JCAHO posts 2004 infection standards

Editor’s note: The Joint Commission has posted "pre-publication" infection control (IC) standards for 2004 on its web site. After much discussion, the standards appear largely unchanged from 2003. Highlights are summarized as follows:

Surveillance, Prevention, and Control of Infection

Overview: The goal of the surveillance, prevention, and control of infection function is to identify and reduce risks of acquiring and transmitting infections among and between patients, staff, physicians and other licensed independent practitioners, contract service workers, volunteers, students, and visitors. Surveillance, prevention, and control of infection covers a broad range of processes and activities, both in direct patient care and in patient care support, that are coordinated and carried out by the hospital. This function links with external organization support systems to reduce the risk of infection from the environment, including food and water sources.

Standards

IC.1.10 The organization uses a coordinated process to reduce the risks of nosocomial infections in patients and health care workers.

Elements of Performance

1. The hospital’s infection control process is based on sound epidemiologic principles and evidence-based information on reducing nosocomial infection.

2. The infection control program is appropriate to the following:

• The hospital’s geographic location

• The volume of patient encounters

• The patient populations served

• The hospital’s clinical focus

• The number of staff.

3. The hospital’s infection control program addresses issues defined by the hospital as epidemiologically important.

4. The hospital connects its infection control program with the local health department to ensure appropriate follow-up and control of infection.

IC.1.20 The infection control process is managed by one or more qualified individuals.

Elements of Performance

1. One or more individuals qualified through education, training, experience, and certification or licensure oversee the infection control process.

IC.2.10 Case findings and identification of demographically important nosocomial infections provide surveillance data.

Elements of Performance

1. Surveillance activities are appropriate to the organization’s demographics and services.

2. Collection of surveillance data on nosocomial infections is ongoing.

3. Surveillance activities include data collected by staff health services.

IC.3.10 When appropriate, the hospital reports information about infections both internally and to public health agencies.

Elements of Performance

The hospital reports information about infections both internally and to public health agencies as required by law and regulation and hospital policy.

IC.4.10 The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, staff, and visitors.

Elements of Performance

1. The organization implements strategies to reduce the risks and prevent transmission of nosocomial infections in patients, staff, and those who come into the organization.

2. The strategies are consistent with current scientific knowledge, accepted practice guidelines, and applicable law and regulation.

3. The mechanisms address the infection issues that are epidemiologically important to the hospital.

IC.5.10 The hospital takes action to control outbreaks of nosocomial infections when they are identified.

Elements of Performance

The organization implements strategies to control outbreaks of nosocomial infections.

IC.6.10 The hospital’s infection control process is designed to lower the risks and to improve the rates or trends of epidemiologically significant infections.

Elements of Performance

1. The nosocomial infection risk-reduction process acts to lower the risks of and to improve the trends in or rates of epidemiologically significant infections.

2. The organization considers endemic rates (presence or occurrence of infections with geographic area) and epidemic rates (outbreak of infection in area or group) when analyzing data.

3. Infection control findings are used to inform organizationwide performance improvement processes.

4. Appropriate action is taken to decrease infection rates or trends.

IC.6.20 Management systems support the infection control process.

Elements of Performance for IC.6.20

1. Management systems, including staff and data systems, support the hospital’s IC objectives.

2. Data are used to improve IC processes.

IC.6.30 The IC process includes at least one activity aimed at preventing transmission of epidemiologically significant infections between patients and staff.

Element of Performance for IC.6.30

At least one activity has been implemented to intervene in the potential transmission of infection between patients and staff.