The Joint Comission Update for Infection Control
Check lists check out A-OK with Joint Commission
Controversy aside, simple tools vital to improving compliance
The seemingly benign use of a checklist to ensure infection control measures are followed during a clinical procedure erupted in controversy recently when a federal agency questioned whether one such program fell into the category of human research. That situation has since been resolved, but the issue may arise again as hospitals seek ways to simplify complex information and standardize critical tasks. Where does the Joint Commission stand?
"The Joint Commission clearly recognizes that improving and changing the processes of care within health care organizations is difficult and sometimes complicated," says Peter Angood, MD, vice president and chief patient safety officer for the accreditation agency. "The use of checklists does present the potential for simplifying some of the processes and to serve as reminders on a regular basis for some of the common issues the providers need to take care of."
Indeed, a Joint Commission survey recently resulted in favorable reviews for a hospital that is using a checklist to guide care and prevent ventilator-associated pneumonia (VAP). "The surveyor seemed very pleased by the initiative," says Joseph DuBose, MD, assistant unit chief of trauma services at Los Angeles County/University of Southern California Hospital. "This is something that we technically should be doing every day anyway; but since we are marking it on a checklist that is being completed and collated, we ran it through our IRB [institutional review board] and they gave us a waiver of [patient] consent. It is something we are doing as a standard of care, and we remove all patient identifiers."
In the aforementioned case, the Office for Human Research Protections (OHRP) shut down a Johns Hopkins program that had pushed catheter-related bloodstream infection rates to zero at many participating intensive care units in the Michigan "Keystone" project. Poised to expand nationally, the program was thrown into limbo after questions were raised about informed consent to patients and the use of a checklist for proper catheter insertion. That decision recently was reversed by the Department of Health and Human Services (HHS). "We do not want to stand in the way of quality improvement activities that pose minimal risks to subjects," Ivor Pritchard, MD, acting director of OHRP, said in the statement. "HHS regulations provide great flexibility and should not have inhibited this activity."
Be proactive
The HHS decision bodes well for Dubose's program and similar efforts, though he advises being proactive and getting IRB consent waivers in place before implementing a checklist program. "We learned from the Hopkins issue," he says. [The checklist] is a very simple thing a spreadsheet. This is not rocket science. We needed to document that we were doing the things we say we are doing."
Well, maybe it doesn't take the "right stuff" of the space program, but DuBose uses another aviation analogy to underscore the common-sense nature of approach. "Just as a good pilot would never take a plane into the air without an adequate pre-flight checklist, we have utilized our quality checklist to ensure that we are guarding daily against potential adverse events," DuBose says. "The checklist is a surprisingly simple device."
A paper format is used, and most of the boxes on the checklist are simple yes/no answers, such as whether the patient had a "sedation holiday" within the last 24 hours, whether the patient was assessed for weaning, and whether the respirator circuit was examined for gross contamination. "Before-and-after" data were collected in a recently published study to determine if the checklist improved compliance with 16 prophylactic measures for VAP, deep venous thrombosis or pulmonary embolism, central line infection, and other ICU complications.1,2
A multidisciplinary team assessed compliance a month before the checklist was implemented, and for three months after the implementation. Results were impressive: The tool improved compliance with every measure that wasn't already at more than 95% compliance. For example, compliance increased from 35.2% to 84.5% for elevating the head of the bed more than 30 degrees, one of the VAP prevention measures. In addition, central line duration over 72 hours decreased from 62.4% to 52.8%, and ventilator duration over 72 hours decreased from 74% to 61.7%.
Betting a bundle
The data that are continuously collected and analyzed in the program include the following VAP prevention bundle compliance measures:
- percentage of head of bed elevation 30 degrees or greater;
- stress ulcer disease prophylaxis;
- deep vein thrombosis (DVT) prophylaxis;
- sedation holiday;
- glucose control type and glucose range;
- central line catheter days and presence or absence of central line;
- documentation of weaning protocol evaluation;
- code status documentation;
- continuous subglottic suctioning;
- endotracheal tube fixation.
"Change always represents a challenge, but with the right efforts and the right champions of these causes, effective tools can be developed and utilized without representing a burden on the organization," says DuBose. "The ICU fellow has been the primary collector, guardian, and critic of the data, proving that in the modern era of health care, we all have to be quality professionals."
Implementation of a daily quality rounding checklist should be based on best-evidence practices applicable to the patient population in question, says DuBose. "It should also include multidisciplinary input and periodic review, and be practical and functional," he says. The checklist allows the bedside team to make real-time correction of deficiencies. "The bedside portion is both simple and effective," says DuBose. "If for some reason DVT prophylaxis has not been administered in a complex ICU patient with multiple medications, or has not been started yet because they had a liver injury, for example, it can immediately be corrected."
The data are recorded on the sheet, and later that day entered into an Excel spreadsheet, with data analyzed on a monthly basis. "If for some reason we see our compliance lower for the month with any respective measure, we can then focus on why that happened and introduce corrective action as needed," says DuBose. Nearly every aspect of the project benefited from multidisciplinary input, including glucose control efforts, he adds. "Without the discussion and input from our nursing colleagues, we would not have recognized the need for further education of the nursing staff to improve glucose control in our ICU," he says.
Teach one, teach many
Currently, the organization's biggest challenge is to teach and educate all staff physicians, nurses, respiratory care therapists, ancillary personnel, and students. "We are one of the largest teaching institutions in the country and have a full array of students from various disciplines who rotate continuously throughout the surgical ICU," says Shirley Shot Nomoto, RN, MSN, trauma program manager.
The trauma interdisciplinary teams conduct daily rounds with specific emphasis on education in areas of quality improvement and patient safety. At the monthly trauma quality improvement committee meeting, measures are reported to the leadership council, medical staff, nursing, lab and pathology, radiology, trauma staff, and ancillary personnel.
"Areas of success are discussed, as well as areas needing improvement," says Nomoto. "Since we have interdisciplinary and collaborative membership at this forum, corrective actions are discussed, including recommendations for improvements."
At one recent meeting, the hospital's leadership council recommended implementing reduction of central line infections as a hospitalwide project for all ICUs. "Physicians and nurses worked together to review the process of reducing errors in the placement of central lines," says Nomoto. "They focused on hand hygiene, maximum sterile barrier precaution, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of central line necessity."
After data on compliance are analyzed, recommendations for improvement are made by the committee members. "Several members participate on both the interdisciplinary teams and the trauma QI committee, so information is communicated accurately and timely," says Nomoto.
Reference
1. DuBose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: The impact of a daily quality rounding checklist. J Trauma 2008; 64(1):22-29.
2. Kusterbeck S. Daily rounding checklist improves compliance. Hospital Peer Review 2008; 33:56.
The seemingly benign use of a checklist to ensure infection control measures are followed during a clinical procedure erupted in controversy recently when a federal agency questioned whether one such program fell into the category of human research.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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