Joint Commission may add report to IC standards
Panel outlines essential IC program elements
A landmark consensus report on the essential elements of a state-of-the-art infection control program is under review by the Joint Commission on Accreditation of Healthcare Organizations for possible inclusion in future standards, Hospital Infection Control has learned.
The consensus panel report provides something of a template for the modern infection control program, addressing a gamut of program functions and resources from surveillance to secretarial support. (See the report's recommendations, p. 54.) Convened by the Society for Healthcare Epidemiology of America, the consensus ad hoc panel included representatives of the Joint Commission, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and the Centers for Disease Control and Prevention. The report was recently published jointly in the American Journal of Infection Control and Infection Control and Hospital Epidemiology, the journals of APIC and SHEA respectively.1
"From the Joint Commission's perspective, this could potentially impact our standards," says Carole Patterson, RN, MN, associate director of standards at the Joint Commission in Oakbrook Terrace, IL. "While we don't want our standards to be more prescriptive, we might need to take one or two or three things out of these recommendations and make specific standards out of them. That's what we will need to find out from our advisory groups in the field."
While the Joint Commission has generally moved to less specific program requirements to allow flexibility in achieving desired outcomes, the panel's recommendations regarding employee health programs, for example, constitute an area that may warrant new standards, she says. The panel outlined a strategy for cooperation between infection control and employee health departments, calling for routine medical examinations and post exposure management of workers to protect both staff and patients from infectious diseases.
"The one that we have the least amount of specific standards on is the employee health piece," Patterson says. "While our standards for infection control talk about applicability of these standards to patients, visitors, medical staff, and volunteers, there is nothing specific about the concept of managing the health of the employee group."
The report coincides with ongoing discussions at the Joint Commission about addressing employee health issues, including suggestions from a committee on health care safety stating that new standards are needed to protect caregivers.
"All of this happened at the same time, and the publication of this [report] is certainly going to be opportune," Patterson says. "We have this evidence-based consensus process that was used to define these recommendations. So we are going to look at our standards, and share the [report] with all of our advisory groups. That will allow us to develop any changes to the standards that are warranted and have them ready for subsequent editions of all of our manuals."
The consensus panel cites an abundance of data linking nosocomial infections with excess morbidity and mortality, and prolonged hospital stays. Also referenced is a substantial body of literature confirming that effective infection control activities result in fewer infections, improved patient survival, decreased morbidity, and shorter duration of hospitalization.
"In today's managed care marketplace, direct and indirect costs of care have an impact on the competitiveness, and perhaps survival, of the healthcare system or hospital," the consensus panel emphasizes. ". . . Programs that prevent nosocomial transmissions from healthcare workers to patients provide important cost savings for the institution and the healthcare insurer. Similarly, maintenance of employee health, avoidance of infection-related absenteeism, and prevention of healthcare worker claims concerning unsafe working conditions are important health and safety goals for the healthcare system and also may provide cost savings."
Tracking a moving target
Amid the ongoing changes in health care delivery - and related concerns that infection control might be subsumed within broader quality enhancement programs - the report serves in part as a consensus definition of an evolving field.
"To me there are two purposes to the document," says Candace Friedman, BS, MT(ASCP), MPH, CIC, the panel's APIC representative. "One is to just to come out officially as the professional organizations and say this is what we think a program should look like. But on a more practical level for an infection control person - regardless of where they fit in the organization - it's to help them think through what they need."
An infection control professional in the University of Michigan Health System in Ann Arbor, Friedman evaluates her program annually to keep up with changes in health care.
"You constantly have to change, but you need a basic framework to work from, so this I think will help people work things through," she says.
This consensus paper focuses on the requirements and activities of infection control programs in hospitals, leaving to a future panel the task of outlining infection control program needs beyond the hospital setting. (See related article in Healthcare Infection Prevention supplement, inserted in this issue.) While such trends have been much discussed, the panel underscored the continuing importance of infection control programs within hospitals.
"Despite shorter hospital stays and a decreasing census, there is, in fact, an increased potential for nosocomial infections due to the changing demographics of the population and new, increasingly invasive technology," the panel concluded. "Patients in hospitals will be sicker; there will be new antibiotic-resistant microorganisms; there will be new infectious diseases. Thus, the need for infection control as a specialty practice in the hospital will continue to increase."
Rethinking the old ratio
With ongoing interest in staffing levels and downsizing trends, the panel faced a critical issue regarding the traditionally suggested ratio of one ICP per 250 beds for an effective program. Many observers have suggested for years that infection control staffing levels should be greater than that ratio, which came out of the CDC SENIC study.2 The panel noted that the amount and complexity of the ICP's work has grown due to increased severity of illness of the patient population and more health care delivery beyond the hospital.
"Therefore, the old ratio of one ICP per 250 beds is no longer adequate, because the notion of a ratio tied to beds is now insufficient to define the scope of the work of an ICP," the panel concluded. "In most acute-care hospitals today, the scope of work of ICPs is much greater than that provided by the old ratio."
The panel did not, however, suggest a new staffing formula or ratio, recommending instead that personnel resources for infection control and epidemiology in hospitals should be proportional to the size, sophistication, case mix, and estimated risk of the populations served by the institution. The panel discussed using patient discharges rather then hospital beds to devise a new ratio, but ultimately decided the differences were too great among various hospitals, notes panel chairman William Scheckler, MD, hospital epidemiologist at St. Marys Hospital Medical Center in Madison, WI.
"There are a lot of people that would like us to come up with some different numbers," he says. "One ICP to 250 beds is really archaic. If you really want to do a good job with the program, you probably need a ratio that is tighter than that, but we specifically avoided [a new ratio] because we thought it was too simplistic."
Overall, the report is designed to reflect the best of current practice rather than an ideal rarely achieved by infection control programs, he adds.
"Some of the 23 recommendations are general in scope, but if you do all of the things listed here, you will be at the current state of a quality program," he says. "We designed these with the notion that no matter what the size of the hospital and the amount of activity it had, this ought to be doable for virtually everyone."
In that regard, the consensus report could be "carefully exploited" by infection control professionals who take it before their respective hospital committees and administrators seeking program upgrades or additional resources to meet the recommendations, Patterson adds.
"It could give them a lot more visibility," she says.
References
1. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Infect Control Hosp Epidemiol 1998; 19:114-126.
2. Haley RW, Culver DH, White J, et al. The efficacy of infection surveillance and control programs in preventing outbreaks of nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121:182-205.
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