JCAHO Update for Infection Control

Spotlight special projects during JCAHO inspections

Multidisciplinary effort impresses surveyor

Don’ t be shy about emphasizing your success stories when an accreditation surveyor begins making the rounds.

An infection control professional who did just that — including posting a display board outlining the program in a neonatal intensive care unit (NICU) — received glowing reviews during an inspection by the Joint Commission.

"When the surveyor came and looked at the story board and saw the whole process, she was really impressed that we had done this interdisciplinary project and that we had displayed it the way that we did," says Ellen Novatnack, RN, BSN, CIC, infection control professional at St. Luke’s Hospital in Bethlehem, PA.

Concerns mounted when Novatnack and colleagues found that central/umbilical line-associated bacteremia rates in a low birth weight (less than 1,000 g) NICU were above the 90th percentile when benchmarked against other surveillance hospitals in the Centers for Disease Control and Prevention’s (CDC) National Nosocomial Infection Surveillance (NNIS) System.

At the same time, device (central and umbilical line) utilization ratios were below the 25th percentile when compared to other NNIS hospitals, so the ICPs hypothesized that the high infection rates were related more to infection control issues than to device use. There were a variety of pathogens involved, but the primary culprit appeared to be coagulase-negative staphylococcus.

Hospital representatives from infection control, the NICU, and support services collaborated to identify problems, make recommendations, and provide staff education, she says. Overall, some 36 interventions were implemented, including a key change in hand hygiene.

"We went to a waterless agent, and we actually put a pump at every single beside," Novatnack says. "Because the way our NICU is set up, there were only four sinks in the geographical area of 20 cribs. So we put a pump at every bedside."

Following the interventions, the NICU reported six consecutive months of zero infections, achieving a new benchmark status below the 10th percentile in the NNIS system. The NICU staff gained a heightened awareness that infection control preventive activities reduce infection rates, she says. And, as noted, a JCAHO surveyor was impressed with the multidisciplinary approach and favorable results.

"Joint Commission was on its way, so we wrote this up as a performance improvement project and put it on story board," Novatnack says. "So we actually had this on a display board in the NICU, because one of the things that Joint Commission looks for is whether you are getting information back to staff. This truly was an interdepartmental project. We wanted them to see that we went through all of us, made changes, and the results were positive because the rates were lowered."