Joint Commission’s request for fatal infection data may yield little meaningful prevention information

Infection control breaches will not be easy to document

Infection control professionals attempting to comply with accreditors and do a root-cause analysis of fatal nosocomial infections must set narrow patient definitions and work closely with their quality improvement colleagues if any meaningful prevention data are to come out of the controversial initiative, an ICP warned.

One problem is that even the most in-depth analysis of a patient’s care may not reveal a minor breach in infection control, which is all it takes in some cases to reverse the course of recovery.

"A lot of infection control practices aren’t charted in the [patient’s] chart," said Teresa Garrison, RN, MSN, CIC, CNLCP, an ICP with BJC Healthcare System in St. Louis. "So you are not going to see charted [for example] that the patient’s central line dressing change was loose, and instead of changing it the nurse just taped it up a little bit better. So all of the things that put patients at risk actually aren’t in the chart. I am still not convinced that doing a root-cause analysis is going to yield us much information on infection prevention."

Earlier this year, the Joint Commission on Accreditation of Healthcare Organizations issued a Sentinel Event Alert stating: "Manage as sentinel events all identified cases of death and major permanent loss of function attributed to a nosocomial infection (i.e., except for the infection, the patient would probably not have died or suffered loss of function)."1

The Joint Commission cited the Centers for Disease Control and Prevention’s (CDC) definition of a nosocomial infection as: "a localized or systemic condition: 1) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s), and 2) that was not present or incubating at the time of admission to the hospital." Infections that lead to patient deaths or permanent loss of function should be regarded as sentinel events and subjected to a root-cause analysis with the idea of preventing such infections in the future.

Review unexpected’ deaths

Although such reporting is voluntary, Joint Commission surveyors may ask ICPs whether they have done anything with regard to the Sentinel Event Alert, said Garrison, who spoke recently in San Antonio at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). She described a possible approach to the Joint Commission’s request that has been undertaken as a pilot program in one of the BJC hospitals. One of the first data elements ICPs looked at was "unexpected" patient deaths, which were already being tracked by hospital case managers.

"They already have a definition for unexpected deaths, and it is very, very narrow," she said. "I would suggest that when you look at this for your hospital, you create something just as narrow. So, for example, a patient coming in by ambulance that is a trauma, CPR in progress, doesn’t make the definition. Any patient in the hospital who has had a change in his code status and is now a do not resuscitate’ doesn’t make the definition. What you are left with is truly fairly healthy people who are coming in for something and then they really are dying."

From that group, ICPs may be able to find some patients who died as a result of a nosocomial infection, but conducting the root-cause analysis will not necessarily fully explain the event.

"We wrote into the plan that we would review patients with unexpected death, and if they had a nosocomial infection, we would collaborate with performance improvement and risk management to decide at that point whether we are going to do a root-cause analysis," she says. "We also put into the plan that we were going to review resources needed for all of these root-cause analyses and also look at the yield of information in terms of infection prevention."

Tips on what surveyors are looking for

In a presentation titled "Tips From the Troops," Garrison told APIC attendees what fellow ICPs are actually reporting after their Joint Commission inspections. Thus, she was able to advise ICPs on many of the questions surveyors are asking about the 2003 standards, which will continue into 2004 with very little change.

"The Joint Commission has become much more sophisticated in the way they look at our data and the questions they are asking us," she said. "This year, I have heard a lot of focus on baseline. What is your historic baseline? What are you doing about it?’ And then stability. They have really been asking, for the first time, Are you sustaining the gain?’ They are excited when you are able to drop a rate and make an improvement, but what they really want from you now is that you sustain that improvement and keep it going over a long period of time."

In the same vein, stopping an outbreak will certainly be viewed favorably, but surveyors may go a step further and ask the ICP what was learned from the experience.

"Although they love how you found the outbreak, controlled it, and improved things over time, their main questions this year have been, What have you learned about the process that you used to complete the investigation?’" Garrison said. "So if you learned something from your process that you would do differently the next time you have an outbreak, be sure to be able to describe that. Also, the trick here is to make sure you have implemented that revision in your [program policies]."

Overall, the Joint Commission requires that infection control programs reduce the risk of acquiring and transmitting infections among and between patients, staff, and visitors. To find evidence that such efforts are in place, they will look for the ICP to use five active verbs: identifying, analyzing, preventing, controlling, and reporting. "They are going to look at those, not only in the document review that you provide and in your interview, but they also are going to look for evidence of those activities from other staff members at the hospital when they are touring patent care areas," Garrison said.

To begin with, have a written program description that includes the infection control goals you are working under for the current year, she advised.

"Your annual goals need to be measurable, realistic, and coordinated with the organization’s performance improvement [plans]. The Joint Commission loves this closed feedback loop, so you need to be sure you can tie what you are doing back to the organization’s overall performance improvement plan," Garrison said.

Indeed, the Joint Commission will be looking for evidence of communication and interaction with other programs as part of its emphasis on multidisciplinary care. "The Joint Commission wants a multidisciplinary approach, and I think it fits us very well," she said. "What is so great about infection control is that we are everywhere and we get to go everywhere. We are constantly working across departmental lines, so to be sure to include that in your surveillance plan."

Show clear link to occupational health

ICPs should have a statement of program oversight that clarifies their supervisor and the link between the program and hospital administration.

"You also need a statement on infection control authority," she said. "Do you have the authority to close down a ward to new admissions if it is experiencing an outbreak? If you don’t have that authority, who has it? Be sure to include that statement in your program description."

In outlining your program, be sure to show a clear link with occupational health, an area of increasing interest to the Joint Commission, she emphasized. "The Joint Commission is continuously looking for [infection control] collaboration with occupational health."

By the same token, the Joint Commission is looking closely at hospital staffing patterns, and surveyors may want to know whether infection control has sufficient manpower. "You need to have some rationale for the staffing that you have in your department," Garrison said. "And you need to be able to explain the rationale for that. This can be controversial, especially in your interview when [the Joint Commission surveyor] is asking you about your staffing, and your CEO is sitting right there at the table with you."

If you are using a formula, like the CDC’s national nosocomial infection surveillance system’s 1.5 FTEs for the first 100 beds, explain that to the Joint Commission, she said.

"You need to have some statement about how you determine whether your staffing is adequate or not," she said. "Then have a staffing plan that addresses staffing variances. I doubt that many of us get any more ICPs when census goes up or when there is an outbreak. You need a statement that shows that these are fixed positions, but what are you going to do when you have an outbreak? How are you going to be able to handle the staffing and your daily workload?"

The Joint Commission requires that ICPs do case finding and identification of demographically important nosocomial infections via surveillance. "The tip here is to describe your surveillance," Garrison said.

"Is it targeted or total house?" she asked. "The Joint Commission does not ban total-house surveillance, so if you have a good rationale for that, they’re not going to say you can’t do it. But whatever your surveillance [approach], it needs to encompass the patient care that is provided in your facility and to cover occupational health services."

But creating a paper trail of surveillance data will not mean much if workers on the floor don’t know which bugs are causing problems in the hospital.

"How have you acted on your surveillance findings?" Garrison said. "When they tour patient care areas, they are asking staff nurses, What kind of infections do you see on your unit? And what are you, the staff nurse, doing to reduce infections on your unit?’"


1. Joint Commission on Accreditation of Healthcare Organizations. Infection control-related sentinel events. Sentinel Event Alert 2003:28.