ED Accreditation Update
Deadline nears for HAI NPSG
ED managers suggest doing a final checkup
While The Joint Commission has not introduced any new National Patient Safety Goals (NPSGs) for 2010, that doesn't mean the clock has stopped on the implementation of earlier goals. In fact, three requirements under Goal 7 relating to the prevention of health care-associated infections (HAIs) will go into effect Jan. 1, 2010. The requirements — NPSG 07.03.01, NPSG 07.04.01, and NPSG 07.05.01 — address, respectively, multidrug-resistant organisms (MDROs), central-line bloodstream infections, and surgical-site infections (SSIs). (Editor's note: The Joint Commission also has revised some of the 2010 National Patient Safety Goals, including the Universal Protocol. For more details, see Joint Commission Online — Sept. 9, 2009, which can be found at www.jointcommission.org/Library/jconline.)
A specific series of steps was laid out by the commission to help lay the foundation for compliance, notes Kelly Podgorny, RN, MS, CPHQ, a project director in The Joint Commission's Division of Standards and Survey Methods. These included oversight, coordination, ensuring there are adequate resources, assigning accountabilities, and developing a timeline. They were set out in specific milestones, with the final one being a pilot test in at least one hospital unit by Oct. 1, 2009.
Assuming your department has been following this roadmap, however, there still are steps you can take in the next few months to give your ED a final "check-up." In fact, say ED managers, these practices can be implemented for any requirement or standard. "We have a nurse who is specifically assigned for process improvement and constant ongoing surveillance of this nature," says Tim Almquist, MD, FACEP, medical director of the ED at St. Mary's Medical Center in Evansville, IN. "She is involved with retrieval of records, making sure that the staff are well educated; so it's a top-of-the-mind awareness to make sure we have taken care of issues related to infection."
For example, he says, his ED inserts central lines, and there are procedures in place for making sure conditions are as sterile as they can be, including sterile draping, cleansing of the skin with antiseptic solution, and having a minimal number of people in the room (usually just the patient, the doctor, and one assistant.) When using ultrasound guidance, the probe is covered with a sterile probe cover or a sterile glove. "We do this as an ongoing procedure, but there will certainly be an extra emphasis now to continually remind people that this is necessary," says Almquist. As the deadline date comes closer, he says, there will be an even greater emphasis on education: peer review, trauma morbidity review, nursing review, and roundtable meetings. "These will occur repeatedly and frequently," he says.
Bruce Auerbach, MD, vice president and chief of emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, MA, says, "There has to be retrospective monitoring of performance or, if you have a formal checklist, reviewing that." Auerbach says his staff are creating such a checklist for the new goal. "We did the same thing with conscious sedation," he says. "The checklist included such elements as vital sign monitoring and oxygen saturation monitoring."
The checklists are reviewed by Auerbach or the nursing director. "Where there are deficiencies, we address them," he notes. "If something was getting in the way of us being able to comply with the process, we'd find a workaround that would appropriately address the issue." For example, Auerbach's department already has redesigned how patient rooms are set up. "We found we had needle boxes too far from the bedside, and doctors and nurses were sticking themselves walking those four steps to the sharps," he says. "Now we have them stored at arms' reach."
Communication with physicians who are failing to follow proper procedure also is important, says Bruce Jones, DO, medical director at Doctors Hospital in Columbus, OH. As in other EDs, quality assurance nurses track data. "If we find certain physicians falling out with any of our measures, we go back and report to them," he says.
The discussion is not accusatory, says Jones. In fact, most discussions are generic. He might say, "We had two parameters that fell out." The talk is more informational, "so that this issue will be on their radar," Jones says. "We just keep reinforcing the message, if need be, and eventually they catch on."
While The Joint Commission has not introduced any new National Patient Safety Goals (NPSGs) for 2010, that doesn't mean the clock has stopped on the implementation of earlier goals.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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