JCAHO: Serious nosocomial infections are sentinel events, RCA necessary
JCAHO: Serious nosocomial infections are sentinel events, RCA necessary
Emphasis on infection control part of JCAHO’s patient safety focus
Serious nosocomial infections should be considered sentinel events and thoroughly investigated, according to new information from the Joint Commission on Accreditation of Healthcare Organizations. This interpretation could lead to a significant increase in the number of sentinel events for any health care provider, though it may not be possible to reach the same conclusions with a nosocomial infection as with other sentinel events.
The new interpretation on nosocomial infections comes as the Joint Commission is raising the profile of infection control, part of its continuing emphasis on patient safety. The Centers for Disease Control and Prevention (CDC) also has put more focus on hospital-acquired infections, a departure from its longstanding position that infection rates within a given benchmark range were more or less acceptable. Instead, the CDC — under the direction of veteran health care epidemiologist Julie Gerberding, MD — now is emphasizing the importance of striving for zero infections.1 The Joint Commission is in the process of making a similar paradigm shift, particularly in its view of serious hospital-acquired infections, says Paul Schyve, MD, Joint Commission senior vice president.
"We have specifically begun discussing exactly that issue," Schyve says. "If a patient dies in a hospital or has a permanent disability as a result of a nosocomial infection, the hospital really should think about that as a sentinel event and treat it and evaluate as such. When the outcome is that serious, it is not the same as saying, Let’s add these [infections] up and look for trends and patterns.’ It is, in fact, a sentinel event. Everybody understands that there are nosocomial infections that occur, [but] it seems that people haven’t perhaps thought of them in quite those terms. We will be urging people to think of it that way."
As part of that emphasis, the Joint Commission plans to advise accredited organizations in the near future that nosocomial infections resulting in death or serious injury also should be reported to the Joint Commission’s database.
Quality improvement professionals may find Schyve’s advice difficult to implement, says Patrice Spath, RHIT, a consultant with Brown-Spath & Associates in Forest Grove, OR. Spath says she supports the basic idea of paying more attention to nosocomial infections in hopes of preventing future problems and expects that other quality improvement professionals would be willing to analyze serious nosocomial infections as well. But she wonders how many hospitals will report nosocomial infections as sentinel events to the voluntary database when many already opt out of reporting more clear-cut situations. Adding serious nosocomial infections to the list won’t change anything for those organizations, she says.
Spath also is concerned that nosocomial infections, by their nature, are difficult to trace back to a root cause. That might mean that even the most well-intentioned organizations won’t be able to investigate them as thoroughly as with other sentinel events, and they won’t come up with conclusions that are as practical and usable.
"One challenge with nosocomial infections is that these tend to be patients with a host of illnesses anyway, usually very compromised patients. So it would be very difficult to say this patient had congestive heart failure, diabetes, and a host of other things, but then he got pneumonia and that’s why he died," she says. "And it’s difficult to say that this patient died because a specific nurse on the night shift didn’t wash her hands. You usually can’t pin it down that much."
That doesn’t mean that a nosocomial infection shouldn’t be thoroughly investigated when it leads to patient harm, Spath says, but putting the "sentinel event" label on it may be counterproductive.
"The sentinel event label makes it sound like something that was preventable, and a nosocomial infection may or may not be preventable," she says. "And too often, when we put a label on something, people end up arguing about the label and they miss the point. They forget the goal of why you put the label on it."
Spath notes that the National Quality Forum eliminated nosocomial pneumonia from its proposed list of quality measures because there was insufficient evidence of predictability, meaning it was difficult or impossible to determine the root cause in many cases. Adjusting for the patient’s risk also made investigating pneumonia difficult, the group said.
The best approach may be to broaden your organization’s parameters for what adverse incidents are considered for root-cause analysis, Spath says. Most hospitals have a system in which significant events are reviewed by a committee or ad hoc group that determines whether a root-cause analysis is in order, so Spath says nosocomial infections should be referred to them.
"Broaden your thinking about which events go to that group for consideration for a root-cause analysis," she says. "Let the sorting out happen at that level. If you have a perfectly healthy 35-year-old in for routine surgery and he dies from septicemia, I might consider that a sentinel event that needs investigation. If it’s an immunosuppressed cancer patient who dies from an infection, what would be the value of a root-cause analysis in that case?"
Spath suggests including an infection control practitioner (ICP) in that preliminary review, or including one even earlier to help decide which infection cases should go to the committee for review.
"There are so many factors involved in whether they get the initial infection and how it affects them that it would be impossible to say all patients who die from a nosocomial infection should get a root-cause analysis," she says.
Screening also can occur in physician mortality reviews, she says. You might want to ask physicians to include another question on their mortality review forms — asking if the case would benefit from a root-cause analysis to determine how future nosocomial infections of this type could be prevented. In many cases, the physicians will note that there is nothing to be learned from the infection, she says, but the cases they recommend might be especially meaningful. It might be necessary to educate the physicians more about root-cause analysis.
"If physicians don’t see the root-cause analysis as a punitive activity but as a positive, then they might be the best screeners to determine which cases might benefit from a closer look," she says.
The Joint Commission convened the first meeting of a special task force on infection control recently, after ICPs protested a proposal to consolidate and reduce the number of infection control standards in 2004, when the commission plans to implement its ambitious Shared Vision/ New Pathways accreditation program.
The Shared Vision program represents one of the most comprehensive revisions of the accreditation process the Joint Commission has ever attempted. The changes are nothing less than "revolutionary," says Dennis O’Leary, MD, Joint Commission chairman. "The net effect of these changes will be to substantially increase the relevancy of the accreditation process to health care organizations and to direct even greater attention to improving patient safety and health care quality," he says. "We [have] operated, in part, out of a black box. I mean, the organizations knew what the standards were. They knew what the intent was, but they weren’t sure exactly what the surveyors were looking at and how they were being scored for their compliance on the standards. Now, it’s all transparent."
The infection control aspect of the new approach will be added after the considerations of the newly formed task force, a panel of about 20 members that will include ICPs, epidemiologists, other clinicians, and administrators, Schyve says. But what began as a flap over standards has now opened up into a much wider discussion about infection control and what many believe is its key for survival — accreditation requirements by the Joint Commission.
Reference
1. Gerberding JL. Hospital-onset infections: A patient safety issue. Ann Intern Med 2002; 137:665-670.
Serious nosocomial infections should be considered sentinel events and thoroughly investigated, according to new information from the Joint Commission on Accreditation of Healthcare Organizations.Subscribe Now for Access
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