JCAHO sounds alarm about deadly nosocomial infections

If 90,000 a year die, why are so few reported?

The Joint Commission on Accreditation of Healthcare Organizations has sent out a sentinel alert to all accredited facilities calling for them to report fatal nosocomial infections. The Jan. 22, 2003, alert follows an earlier direct appeal for the information by Dennis O’Leary, MD, president of the Joint Commission. The request for data has raised concerns among infection control professionals, who argue that ascribing deaths to infections is a complex matter confounded by underlying illness and a host of other variables.

The Joint Commission bulletin argued that "the deaths of patients from hospital-acquired infections are being seriously underreported across America." The Sentinel Event Alert, sent to nearly 17,000 JCAHO-accredited health care facilities, also urges compliance with new guidelines from the Centers for Disease Control and Prevention (CDC) that advise health care professionals to use alcohol-based hand rubs to prevent nosocomial infections. The CDC estimates that more than 2 million patients annually develop infections while hospitalized for other health problems and that nearly 90,000 die as a result of these infections.

Despite these high figures, the Joint Commission’s 7-year-old patient safety reporting database includes only 10 such reports that cover 53 patients, the alert stated. "We are receiving a disproportionately low volume of reports on the number of patient deaths from infections acquired in the health care setting, possibly because many health care organizations do not view these events as errors’ under the definition of a sentinel event," O’Leary wrote in the alert. "However, in view of the importance and high visibility of such occurrences, we are urging health care organizations to share this information with the Joint Commission, just as they might share information about other types of sentinel events with us."

Due to the nature of such events, the Joint Commission said in the alert that it is likely that health care facilities will have already conducted the related in-depth analyses required as part of the accreditation standards. Increased reporting will lead to greater understanding of the factors that lead to their occurrence and effective strategies for prevention.

In a related development, the Joint Commission has formed a infection control panel to review infection control standards. As previously reported in Hospital Infection Control, the expert panel will consult with the Joint Commission about infection control standards as the organization continues sweeping revisions in the accreditation process.

Slated to meet for the first time in February, the panel members include:

  • Mary Alexander, CRNI, Infusion Nurses Society
  • Judene Bartley, MS, MPH, CIC, American Hospital Association
  • Marianne Billeter, PharmD, American Society for Health-System Pharmacists
  • John Boyce, MD, FACP, Hand Hygiene Task Force
  • John D. Christie, MD, PhD, FCAP, College of American Pathologists
  • Georgia Dash, RN, MS, CIC, Association of Professionals in Infection Control and Epidemiology
  • Loreen A. Herwaldt, MD, American Society of Microbiology
  • Elaine Larson, RN, PhD, FAAN, CIC, American Nurses Association
  • John Molinari, PhD, American Dental Association
  • Gary Overturf, MD, Pediatric Infectious Disease Society
  • Gina Pugliese, RN, MS, American Society for Healthcare Risk Management
  • Jeffery Roche, MD, MPH, American Public Health Association
  • Matthew Samore, MD, American College of Physicians
  • William E. Scheckler, MD, University of Wisconsin School of Medicine
  • Steve Solomon, MD, Centers for Disease Control and Prevention
  • Bryan Simmons, MD, Methodist Health System
  • Keith St. John, Certification Board of Infection Control and Epidemiology
  • Michael Tapper, MD, Society for Healthcare Epidemiology of America
  • Jeremiah G. Tilles, MD, American Medical Association
  • Robert Weinstein, MD, Infectious Disease Society of America
  • Dale Woodin, CHFM, American Society of Healthcare Engineers