Proposed NPSGs focus on additional HAIs

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Proposed NPSGs focus on additional HAIs

New requirements incorporate best practices for VAP and CAUTIs

After reading this article, you will be able to:

  • List the proposed requirements for two new National Patient Safety Goals
  • Recognize best practices to prevent CAUTIs and VAP
  • Explain the importance of a gap analysis

Remember in August 2010 when The Joint Commission announced there would be no new National Patient Safety Goals (NPSG) for 2011? Although that statement still holds true, it seems The Joint Commission has already set its sights on new goals for implementation in 2012.

In December 2010, the regulatory agency announced it would be seeking input on two NPSGs that address HAIs, specifically ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI). The comment period ran from December 2 to January 27, 2011. 

Fortunately for IC departments, the new goals address many of the evidence-based practices that are already implemented in most hospitals across the country. The proposed goals are based on strategies found in the HAI Prevention Compendium developed by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America in partnership with APIC, The Joint Commission, and the American Hospital Association. 

 In fact, since the Institute for Healthcare Improvement (IHI) published the “ventilator bundle,” it is uncommon to come across a hospital that does not use the bundle to reduce infections, says Patricia Pejakovich, RN, BSN, MPA, CPHQ, senior consultant with The Greeley Company, a division of HCPro, Inc., in Danvers, MA.

“I wasn’t expecting it, but when I read [the new goals] I thought, ‘Well, this isn’t going to be a big deal for hospitals because almost everybody has implemented ventilator-associated pneumonia prevention,’ ” Pejakovich says. “The bundle that came out from IHI is really considered a standard of practice at almost all hospitals, so that shouldn’t be a problem.”

Additionally, CAUTIs are listed by CMS as “ never events,” meaning hospitals are no longer reimbursed for patients who acquire CAUTIs while in the facility. 

Therefore, these infections have garnered more attention, and prevention measures have already been implemented in many hospitals. “Everybody has started being very cautious of catheter usage and trying to remove catheters much more rapidly than they did before, so I don’t think it will be a big deal for hospitals,” Pejakovich says. 


Demonstrating compliance

There is nothing in the proposed documentation that indicates these HAI interventions need to be documented, but there could be some issues demonstrating particular prevention measures for VAP or CAUTIs to a Joint Commission surveyor. 

For example, the proposed standards indicate that catheter usage and duration should be limited to situations necessary for patient care. In other words, catheters should be constantly reevaluated to ensure they are needed.

“In ICUs and places where they do more of a bedside rounding, you have the discussion going on between the [licensed independent practitioners], the physicians, the nurse practitioners, and the nurses, and I think you get much more of a discussion and dialogue than you do in some of the med-surg units where many times the physicians come in, go see the patients, write orders, do progress notes, and vacate,” Pejakovich says. 

“I don’t think you have as much discussion going on, so I think there might be a little bit of a challenge for some of the units to have with the physicians when they make their rounds.”

Nurses always have multiple patients, so they may be caring for another patient when the physician comes in. In this case, there needs to be some kind of mechanism that reminds the physician to check the catheter. Pejakovich says it may be beneficial to involve electronic medical records in the process, through which physicians or nurses can be assigned a computerized “task” to remind them to consider catheter removal.

“Because we all have so many things on our plate, the caregivers have so much on their plate, there needs to be some kind of reminders,” she notes. 


Conducting a gap analysis

Since most hospitals have already implemented the evidence-based best practices covered in the proposed goals, they likely won’t have much difficulty ensuring that they are in compliance with any new or potential NPSGs. However, even if you’re sure that your policies and procedures already fit the proposed requirements, it’s beneficial to conduct a quick gap analysis to determine whether there are any areas that you may need to address.

Pejakovich says she offered the same advice when NPSG.07.04.01 came out, which focused on catheter-associated bloodstream infections. 

Many hospitals had already implemented evidence-based best practices for bloodstream infections at that time.

“When those first came out and I would try and talk to some of the people about it, they would say, ‘Oh, we’ve already done that,’ ” she says. “And I would say, ‘But have you looked specifically at each one of the indicators, the elements of performance [EP]? Have you looked at those specifically to make sure you are meeting all of them?’ ”

For example, some IPs or medical staff members may not realize that they need to reevaluate the patient’s catheter, or they may not be very strict in ensuring compliance with that measure. 

A gap analysis will point out those deficiencies, allowing them to be easily fixed, and it doesn’t take much time or effort to compare your policies and procedures with specific EPs.

“Once this becomes finalized, I would strongly encourage that each organization do a comparison of what’s required and what they have in place, and then come up with it to see if there are any gaps or not,” Pejakovich says. 

“They could be in a very good situation and not have a lot of work to do at all for implementation, or they could decide they have a couple things yet to do.”

Additionally, hospitals may find that they have certain evidence-based best practices written into their policies, but actual compliance with those policies may be lacking when it comes to physicians or frontline staff. 

With the prospective weight of a standard, it may be a good time to reeducate staff on the proper protocols.

Whenever there is a discussion about NPSG compliance, there is also a consideration given to how much of the responsibility falls to the IP versus the amount that falls to the quality and patient safety team. 

In this case, as with most others, the responsibility is split almost equally, Pejakovich says. 

But IPs play an especially large role in data collection and HAI prevention in general, so implementing these best practices and effectively training staff members will fall to them. 

IPs will also be responsible for observing staff members to ensure that each preventive step is being followed.


Submitting comments

Healthcare employees are encouraged to submit their thoughts on the new National Patient Safety Goals through The Joint Commission’s online survey, the online form, or via mail. The deadline for comment submission is January 27.

Patricia Pejakovich, RN, BSN, MPA, CPHQ, senior consultant with The Greeley Company, a division of HCPro, Inc., in Danvers, MA, has always encouraged IPs and patient safety officers to submit comments on any new standards that may affect them, but that advice sometimes falls on deaf ears.

“I don’t think people really take enough time to comment,” says Pejakovich. “Especially this one when they look at it and say, ‘Yeah, yeah, we’re already doing it.’ So I don’t know that we’ll already see too many comments on it.”


Proposed requirements

Below is a summary of the proposed National Patient Safety Goals from The Joint Commission involving ventilator-associated pneumonia and catheter-associated urinary tract infections. For more information, find the full standards at

The proposed goals are as follows:

  • NPSG.07.06.01—Implement the following evidence-based practices to prevent ventilator-associated pneumonia:

- Perform appropriate hand hygiene

- Position ventilator patients appropriately

- Regularly provide antiseptic oral care

- Perform daily assessments to gradually remove ventilator 

- Implement daily sedation interruptions according to the plan of care

- Select measures and monitor compliance according to evidence-based best practices

  • NPSG.07.07.01—Implement the following evidence-based practices to prevent indwelling catheter–associated urinary tract infections:

- Limit use of indwelling catheters

- Use antiseptic techniques for insertion and care

- Secure catheters for unobstructed flow

- Maintain sterility

- Replace urine collection system and collect samples

- Select measures and monitor compliance according to evidence-based best practices