JCAHO Update for Infection Control

Joint Commission seeking core measure test sites

Two measures deal with infection prevention

The Joint Commission is seeking volunteer hospitals with intensive care units (ICU) that would like to be considered for participation in a pilot test of six proposed ICU core measures.

The core measures include ventilator-associated pneumonia and central line associated bloodstream infections (BSIs).

The pneumonia measure will look at the relationship between patient head elevation and the development of vent-related pneumonia.

The numerator statement for the measure is the number of ventilator days during which the head of the patient’s bed is elevated at least 30 degrees. The denominator is the total number of ventilator days.

The central line BSI measure numerator is central line BSIs by type of ICU. The denominator is the number of central line days by type of ICU.

The pilot test will consist of a four-month period of data collection with monthly transmissions to the Joint Commission. The objectives of the pilot test include:

  • evaluation of the reliability of the measure set on three dimensions (the data element level, the measure level, and the accuracy and completeness of case finding);
  • evaluation of the data collection effort;
  • assessment sampling strategies;
  • evaluation and validation of risk models.

Pilot sites will be selected based on criteria that will allow for the broad representation of ICUs across the country necessary to test the measures.

Based on information received, approximately 100 hospitals will be identified and contacted. Pilot sites will be provided with detailed measure specifications, data abstraction/collection tools, abstractor guidelines, and training prior to the implementation of the pilot test.

For more information on the pilot project, go to: www.jcaho.org.