New Patient Safety Goals focus on infection prevention

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New med rec, UP requirements also released

Revised elements of performance (EP) for medication reconciliation and the Universal Protocol™ (UP) worry some in the field, but the addition of new requirements for reducing healthcare-associated infections (HAI) has so far not stirred up a lot of angst.

Some safety advocates even say The Joint Commission’s new expectations for managing HAIs may lead to wider use of the same type of medical checklist that produced dramatic results in Michigan, where hospitals reduced catheter infections to zero and saved more than 1,500 lives and nearly $200 million.

In late June, The Joint Commission (formerly JCAHO) released its 2009 National Patient Safety Goals (NPSG), which include three new requirements for infections:

NPSG.07.03.01: Prevention of HAIs resulting from multiple drug–resistant organisms (MDRO) using evidence-based practices (this applies, but is not limited, to methicillin-resistant Staphyloccus aureus [MRSA], Clostridium difficile, and vancomycin-resistant enterococci)

NPSG.07.04.01: Prevention of central line–associated bloodstream infections using evidence-based practices

NPSG.07.05.01: Prevention of surgical site infections using evidence-based practices

Goals phased in over one-year period

All new infection control requirements have a one-year phase-in period, with full implementation expected by January 1, 2010.

“I do appreciate the way they’re phasing in things,” says Sandy Jones, RN, patient safety officer at Rockford (IL) Health System. “Many of the things that they’ve changed are things that we at Rockford Health System, and most other hospitals that I’m familiar with, are already working on.”

Many hospitals are already working on the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign and participating in the Surgical Care Improvement Project, which will put them a step ahead in the game, Jones adds.

The Joint Commission expects hospitals to put protocols and processes in place to reduce infections, not eliminate them, says Donald Goldmann, MD, senior vice president of IHI. Instead, the accreditor wants organizations to develop a plan and pilot test it during 2009.

In the case of reducing catheter-associated infections, The Joint Commission expects hospitals to use a checklist and protocol for central venous catheter insertion. That comes as welcome news to Goldmann. If an accrediting body requires checklists to be used, the Office for Human Research Protections cannot deem the practice human research and try to stop their use.

“Hospitals should look at their own experience and determine what is epidemiologically important,” Goldmann says. “That gives hospitals appropriate flexibility as to what they should work on. I like it because it goes beyond MRSA and Clostridium difficile.

In New York City, for example, hospitals would want to look at an MDRO called Klebsiella, which is killing patients and is almost untreatable.

Hospitals should aim to reduce infections by 50%

Eliminating MRSA entirely, Goldmann says, may not be possible right now.

“That said, it ought to be possible based on what I’m seeing to reduce your MRSA rate over a year, or over a year plus, by 50%,” he says. “I think that that should be really feasible.”

That view was echoed by William Munier, MD, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ). “The bugs are very creative and they keep mutating and changing,” Munier says. “I think, yes, it’s very difficult to eliminate them. But we can certainly do much better than we’re doing now.”

Hospitals should look at the protocols of the Centers for Disease Control and Prevention, IHI, and AHRQ, say Munier and Goldmann.

Renumbering presents a challenge

The renumbering of the goals this year may present a challenge to hospitals, Jones says, adding that, overall, she thinks the number of new requirements this year is less burdensome than other years—a view not entirely shared by some others in the field.

The 2009 additions to the NPSGs represent the largest number of new requirements since they were announced in 2002, says Bud Pate, REHS, vice president of content and development at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

“Universal Protocol and medication reconciliation are going to be the most challenging for the field,” Pate says.

Med rec requirements called unclear

The new requirements for medication reconciliation are:

NPSG.08.01.01 (formerly requirement #8A): Any differences found between a patient’s home medication list and the list of medications ordered during a patient’s stay must be clarified and documented while the patient is in the hospital. This goal also requires that during a transfer of a patient’s care within the hospital, part of the documented handoff must concern the most up-to-date reconciled medication list.

NPSG.08.02.01 (formerly requirement #8B): This goal reinstates the requirement that hospitals provide a list of a patient’s medications to the patient’s primary care provider, and if this cannot be done, providing that list to the patient and his or her family will suffice. It is acceptable to send the list to the next provider of care or referring provider, and this must be documented. Another area in which many new documentation requirements were added is the UP.

NPSG.08.03.01: The patient and his or her family receives a complete list of the patient’s medications with a documented explanation of that list upon discharge.

NPSG.08.04.01: In settings in which medications are prescribed minimally or for a short time, modified medication reconciliation processes are carried out.

The requirement that during a transfer of a patient’s care within the hospital, part of the documented handoff must include the most up-to-date reconciled medication list is especially confusing, Pate says.

“There’s a new list required, new documentation,” he says. “This will require that with every new medication order, there is medication reconciliation against current meds. This appears to mean home medications, but [the goals] aren’t really clear.”

UP revisions require checklist

The new requirements for UP include:

UP.01.01.01 (formerly requirement 1A): The biggest change here involves incorporating a checklist when the patient moves from the preprocedure setting. In addition to the existing relevant documentation and correct diagnostic and radiology results, The Joint Commission has required a signed consent form. Any blood products, implants, and special devices that will be used must be confirmed as a part of the checklist.

UP.01.02.01 (formerly requirement 1B): EP 1, concerning marking the site, now applies to all procedures that involve incision or percutaneous puncture. Also, this goal specifies that the surgeon or professional performing the operative procedure must initial the site. Additionally, there is added language about the way in which spinal procedures should be marked, and how facilities must have an alternative process in place to identify the surgical site for patients who refuse the site marking and for certain procedures that are difficult to mark.

UP.01.03.01 (formerly requirement 1C): This goal on performing the timeout now includes language about the need for separate timeouts to take place when more than one procedure is being performed. Also, the timeout should now include an accurate procedure consent form, address whether antibiotics or fluids will be needed, and mention any safety precautions that should be taken based on a patient’s history or medication use. All steps of the UP and timeout must be documented.

Rather than elucidate what is expected for hospitals, Pate says, the new UP requirements make it less clear what clinicians need to do.

Pate also takes issue with the EP for NPSG.01.01.01, which says that if the patient is unable to be involved in the process, the hospital will name a caregiver who will be responsible for being part of the identification process.

“I have no idea what that means,” he says.

Editor’s note: Go to to read the full list of the 2009 NPSGs.