Work with infection control staff to study and prevent sentinel events

More infections should be sentinel events, JCAHO says

With the Joint Commission on Accreditation of Healthcare Organizations’ recent emphasis on investigating nosocomial infections as sentinel events, now is the time to start planning how you will coordinate a root-cause analysis with your organization’s infection control professionals. There may be crucial differences in how quality improvement and infection control conduct such investigations, and it is better to plan your response before a sentinel event occurs.

Quality improvement and peer review professionals typically take the lead when it comes to accreditation and complying with standards promulgated by the Joint Commission, but that group’s recent announcement about nosocomial infections indicates a need for interdepartmental cooperation, says Barbara Soule, RN, MPA, CIC, an infection control consultant in Olympia, WA, and president of the Association for Professionals in Infection Control and Epidemiology in Washington, DC. This partnership may be a little different from what quality improvement professionals are used to because, unlike many other departments, infection control already has its own system for investigating serious problems. Though the two departments must work cooperatively, the task won’t be as simple as taking your expertise to infection control practitioners and instructing them in how to conduct a root-cause analysis, she says. Moreover, that kind of instruction won’t even be necessary.

"The methods of investigation we’ve always used are not that different from a root-cause analysis, and we’ve used them for years," Soule says. "The root-cause analysis is structured a little differently, but looking at all the various factors and how they affect outcome is pretty traditional for our work."

Communication will be a priority now that the Joint Commission has made clear it is looking for more investigation of nosocomial infections, Soule says. The Joint Commission recently announced that serious nosocomial infections should be considered sentinel events and thoroughly investigated, a position that could lead to a significant increase in the number of sentinel events for many providers.

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

The most recent Sentinel Event Alert from the Joint Commission states that "Despite the small number of infection-related sentinel event cases reported to the Joint Commission, the number of patients acquiring infections in the health care setting, as well as the number of patient deaths due to an acquired infection, remains high." Only 10 infection-related reports have been reviewed under the sentinel event policy since its implementation in 1996, the Joint Commission says.

In addition to urging more reporting of infections, the Joint Commission urges health care providers to take these steps:

  • Revise orientation and training processes and competency assessments.
  • Revise equipment-cleaning processes.
  • Revise hand-washing procedures.
  • Switch to single-use IV flush vials.
  • Add waterless hand rubs.
  • Define supervisory expectations.
  • Revise critical care privileging and intensive care unit admission criteria.
  • Conduct inservices and team trainings.
  • Institute tracking systems.

Your efforts to comply with the Joint Commission directive and investigate more nosocomial infections will be more successful if you first approach infection control professionals by acknowledging that they already are on the ball, even if their work hasn’t resulted in many sentinel events reported. There is some resentment among infection control practitioners who think the Joint Commission implied that they should start investigating infections, as if they weren’t already doing that, says Carol Elder, infection control practitioner at Mount Carmel West in Columbus, OH.

"I think a lot of infection control practitioners will respond that we’ve always done what they want us to do. They call it a root-cause analysis; we call it an epidemiological investigation," she says. "They’re just calling it something different. If I see two or three patients with an infection that’s unusual, or maybe they had the same procedure, I don’t sit back and wait until we declare it a sentinel event to do a root-cause analysis. I’m already out there investigating it."

Infection control practitioners will not need a step-by-step explanation of how to investigate nosocomial infections, but they may need to be briefed on the particular manner in which the Joint Commission expects the investigation to occur. The differences may be more semantic than substantive, Soule says.

"It might be that infection control professionals need to learn the new process that you use with sentinel events, and the terminology expected by the Joint Commission might be new to them," she says. "It also can be helpful to go over the documents required by the Joint Commission."

How much you need to educate infection control professionals about the sentinel event process might depend on how much they have been involved already. Some organizations already include infection control as a regular part of sentinel event investigations, so Soule says the only needed change might be giving the infection control practitioner a bigger role in some instances. When investigating a nosocomial infection as a potential sentinel event, it might be appropriate to have the infection control representative lead the team.

"If you have a situation in which your quality improvement professionals and infection control professionals have not worked together before on sentinel events and root-cause analyses, this would be a good time to educate each other about how that process works. You might want to do it before an event occurs, but not necessarily," she says. "There can be just-in-time’ training, and a lot of people think that is the most effective. That takes place when you have a potential sentinel event and you get in a room with the team and go over the expectations for the Joint Commission."

Elder says she has met with her hospital’s quality improvement department to discuss the new Joint Commission directive, and she recommends that as a starting point for other providers.

Communication between the two departments will be key to satisfying the Joint Commission without getting in the way of the work already done in infection control, she says. Remember that many infection control departments consist of just one person, so additional paperwork and reporting systems can get in the way of an already heavy work load. Above all, she cautions providers not to implement a system that will hobble infection control’s standard investigation process by waiting for a sentinel event declaration.

"We already investigate faster than if we had to go through a reporting process and then get an official order to investigate the problem," Elder says. "There’s a risk of delaying investigations if you implement some sort of bureaucracy for reporting that delays what we already do, which is to go ahead and investigate as soon as we have reason to."

[For more information, contact:

Barbara Soule, Association for Professionals in Infection Control and Epidemiology, 1275 K St., N.W., Suite 1000, Washington, DC 20005-4006. Telephone: (202) 789-1890.

Carol Elder, Infection Control, Mount Carmel West, 793 W. State St., Columbus, OH 43222. Telephone: (614) 234-1313.]