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Despite
the small number of infection-related sentinel event cases
reported to the Joint Commission, the number of patients acquiring
infections in the health care setting, as well as the number of
patient deaths due to an acquired infection, remains high.
According to estimates from the Centers for Disease Control and
Prevention (CDC), each year nearly two million patients in the
United States get an infection in hospitals, and about 90,000 of
these patients die as a result of their infection. Infections are
also a complication of care in other settings including long term
care facilities, clinics and dialysis centers.
The
CDC works in conjunction with approximately 315 hospitals
throughout the United States to collect data for its National
Nosocomial Infections Surveillance (NNIS) System. A cooperative
effort begun in 1970, the system describes the epidemiology of
nosocomial infections and antimicrobial resistance trends, and
produces nosocomial infection rates to use for comparison
purposes. The most recent NNIS report was published in the
December 2002 issue of the American Journal of Infection
Control and is available on the NNIS website.
According
to the JCAHO database, only 10 infection-related reports have been
reviewed under the sentinel event policy since its implementation
in 1996. Fifty-three patients were affected, of which 14 died.
While the age of the patients afflicted varied, the vast majority
were infants (29) and seniors (19), many of whom were
immunosuppressed. Settings included the newborn and pediatric
intensive care units, long term care facilities or units, general
medical/surgical units, and endoscopy and obstetrics units. The
infecting organisms included HIV, Pseudomonas aeruginosa, E.
coli, MRSA (methicillin resistant Staphylococcus aureus),
salmonella, and Clostridium sordellii. The number of reported
infection-related sentinel event cases represents an insufficient
sample from which to draw any generalizable conclusions and
recommendations.
Numerous
high profile media reports of incidences of patient death
resulting from hospital-acquired infections indicate that such
cases are seriously under-reported to JCAHO. JCAHO emphasizes that
patient death or permanent injury/loss of function as a result of
a nosocomial infection does indeed meet the criteria for
reviewable sentinel events. As such, each event should undergo a
root cause analysis to identify risk reduction strategies, and
should be considered for reporting to JCAHO's Sentinel Event
Database to expand the knowledge base about the scope and
characteristics of serious nosocomial infections, the factors that
lead to their occurrence, and effective strategies for prevention.
Multiple
root causes and risk reduction strategies
As
a result of the sentinel events arising from infections and in
response to the identified root causes, health care organizations
implemented various risk reduction strategies, including the
implementation of relevant clinical pathways for MRSA,
endometritis and urinary tract infection. These strategies
include:
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Revising
orientation and training processes and competency
assessments.
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Revising
equipment cleaning processes.
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Revising
handwashing procedures.
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Switching
to the use of single-use IV flush vials.
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Adding
waterless handrubs.
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Defining
supervisory expectations.
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Revising
critical care privileging and ICU admission criteria.
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Conducting
in-service and team trainings.
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Instituting
tracking systems.
CDC
issues new handwashing guidelines
On
Oct. 25, 2002, the CDC released new guidelines that advise the use
of alcohol-based handrubs in conjunction with traditional soap and
water and sterile gloves to protect patients in health care
settings. The recommendations come as part of the new Guidelines
for Hand Hygiene in Healthcare Settings, and reflect the
positions of the Healthcare Infection Control Practices Advisory
Committee and the Hand Hygiene Task Force (comprising members of
the Healthcare Infection Control Practices Advisory Committee, the
Society for Healthcare Epidemiology of America, the Association
for Professionals in Infection Control and Epidemiology Inc., and
the Infectious Diseases Society of America).
The
hand hygiene guidelines are part of an overall CDC strategy to
reduce infections in health care settings and to demonstrate that
organizations can help prevent the spread of germs from one
patient to another by improving hand hygiene. Information about
the guidelines is available from the CDC, APIC, SHEA and IDSA, and
promotional materials may be obtained from the CDC at www.cdc.gov.
"Clean hands are the single most important factor in
preventing the spread of dangerous germs and antibiotic resistance
in health care settings," says Julie Gerberding, M.D.,
director, CDC. "More widespread use of these [alcohol-based
handrub] products that improve adherence to recommended hand
hygiene practices will promote patient safety and prevent
infections."
JCAHO
plans to review its existing infection control standards and
survey process with the help of a newly appointed infection
control expert panel. One of the panel's goals is to support
organizations' patient safety efforts by lowering nosocomial
infection rates throughout the organization and in targeted
specific vulnerable populations such as surgical, intensive care
and immunosuppressed patients.
Joint
Commission recommendations
JCAHO
recommends that health care organizations:
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Comply
with the CDC's new hand hygiene guidelines.
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Manage
as sentinel events all identified cases of death and major
permanent loss of function attributed to a nosocomial
infection (i.e. except for the infection, the patient would
probably not have died or suffered loss of function). Note:
This recommendation does not require any change in
current surveillance methodology (see the "IC"
standards in your JCAHO accreditation manual).
Resources
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NNIS
definition of nosocomial infection—a localized or systemic
condition 1) that results from adverse reaction to the
presence of an infectious agent(s) or its toxin(s), and 2)
that was not present or incubating at the time of admission
to the hospital.
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Guidelines
for Hand Hygiene in Healthcare Settings – 2002,
Centers for Disease Control and Prevention, http://www.cdc.gov/.
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