practices to prevent HAIs due to MDROs. This requirement applies to, but is not limited to, epidemiologically important organisms such as MRSA, Clostridium difficile(C. diff), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria, the goal states. Of course, infection preventionists have pointed out that C. diff by biological definition does not technically fall into the category of an MDRO.

"We know that microbiologically C. diff is technically not an MDRO," Kuhny noted during a recent Joint Commission webinar on the issue. "However, it behaves like an MDRO, and we have chosen to put it under this goal in an effort to make sure that it is addressed as well as the other [pathogens]. It behaves like an MDRO because it requires isolation and has limited antimicrobial therapy."

Wary of the rise of gram negatives

By the same token, questions have been raised about the inclusion of gram-negative bacteria, she noted. Gram negatives have yielded center stage to MRSA and other gram-positive bacteria in recent years, but they appear on the way to an unwelcome comeback with such threats as emerging carbapenem-resistant Klebsiella pneumoniae. Thus, The Joint Commission included gram-negative bugs in the goal, but it is leaving itup to individual hospitals to decide which, if any, gram-negative problem they should address. Indeed, the whole MDRO effort should be preceded by a risk assessment. The patient safety goal calls for infection preventionists to conduct periodic risk assessments for MDRO acquisition and transmission. (See goal, p. 3.) This may be part of a general infection control risk assessment (required in IC.01.03.01) or separated out, Kuhny said.

"This is the same type of thing but it needs to be focused directly on MDROs," she explained. "In terms of paperwork and how you structure the risk assessment, you can choose to have it either as one part of your bigger, general infection control risk assessment or you could break it out in a separate document. It doesn't matter to us, as long as you can point to it when the surveyors visit."

Based on the results of the risk assessment, the hospital educates staff about HAI and MDRO prevention strategies at hire and annually thereafter.

"We recognize that education will be different for different providers," Kuhny said. "You're going to teach physicians different things than you teach nurses aides and housekeepers. You can definitely customize education and determine what kind of approach you want to take. It can be written, web-based learning, face-to-face — as long as you can demonstrate that the education has been performed."

As part of achieving the goal, the hospital also must educate patients — and their families as needed — who are infected or colonized with an MDRO.

"The minimum requirement here is that you provide education for those people that come up positive for an MDRO, either an infection or colonization," Kuhny said. "Many organizations are choosing to go beyond that and do some basic MDRO education for everyone, but our minimum requirement is that you do it for those people that are infected or colonized."

The MDRO goal calls for the hospital to implement a surveillance program for multidrug- resistant organisms based on the risk assessment. "You may do targeted surveillance," Kuhny said. "That means based on your risk assessment, you can choose which organisms, which units, which types of services you want to target in your surveillance program and prioritize."

Measure and monitor

The hospital must 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.

The monitoring process includes both outcome and process measures, which will likely vary significantly from one organization to another.

"So, your outcome measure here is actual infection rates," Kuhny said. "How many people have a negative outcome and are actually infected? Then there are a minimum of two required process measures. The first one is whether people are complying with practices. One example here of something that you might do is measure isolation compliance. Are people wearing the gowns and gloves when designated?"

The hospital must then provide the MDRO surveillance data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

"This is a really important thing," she stressed. "Key stakeholders go from your frontline staff up to — we hope — your board members. Everyone that has some decision-making [responsibility] in the organization concerning MDROs should get the surveillance data so they have feedback and know how they are doing. The frontline staff decide many times who gets isolated and how the precautions are going to be implemented. The board members decide what resources are available to support such programs."

Then, the hospital implements policies and practices aimed at reducing the risk of transmitting MDROs, ensuring they meet regulatory requirements and are aligned with evidence-based standards. Organizations should compare their existing policies and procedures with relevant guidelines and update as needed.

When indicated by the risk assessment, the hospital should implement a laboratory-based alert system that identifies new patients with multidrug-resistant organisms. The alert system may be either manual or electronic or a combination of both of these methods.

"This means when the laboratory test comes back positive — a culture or what have you — will the people who need to know, know quickly?" Kuhny said.

Turnaround times are not going to be specified by The Joint Commission, but remember new — both new admissions and new culture results — reporting should be determined based on needs related to both isolation and treatment, she said. "The people who need to know are those making the isolation decisions, which is usually the nursing staff," she said. "In addition, the people who are making a treatment decision. Are we going to treat this MDRO — do we need to prescribe antimicrobials? How quickly did that information get to those people?"

Don't 'batch' reports

Daily batching of these reports is generally discouraged.

"If you are only transmitting this information once a day it may very well not meet the needs of your patients," Kuhny said. "We would encourage you to do it on a more timely basis."

When indicated by the risk assessment, the hospital then implements an alert system that identifies readmitted or transferred MDRO-positive patients. This means that all patients must be identified, but it does not mean that isolation is appropriate or required in all circumstances.

"This does not mean that all patients that ever had an MDRO need to be isolated when they are readmitted to the organization," Kuhny said. "It just means that the information about that previous positive result needs to get to the people that need it."