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CMS Report: AOs missing fire safety and IC deficiencies during survey

Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious life safety, environment of care, and infection control issues the federal agency says they are still missing during surveys.

In the newest report to Congress assessing AO performance, CMS says the overall disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, says the report. CMS is particularly concerned that AOs are missing key Life Safety Code® (LSC) deficiencies, with fire and smoke barriers, sprinkler systems, electrical systems, hazardous areas, and means of egress taking the top five categories for missed problems in fire safety at hospitals.

Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 LSC, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.

This is on top of TJC’s response to criticism in the report released last year. TJC began pushing its own surveyors to cite every life safety deficiency, no matter how small, Allen says.

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Hospitals Can Improve Their Infection Prevention Strategies, Study Finds

By Jay Kumar

A new review of 144 studies found that healthcare-associated infections (HAI) can be reduced by as much as 55% through the implementation of evidence-based infection prevention and control strategies. Published in the Society for Healthcare Epidemiology of America’s (SHEA) journal Infection Control & Hospital Epidemiology, the study points out that hospitals can do much more to reduce infections.

“Healthcare-associated infections come at a considerable expense to patients and families, but also cost the U.S. healthcare system an estimated $9.8 billion each year,” said Keith Kaye, MD, MPH, president of SHEA, in a release. “There have been tremendous advancements in developing strategies to prevent and control HAIs. This study demonstrates a need to remain vigilant in identifying and maintaining key infection control processes to ensure they can be optimally used to prevent infections, which in some cases are life-threatening.”

The review was conducted by researchers from University Hospital Zurich and Swissnoso, the Swiss National Center for Infection Control, who examined 144 studies published worldwide (including 56 done in the U.S.) between 2005 and 2016 to determine the proportion of HAIs prevented through infection control interventions in different economic settings. The papers reviewed studied efforts designed to prevent at least one of the five most common HAIs using a combination of two or more interventions, including education and surveillance or preoperative skin decolonization and preoperative changes in the skin disinfection protocol.

The interventions produced a 35% to 55% reduction in new infections, the researchers found. The largest effect was for prevention of central line-associated bloodstream infections; other infections studied included catheter-associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, and healthcare-associated pneumonia.

The study’s lead author, Peter W. Schreiber, MD, a researcher from the Division of Infectious Diseases and Hospital Epidemiology at the University Hospital of Zurich, said the review’s results show that hospitals are not doing enough to fight infections. “Our analysis shows that even in high-income countries and in institutions that supposedly have implemented the standard-of-care infection prevention and control measures, improvements may still be possible,” he noted. “Healthcare institutions have a responsibility to improve quality of patient care and reduce infection rates by effectively implementing customized multifaceted strategies and improv[ing] patient outcomes.”

Last Flu Season Led to 80,000 Deaths

Federal public health officials are urging everyone six months and older to get vaccinated against influenza in the wake of last winter’s severe flu season, which resulted in a record high of 900,000 hospitalizations and more than 80,000 deaths.

“Last season illustrated what every public health official knows—influenza can be serious in people of all ages, even in the healthiest children and adults,” said U.S. Surgeon General Jerome M. Adams, MD, MPH, at a news conference Thursday. “It is critical that we focus national attention on the importance of influenza vaccination to protect as many people as possible every season.”

The press conference was held to highlight what officials see as disappointing flu vaccination coverage estimates in recent years. Over the last several flu seasons, coverage among children aged six months to 17 years has remained steady but fallen short of national public health goals, which are 80%. During the 2017-2018 season, coverage dropped by 1.1 percentage points overall, with young children aged six months to four years with a decline in vaccination coverage of 2.2 percentage points. Even with the drop, vaccination coverage was highest in this age group (67.8%) and lowest among children aged 13 to 17 years (47.4%).

The CDC estimates that 78.4% of healthcare personnel were vaccinated during the 2017-2018 season, up 15% since the 2010-2011 season. Vaccination coverage was highest (91.9%) among healthcare workers in hospital settings and lowest (67.4%) among those working in long-term care settings. The CDC’s FluVaxView site has a more in-depth breakdown of these statistics.

Joint Commission Revises Scoring for IC Standard

The Joint Commission (TJC) announced scoring changes for its IC.02.02.01 standard, which requires facilities to reduce infection risk associated with medical equipment, devices, and supplies. The standard was included on TJC’s list of most-cited standards.

In the latest post in its 4-1-1 on Survey Enhancements series, TJC focused on high-level disinfection and sterilization. Effective as of September 1, the revisions are meant to hone in on the process steps that pose the highest risk to patients. TJC plans to monitor the revisions over the next several months to ensure scoring is consistent.

For example, IC.02.02.01 was previously scored on the finding of visible bioburden and dried blood of instruments. Now surveyors will cite hospitals if the wiping or flushing of soiled instruments isn’t observed during a case in the operating or procedure room and it’s clinically appropriate, or if an item that’s ready to be used on a patient is visibly soiled.

Standard findings recorded before September 1 will not be removed. Hospitals that are in the clarification window or preparing an Evidence of Standards Compliance report should document their compliance with the revised scoring guidelines.

Be ready for surveyor focus on dialysis

Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance. Which means you should, too. Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD). A single procedure takes about several hours, during which a patient’s blood is filtered and cleaned inside their body (peritoneal dialysis) or outside of it (hemodialysis). There are many possible points of failure in a dialysis treatment, and infections are a major risk. That’s why surveyors are being extra stringent about compliance, say Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, an associate of the company. Both are Joint Commission alumni.

The Joint Commission isn’t delicate when telling people what surveyors are looking for, nor when citing them. Three focus areas have come up repeatedly at Joint Commission presentations: sterile compounding, pain standards, and dialysis. And there’s been a corresponding uptick in scoring for all of these areas in 2018.

“When The Joint Commission indicated that dialysis is going to be a focus area, the field should be prepared for more detailed surveys than we have seen in the past,” Cowel says. “Take this as a heads-up notice. We have seen an uptick in dialysis scoring; in fact, we have seen scoring in dialysis in more than half of the survey reports we have seen in recent months.”

There are plenty of examples that hospitals can focus on, Good notes.

“Note that hospitals that are providing inpatient hemodialysis or contracting for the service need to pay attention to the room where dialysis is being provided, particularly if [it’s] not in the patient’s room,” Good says. “I have seen rusty air conditioning units, soil around the unit, blood spots on the floor, tiles missing behind the dialysis machine, wet towels on the floor, [and] sinks designated solely for hand hygiene being used for emptying bottles of concentrate that were used for patient dialysis.”

Cowel and Good have seen numerous findings in dialysis in recent months, including the calibration of the pH/conductivity meter not being tested per the manufacturer instructions for use (IFU). Other common findings they’ve seen include:

  • Not having an eyewash station when bleaching of a portable dialysis machine is done in a patient room.
  • Not conducting a special check of a patient’s catheter that was locked with high-concentration anticoagulant, in clear violation of the hospital’s policy on high-risk medications.
  • Improper management of medicines administered during or before dialysis treatment. For example, a dialysis nurse transporting multidose vials of heparin, despite the fact they should be considered single-dose vials.
  • Not documenting vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, per hospital policy.
  • Not recording that consent was received from a new dialysis patient or that a conversation about risks and benefits occurred.
  • Not verifying that the amount of fluids or medications administered to a patient match the medical order. For example, if a nurse administers 100cc normal saline (NS) instead of 200cc NS per the protocol order set for hypotension during dialysis.

More on dialysis compliance will be in the upcoming edition of Briefings on Accreditation and Quality