JCAHO Update for Infection Control

Patient safety goals include key infection control issues

ICPs tackle issue of investigating nosocomial deaths

The Joint Commission on Accreditation of Healthcare Organizations has set patient safety goals for 2005 that include several high-profile infection control issues.

The goals include high compliance with hand hygiene; reducing influenza and pneumonia in long-term care; and a continuation of the controversial edict to investigate patient deaths linked to nosocomial infections.

Regarding long-term care, the JCAHO will be looking for nursing homes in 2005 to develop and implement protocols for administration of both influenza and pneumococcal vaccine.

In the hand hygiene area, the Joint Commission has set high expectations for compliance with guidelines recommended by the Centers for Disease Control and Prevention (CDC).

The hand hygiene goal carries over from 2004, but the Joint Commission added some teeth to the requirement in a Jan. 20, 2005, revision posted on its web site.

Compliance with the CDC guidelines — which emphasize the use of alcohol hand rubs — will be "surveyed through interviews with caregiver staff and direct observation," JCAHO stated. "Caregivers should know what is expected of them with regard to hand hygiene and should practice it consistently. A minimum of 90% compliance will be expected."

The compliance requirement was set at the 90% level despite — or perhaps because of — the dismal historic record of hand washing in health care facilities.

Many studies over the years have found that health care workers typically wash their hands before only about 50% of patient encounters.

Regardless, JCAHO surveyors will score hand hygiene compliance by counting observations.

"One occurrence equals one observation of noncompliance with CDC Category I recommendations," the Joint Commission warned.

"Three occurrences equal a Requirement for Improvement. There is no partial compliance’ for national patient safety goals," it said.

Disclosure laws add controversy

While infection control professionals may welcome the tough stance on hand hygiene, another patient safety goal continues to be controversial. The JCAHO 2005 patient safety goals for hospitals include the recommendation to "manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection."

The goal is carried over from 2004, though some ICPs have argued that ascribing deaths to infections is a complex matter confounded by underlying illness and a host of other variables. The original concerns are being compounded by the national movement to require disclosure of infection rate data.

"There must be five states now that require mandatory reporting," says Robert Wise, MD, JCAHO vice president for standards. "We’re not, at this point, requiring mandatory reporting. The crux of our infection control recommendation is for an organization to better understand its own risks. Clearly, infections that cause death [are occurring], but they are very difficult for a hospital to identify."

Indeed, as state disclosure laws spark discussions in various forums, questions are arising about the accuracy of even the most basic infection control data. "How does one even track nosocomial infections is being questioned," Wise says.

"The difficult issue then is to determine if the infection should be associated with a sentinel event. We know there should be more reported. How many more is the question," he notes.

Indeed, the dearth of data and pressure from the press first raised the issue in 2003, when the Joint Commission sent out a bulletin noting 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, cited 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 those high figures, the Joint Commission’s patient safety reporting database — 7 years old at the time — included only 10 such reports that cover 53 patients, the alert stated. But those reports are gradually increasing, thanks to some ICPs who have embraced the challenge and developed novel ways to track and report the patient fatality data.

Finding data without reinventing wheel

For example, a pilot program to track the data began last year at Memorial Sloan-Kettering Cancer Center in New York City, explains Janet Eagan, MPH, CIC, infection control manager. Eagan and colleagues began by reviewing 10% of patient deaths that occurred in 2003.

To determine if the deaths were related to a nosocomial infection, they established "exclusion criteria" to rule out deaths due to other causes. Exclusion criteria used in the program are death within 72 hours of admission; admissions with fever and chemotherapy-related neutropenia; stage IV incurable metastatic cancer; and positive microbiology culture obtained within 72 hours of admission.

Any of those findings would rule out a nosocomial infection as the cause, and the cases that are left are investigated more thoroughly. In the pilot program, five patient deaths did not meet exclusion criteria and were referred to an infectious disease physician for review.

Nosocomial infection was not found to be the cause of death in any of the cases, and no sentinel event investigations were undertaken. The program now has been implemented on an ongoing basis.

"Now, all discharges as deaths are reviewed by a person in our quality assurance department," Eagan says.

"They review it, and the [cases] that meet exclusion criteria are discarded. Anywhere from 4% to 6% of them are referred to an infectious disease physician. If the physician then determines that it is possible that it was a nosocomial death, it will go to a multidisciplinary review and a root-cause analysis. We report these [data] quarterly to our hospital infection committee," she points out.

For example, in the third quarter of 2004 there were 137 deaths reported, 130 (95%) of which met exclusion criteria. The remaining seven cases were referred for review.

"All of those referrals were found to be deaths that were not caused specifically by the nosocomial infection," Eagan says.

ICPs considering such programs should look at their own patient population, as the exclusion criteria may differ from a cancer treatment center. The system in place at Sloan-Kettering is relatively straightforward, has passed muster with Joint Commission surveyors, and does not require a lot of additional time and labor, she emphasizes.

"We sat down with a group of people and said, How are we going to do this?’" Eagan recalls. "We didn’t reinvent the wheel because we were using QA staff who look at charts anyhow. The point is you have to do it the best you can.

"It’s not going to be 100%, but it’s very close to it. I think that is what everybody needs to understand. A lot of places developed these very intense algorithms that are just almost impossible to do. This is very possible, almost simplistic, but it [addresses] the issue," she adds.

NIH center tracking death data as well

A similar surveillance system has been set up at the National Institutes of Health Warren G. Magnuson Clinical Center in Bethesda, MD. ICPs there began by reviewing all in-facility deaths that occurred from Jan. 1 to Sept. 1, 2003 to determine if mortality could be attributed to preventable nosocomial infections.

For the period, 21 deaths were identified. Of those patients, 11 had nosocomial infections at the time of death. Three cases met criteria for having an infection that may have contributed to the cause of death.

However, none of the deaths was unanticipated due to the patients’ advance underlying disease, reports Angela Michelin, MPH, an ICP in the epidemiology service at the clinical center.

The patients were determined to have nosocomial infections that resulted from severe immunosuppression and end-stage disease with no anticipated improvement from therapy.

In addition to deaths, the ongoing program includes a component to try to identify major loss of function as a result of an infection.

"On a quarterly basis, a list of all in-house deaths is obtained from the medical records department," Michelin explains. "We also request a list of all autopsies from our pathology department so that we know which deaths have autopsy data available."

Overall, data collection sources include infection control surveillance database, death certificates, autopsy reports, electronic information systems, and patient charts.

"Data are collected for the 14-day period prior to death," she points out. "The infection control practitioners review this information and make the initial decision whether any infections are questionable."

Because a large number of the clinic’s patient population is immunocompromised (e.g., stem cell and solid organ transplant, HIV, host defects, oncology) the infections often are unavoidable, she notes.

"But any that are questionable are reviewed in further detail with the hospital epidemiologist," Michelin adds. "We are made aware of infections associated with major permanent loss of function through our more routine practices."

Those include targeted surveillance of high-risk populations through attending multidisciplinary rounds, reviewing daily microbiology logs, and an alert notification system for certain infections from the microbiology laboratory.

"This keeps us well informed of unusual situations, and any that were questionable would similarly be reviewed with the hospital epidemiologist," she says.