JCAHO Update for Infection Control: Flip-flop’ flap: Joint Commission urges ICPs to report fatal, impairing nosocomial infections as sentinel events’

ICPs back on their heels’ as JCAHO reinvents itself

In an unusual direct appeal to health care facilities, the chairman of the Joint Commission on Accreditation of Healthcare Organizations is asking for reports of nosocomial infections that result in patient deaths or permanent loss of function.

"We have until recently believed that the [Joint Commission] database is representative of the broad universe of sentinel events," Dennis O’Leary, MD, said in an open letter to all accredited institutions. "Now, in retrospect, it appears that we are receiving a disproportionately low volume of reports on [deaths and impairment due to infections]. In view of the importance and high visibility of such occurrences, we urge you to share this information with the Joint Commission, just as you might share information about other types of sentinel events with us," he wrote. "Given the nature of these events, we believe it likely that you will have already conducted the related in-depth analyses anticipated by Joint Commission standards."

However, reporting to the JCAHO Sentinel Event Database continues to be voluntary, he said. O’Leary acknowledged that such events are often already being reported to various government agencies and confidentiality is no small concern. "While the Joint Commission has thus far been able to maintain the confidentiality of all sentinel event information reported to it to date, we do understand that confidentiality concerns limit the number of cases actually brought to our attention," he explained.

The request comes as the Joint Commission continues a dramatic process to reinvent itself in an age of patient safety. Scalded by criticisms in the press that it is lax on infection control, the Joint Commission recently warned that it was going to become more aggressive in the area.

"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," says Paul Schyve, MD, Joint Commission senior vice president.

In addition, the Joint Commission is scheduled to convene the first meeting of a special task force on infection control in late January or early February. The agency decided to form the panel 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 whole series of events is befuddling to some ICPs.

"First of all, they tell us they are going to cut infection control regs — [making us] a less important part of the survey process," explains Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN. "All of the ICPs ask, What are you guys thinking?’ Now, we have the opposite end of the spectrum, wanting us to report fatal or life-impairing infections. Wait a minute, either they are important or they are not," she continues. "It just doesn’t seem to be very well thought out on the Joint Commission’s part. I think they really have ICPs back on their heels right now because of this flip-flop."

That said, ICPs certainly view such serious nosocomial infections with deep concern, she emphasizes. "I am working every day to prevent those things from happening," she says. "To add additional reporting, I guess I want to know to what end? Is this going to improve patient outcomes by reporting it? What are they looking for — are they just looking for data so they can tell folks their survey process is [thorough]?"

William Scheckler, MD, one of the recently appointed members to the Joint Commission’s infection control task force, says in informal discussions with JCAHO officials, he has strongly disagreed with interpreting nosocomial infections as sentinel events. Traditionally, nosocomial infections have been regarded as "complications" rather than sentinel events, he explains.

"[Sentinel events] are supposed to be limited to "unexpected serious injury or disability," says Scheckler, hospital epidemiologist at St. Mary’s Hospital in Madison, WI. "Hospitals do not have to report these directly to the JCAHO as long as they keep track of them and do the proper analysis of such events and demonstrate they are doing so when their accreditation visits occur. I hope this new advisory panel can discuss this issue at some length."

Such infections are probably not reported to the Joint Commission as sentinel events very frequently because it is actually quite rare that a nosocomial infection is the obvious sole reason for a patient death, adds Patti Grant, RN, BSN, MS, CIC, director of infection control at RHD Memorial Medical Center in Dallas. Patients frequently have multiple underlying diagnoses across the broad spectrum of disease, from diabetes to pulmonary hypertension, she stresses. In contrast, a wrong-site surgery or medication error is 100% external to the patient.

"A nosocomial event is rarely 100% external, and involves the patient’s internal ability to fight infection, their colonization with endogenous pathogens, the invasive procedures required to save their life," Grant says. "Calling a wrong-site surgery a catastrophic sentinel event is obvious, and correct, and must be reported if patient safety is ever to improve. But in my 12 years of infection control, I can honestly say that I have seen very few black-and-white [cause/effect] deaths from a nosocomial infection."

Even with morbidity associated with a nosocomial infection, there are often many extraneous variables that confuse the issue, she notes. "Which came first, the chicken or the egg? The patient’s intrinsic risk factors for infections are fluid and complicated — making such a call’ for a sentinel event reckless. We must be responsible to our professionalism, JCAHO included, and not be cavalier about requesting, or supplying, such potentially misguided information."

Pushing for such data could cause a chill factor on open discussions in the medical literature, she adds. "My overall fear of this type of reporting, and for that matter most external’ benchmarking of nosocomial infection surveillance, is that it will stifle our openness with publication in peer-review journals of outbreaks and [hinder our] success with process improvement."