The Joint Commission Update for Infection Control
JC deadline on MDRO goal is Jan. 1, 2010
The Joint Commission's 2009 patient safety goal regarding multidrug-resistant organisms (MDROs) includes the following key provisions and deadlines:
• Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals. This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant Enterococci (VRE), and multiple drug-resistant gram-negative bacteria.
This requirement had a one-year, phase-in period that includes defined expectations for planning, development, and testing (milestones at three, six, and nine months in 2009, with the expectation of full implementation by Jan. 1, 2010.) As of Jan. 1, 2010, hospitals should have addressed the following issues to comply with this goal.
• Based on the a risk assessment, the hospital educates staff and licensed independent practitioners about health care-associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter. The education provided should recognize the diverse roles of staff and licensed independent practitioners and be consistent with their roles within the hospital.
• The hospital implements a surveillance program for multidrug-resistant organisms based on the risk.
• The hospital measures and monitors multidrug-resistant organism prevention processes and outcomes including the following:
— Multidrug-resistant organism infection rates using evidence-based metrics
— Compliance with evidence-based guidelines or best practices
— Evaluation of the education program provided to staff and licensed independent practitioners
• The hospital provides multidrug-resistant organism surveillance data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.
• The hospital implements policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).
• When indicated by the risk assessment, the hospital implements a laboratory-based alert system that identifies new patients with multidrug-resistant organisms. The alert system may be either manual or electronic or a combination of both of these methods. The alert system may use telephones, faxes, pagers, automated and secure electronic alerts, or a combination of these methods. In addition, if indicated by the risk assessment, the hospital implements an alert system that identifies readmitted or transferred multidrug-resistant, organism-positive patients.
The Joint Commission's 2009 patient safety goal regarding multidrug-resistant organisms (MDROs) includes the following key provisions and deadlines:You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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