Intensive, expensive, and, in some cases, controversial

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The Joint Commission has announced its 2009 National Patient Safety Goals (NPSG), and they include “extensive and fairly prescriptive” requirements for IC departments that place a sizable burden on ICPs, particularly those without enough staff members or resources, says Libby Chinnes, RN, BSN, CIC, an IC consultant at IC Solutions, LLC, in Mount Pleasant, SC.

“For smaller hospitals without the resources, [implementing the goals] is going to be extremely difficult,” says Terry Burger, BSN, RN, CIC, CNA, BC, director of IC and prevention at Lehigh Valley Hospital in Allentown, PA. “We’re a resource-rich hospital and we’re struggling to meet all the regulatory requirements.”

Burger says the requirements may “pull very highly trained, skillful, and well-educated ICPs from doing what they do so well, which is to educate.” Instead of being on the floors intervening and providing education, ICPs are doing data entry.

The Joint Commission (formerly JCAHO) is rolling out its IC-related goals throughout 2009, and hospitals must be fully compliant with the new goals by January 1, 2010.

Three new areas have been added to the existing NPSGs. Prior to these additions, facilities were only required to comply with CDC or World Health Organization hand hygiene guidelines and to manage infections that result in permanent injury or death as sentinel events.

The new requirements will also mandate that facilities focus on:

  • Central line–associated bloodstream infections
  • Surgical site infections
  • MDROs

The Joint Commission says hospitals should determine what epidemiologically important MDROs to focus on based on their specific hospital risk assessment. These organisms include but are not limited to MRSA, C. diff, vancomycin-resistant enterococci, and multiple drug–resistant gram-negative bacteria.

New EPs to meet

Along with each of these three areas also come new elements of performance (EP) that spell out how facilities must comply with the regulations. These EPs offer much more detailed instructions than those offered recently, Chinnes says.

The number of EPs also seems excessive, Burger says, adding that many ICPs she has spoken with are wondering why they were included in the goals when some of the requirements are already covered by existing standards.

Although many sites have been working to prevent central line–associated bloodstream infections, surgical site infections, and MDRO transmission for several years, many hospitals have not implemented all the evidence-based recommendations for a host of reasons, says Chinnes. Some hospitals may have financial reasons for holding off, she explains, whereas other facilities might be following the recommendations but have not implemented them hospitalwide.

“Most people are doing a lot of these interventions—for instance, taking steps to reduce central line infections and drug-resistant organisms,” Chinnes says. “But many have concentrated on implementation of these initiatives in their high-risk units, such as ICUs.” However, the NPSGs require hospitals to take these initiatives hospitalwide by 2010, she says, although they can pilot programs on a single unit.

Some facilities have not instituted The Joint Commission’s new recommendations because, when it comes to MDROs, they may consider the interventions in the goals too labor-intensive, expensive, or controversial, Burger says.

Although the goals for surgical site infections and catheter-associated bloodstream infections are clearly evidence-based, the literature behind the MDRO goal, NPSG.07.03.01, with its 13 EPs, is more contentious, she adds.

“There is evidence in the literature that challenges the efficacy of universal screening for MRSA,” Burger says, adding that not only is the evidence ambiguous, but the goal might also result in access issues at many facilities.

“Lehigh Valley Hospital has approximately 1,000 in-patient beds, and we currently perform nasal screen surveillance for MRSA on all newly admitted nursing home patients as required by ACT 52 in Pennsylvania. Our hospital is planning to expand the nasal screening for MRSA to all patients admitted to critical care units in August 2008,” Burger says. “Any facility that has a mix of semiprivate and private rooms is finding it challenging to place all the newly identified patients that are colonized with MRSA into isolation. Hospitals are already struggling with access issues, and this creates another burden.”

Getting it done

Aside from controversy, the key barrier to implementing these goals at some facilities is a lack of resources to get the job done. The Joint Commission goals arrive on top of other responsibilities, such as mandatory reporting and the looming Centers for Medicare & Medicaid Services (CMS) reimbursement restrictions.

“ICPs today are facing more and more extensive standards and regulations,” says Chinnes. “We talk about a culture of safety, but many of us in our respective facilities are not there yet.”

Many IC departments have the same number of staff members as they did five years ago, despite increasing requirements and pressures, such as mandatory reporting and ongoing requests for additional staffing. With too many rules and regulations, ICPs might be recording a lot of valuable information, but don’t have the time to do anything with it, Chinnes says.

For ICPs who feel they don’t have the proper resources, now is the time to speak up. The best way to convince administrators to devote more money to IC is to present them with a convincing financial argument, Chinnes says, adding that facilities might face significant financial consequences for skimping on IC, particularly in light of the pending CMS reimbursement cuts associated with preventable infections.

“It costs money to put new tires on a car, but if you don’t, you’re going to pay a lot more in the long run,” she says.

Hurdles to leap

Lack of time and resources will not be the only challenge facilities face as a result of the goals. Some of the goals will be more difficult to implement than others, and implementation will likely come with a high price tag. Hurdles may include:

Training challenges. There’s a good chance you’ll have trouble providing proper education to staff members, as well as patients and their families.

One group that may be particularly challenging is physicians, because they are not employees of the hospital but are privileged to practice at the facility, Chinnes says.

Hospitals will also need to ensure that proper education is provided for patients and family members. Facilities should encourage patients to become involved in their own care, Chinnes says. A lot of facilities have performed training on “speak up” campaigns to encourage patients to remind staff members to wash their hands. This education will need to be more of a focus going forward.

“We’ve educated staff routinely, but we will need to include this as part of orientation and annual training not only for staff, but also for licensed independent practitioners when applicable to their job,” Chinnes says. Education should be ongoing and must ensure that people are educated on policy and procedure changes.

Education at a high price. Education could come with a high price tag at many facilities, Burger says. However, facilities that have e-learning content management systems might not face the same high costs as facilities that need to buy individual training materials on these topics, she says.

Finding the time. In addition to paying for the program, finding the time for this training may be a challenge. “When it come to education, we’re going to have to train the trainer,” Chinnes says. ICPs will need to enlist the help of other staff members, such as members of staff development, to be certain the training reaches everyone it needs to reach.

Trouble with tracking. Putting tracking systems in place may be another challenge. By January 2010, ICPs must ensure that they have systems in place to institute surveillance programs for the MDROs they are targeting based on their risk assessment. They will also need to track employee compliance with infection prevention efforts.

Reporting back critical information. The most important requirement will be ensuring that information about what ICPs find in the course of tracking compliance gets to staff members and clinicians. “You can have the best program in the world on paper, but if you’re not reporting it back to key stakeholders who can implement change at the bedside, it means nothing,” Chinnes says.