Assessing JCAHO’s core measures for surgery
Standards for SSIs could be in place this year
Of the 25 new ORYX core measures defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, some of the most unsettling questions concern the area of surgical procedures
and complications.
Among the most troubling issues is the requirement that selected surgery patients be screened for surgical site infections (SSIs) within 30 days of surgery. The surgery measurements also include the timing for administration of preventive intravenous antibiotics. Both continue to raise questions in the medical community.
Many wonder how to handle the data reporting on SSIs so that the results are fairly assessed. Should there be a prescribed method for follow-up? Are postcards effective? Should someone be calling each patient? For hospitals with an already active directive for post-discharge surveillance, there are bound to be a greater number of infections reported. For those who do not proactively pursue these data, the numbers for SSIs will be much smaller, since there is no record of them.
"It’s a real problem area," says Paula Swain, RN, MSN, CPHQ, of Swain & Associates, in St. Petersburg, FL. "Shorter lengths of stay aren’t helping it either." Swain says there are three
factors that really affect this:
1. A huge trust issue — doctors are coming forward, and if the doctor or the staff haven’t followed through, there could be "fallout" into the physician’s credentialing file.
2. Quality control — people may say they’re doing the post-op interview, but if there’s no response from a patient, it’s hard to know if it’s because the interview wasn’t completed or the patient had no problem.
3. Aggregate analysis — can you be sure you have all the data and they are real and accurate?
Swain advises hospitals to address those problems by "using infection information to see what exactly you need to address and finding a physician champion and asking him or her to help devise a data collection methodology."
Sharon Springer, project director in the division of research at the Joint Commission, explains that JCAHO is in the process of putting together the technical specifications for the ORYX measures. "We’ve started with the acute myocardial infarction measures," she explains. "Then we’ll go on to pneumonia, and the third will be for surgical procedures and complications. We’re doing these specifications taking one measure at a time."
Springer says JCAHO is doing literature searches and looking at post-discharge surveillance methods. "We want to make sure we can identify the method that gives us the best quality of data," she says. "At this point, I don’t know if there is any one best method. But we hope to standardize this by the end of the year."
Laura Harrington, practice director for external peer review at the Marblehead, MA-based Greeley Company, a consulting company which provides JCAHO survey preparation training, suggests that "to establish objective criteria, hospitals might start by looking at the factors that influence infection rates, such as clean vs. dirty procedures, instrumentation, surgical technique, and even the operating room environment."
Harrington says there are different structures for this in different hospitals, but recommends having an epidemiologist in charge of infection control. "When setting up a program to track infections, it’s necessary to look at several criteria," including:
total number of procedures;types of procedures;
the physician involved;
the surgical team;
the room in which the procedures took place ("Look at the trend," she says. "Is it always room #13?");
type of procedure;
clean vs. dirty cases (such as colon resections).
"It’s important when measuring all this to drill down hard on this kind of data," she emphasizes.
The ORYX measures also include the administration of surgical prophylactic antibiotics.
"Undesirable patterns or variations in the data may warrant investigation into prophylactic antibiotic practices," state the measure’s description. "Studies that have evaluated these practices commonly identify inconsistencies in the time of the antibiotic administration in relation to surgery. To support examination of the relationship between the timing [of the antibiotic administration] and the SSI, hospitals are encouraged to participate in the surveillance and prevention of SSIs for the same surgical procedures."
"This is a very complicated issue," says Swain, "because administering the antibiotic is a highly integrated activity involving nursing, pharmacy, anesthesia, doctors, recovery room people, etc. They’ve got to get everything in order about 30 minutes before the knife falls. But anyone who has worked in an operating room [OR] knows that the scheduling is fragile." She points out that getting the right drug to the right practitioner who then gets it to the right patient at the right time is a real study in logistics.
"But hospitals are now trying to streamline
the process," Swain says. "Some are delegating someone who can set up the process so the doctor can administer precisely when necessary."
Harrington suggests that hospitals take a look at the overall outcome. "Are you seeing an advantage to giving antibiotics pre-surgically? We’re talking cost here. Of course, it’s important to do it for high-risk patients such as those with comorbidities or cases that are typically more high risk, such as emergency abdominal surgery where there is no time to clear the stomach and bowel."
In some of the best practice scenarios, she says, "hospitals today are developing antibiotic task forces to look at outcomes and make a determination about administering these prophylactics based on types of cases."
There are a lot of factors that influence post-surgery infection. "When looking at infection control data for purposes of peer review," says Harrington, "take these factors into consideration. There is so much early discharge and home health care that you can’t place all the ownership for these cases on the physician." She adds that sometimes the situation can become unnecessarily punitive. "Saying that the physician is in control is not always fair in today’s health care environment.
Harrington says that peer review should not be done punitively. "There should be more help, more mentoring. Have a senior physician scrub and oversee surgeries where there are questions about the doctor or the OR staff."
Cases should be benchmarked against the national standards for that particular surgical procedure. For instance, we should look at the infection rates for open heart surgery across the country."
She notes that some hospitals create multidisciplinary infection control teams. They might even include maintenance managers to check the air filters in an OR and make sure other maintenance matters are up to speed. "It’s critical to trend infection rates over time. Are the numbers really telling you something, or are they just too small to be measured at this time?"
While JCAHO is committed to reducing the number of SSIs, many questions remain regarding how to look at the infection numbers. Will hospitals be able to choose the procedures to be measured? Can that be done fairly? Will it produce quality data? How safe is the doctor’s position when an infection issue arises?
Until precise measurement methods are prescribed by JCAHO, these questions remain unanswered.
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