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New NPSG addresses CAUTIs

New NPSG addresses CAUTIs

What you need to know for compliance

The Joint Commission released a new National Patient Safety Goal (NPSG) on May 17. The new goal, NPSG.07.06.01, addresses the need to prevent catheter-associated urinary tract infections (CAUTI). It's similar to previous NPSGs on infection control.

According to The Joint Commission, CAUTI is the most frequent healthcare-­acquired infection (HAI) and represents up to 80% of HAIs in hospitals. The goal applies only to hospitals and critical access hospitals, which should start conducting a gap analysis to understand where they are in relation to what is now required, says Elizabeth Di Giacomo-­Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and advisory board member for the Association for Healthcare Accreditation ­Professionals (AHAP). She notes that the goal does not apply to pediatric populations.

NPSG.07.06.01 was one of two proposed goals; the other concerned ventilator-associated pneumonia. ­However, due to the lack of an agreed-upon definition for this HAI, it failed to pass as a goal, according to a Joint Commission statement.

"The new NPSG on CAUTIs has a realistic overall goal," says Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of accreditation, clinical compliance, and policy management at Northwestern Memorial Hospital in Chicago and AHAP advisory board member. Eisenberg notes that The Joint Commission is leaving the details of implementation to individual hospitals.

Hospitals must have a plan in place by 2012 for full implementation by January 1, 2013. The goal essentially requires hospitals to follow evidence-based practices from the Society of Healthcare Epidemiology of America's ­Compendium of Strategies to Prevent Healthcare-­Associated Infections in Acute Care Hospitals and the Centers for Disease Control and Prevention's Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009, for insertion and management practices of urinary catheters. The goal has four elements of performance (EP), summarized here:

  • EP 1: The hospital must have an implementation plan in place by 2012.
  • EP 2: Insertion of urinary catheters must follow ­evidence-based guidelines, including using accepted techniques, inserting only when necessary, and limiting duration of use.
  • EP 3: Management of urinary catheters must follow evidence-based guidelines. Catheters must remain unobstructed and sterile, and be replaced when required. Urine samples must also be collected.
  • EP 4: CAUTIs must be measured and tracked in high-volume areas in accordance with evidence-based guidelines. In addition, hospitals must evaluate the effectiveness of their CAUTI prevention program.


Hospitals are also required by EP 4 to conduct a risk assessment to determine high-volume areas of patients using urinary catheters. This requirement also relates to IC.01.03.01, EP 2.

"Hospitals should identify a CAUTI team," says Jean Clark, RHIA, CSHA, director of accreditation at ­Roper Saint Francis Healthcare, in Charleston, SC, and AHAP advisory board member. "Look at any data already collected and define a baseline for CAUTIs in the ­organization … Start now rather than later." Clark reminds ­accreditation and ­patient safety professionals that implementing the new goal will take medical staff ­cooperation, education, monitoring, and data analysis to improve performance.

The key for organizations is to use the time given to them in 2012 to develop and implement a comprehensive plan, says Eisenberg. "Don't wait until the last quarter of 2012 to figure this one out."