Category Archives: Hospital Accreditation

JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

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Well, I am not yet quiet finished on trying to tell you all about the Joint Commission International (JCI) Standard MCI.20.1. In this post I wish to share on the what, why and how about utility system management and utilisation review, the remaining two other important parts of the improvement activities of a hospital by which the hospital attempts to aggregate data to provide a profile of the hospital over time which then will allow the comparison of the hospital’s performance with other hospitals. Utility system management and utilisation review are the last of the four improvement activities of a hospital identified in the intent statement of the JCI Standard MCI.20.1.

My intent is to discuss in this post:

  1. in brief about utility system management and utilisation, as this single post cannot cover all about utility system management and utilisation review; and
  2. more importantly to highlight to management and hospital leaders when one is entrusted to champion the course of all the JCI Management of Communication and Information (MCI) standards, the probability when a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, is expected to present the case of a process for both utility system management and utilisation review, when surveyors examine evidence under JCI Standard MCI.20.1 ME 1 the process to aggregate data from utility system management and utilisation review at a hospital in response to identified user needs  – in order to satisfy the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”.

Before I go on, my intent (ii) above is true for aggregate data from risk management as well as for infection prevention and control as  I have posted in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” and in JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” respectively (each of these links will open in a new tab of your current browser window).

Medical insurance in Malaysia, provided by insurance companies and banks which provide a few plans for anyone to choose from based on own budget and needs, functions as a form of protection to cover unforeseen expenses arising from illness, injury or accidents – which can be very expensive, especially if hospitalisation and / or surgery is required.

Malaysian readers will already be aware that insurance companies in Malaysia provide coverage plans for medical services for their clients at any hospital. Malaysian readers will also be aware that health insurance companies in Malaysia request medical reports for approval of claims to confirm that any insurance plan provides for the coverage of medical services rendered.  While this is true for Malaysia, I have never known the need for utilisation review to review a request for medical treatment in Malaysia.

Let us now assume that utilisation review by insurance companies is practised in your settings and take this discussion from there.

Utilisation review refers to reviews of past medical treatment, for example in the United States where insurance companies perform an utilisation review to review a request for medical treatment. I have below a cropped infographic which provides the anatomy of health insurance coverage in the U.S. (click the infographic which will open in a new tab of your current window for a larger view).

health-insurance infographic croppedThe purpose of the review is to confirm that the plan provides coverage for a patient’s medical services typically found on an insurance policy’s precertification list.  The utilisation review also help an insurance company minimise costs and determine if the recommended treatment is appropriate. The company could deny coverage as a result of a utilisation review.

What about care based on medical necessity in the future, for example for approval for additional treatments while you’re undergoing medical care (a concurrent review)?

Utilisation management is the process of preauthorisation for medical service as it refers to requests for approval of future medical needs, and this term is often used interchangeably with utilisation review since both utilisation review and utilisation management involve the review of care based on a medical necessity.

Thus, the term “utilization review” refers to a retrospective review – the review of treatments or services that have already been administered, and involves the review of medical records in comparison with treatment guidelines. The insurance company uses the results to approve or deny coverage a patient has already received, and the information can also be used in a review of the insurance company’s coverage guidelines and criteria for a particular condition. The insurance company looks through a patient’s medical records for evidence of appropriate low-cost health care. It then compares this patient’s medical records to those of other patients with the same condition. It will then review, and possibly revise, its treatment guidelines and criteria to ensure that the provided care is adequate, and medically current, for the condition.

Therefore, hospitals get actively drawn into the process of the collection of information, including the symptoms, diagnosis, results of any lab tests and list of required services by providing clinical documentation that supports their treatment decisions.

I think Health Information Management (HIM) / Medical Records (MR) practitioners have a clear role in utilisation review if their setting is appropriate. HIM /MR practitioners will need to be aware (i) of the existence of an utilisation review policy and the relevant processes, and (ii) to contribute to good records keeping since a high retrieval rate of medical records can be expected when patients’ medical records are examined for evidence of appropriate low-cost health care and for comparison of treatment among other patients’ medical records for a similar condition, by the insurance companies.

I think to round-up the discussion on utlisation review, it is safe to justify then if a hospital –  which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs when data is aggregated for utilisation review.

Now, allow me to move forward to present utility system management.

Hospitals have different medical equipment and utility system needs based on their mission, patient needs, and resources. Regardless of the type of system and level of its resources, a hospital needs to protect patients and staff in emergencies, such as system failure, interruption, or contamination. The safe, effective, and efficient operation of utility and other key systems in the hospital is essential for patient, family, staff, and visitor safety and for meeting patient care needs.

The business of utility system management in a hospital is about:

  1. a constant potable water and electrical power supply
    1. first identifying  the areas and services at greatest risk when power fails or water is contaminated or interrupted, secondly to reduce the risks of such events and thus ensuring an uninterrupted (24-hour basis, every day of the week) source of clean water and electrical power, and when necessary regular and alternative sources of power and water must be identified that can be sourced in emergencies
    2. emergency processes to protect hospital occupants in the event of water or electrical system disruption, contamination, or failure
    3. testing its emergency water and electrical systems on a regular basis appropriate to the system and the results documented
  2. regular inspection and maintainance of electrical (example, frayed electrical lines), water, waste (example, waste contamination in food-preparation areas), ventilation  (example, inadequate ventilation in the clinical laboratory), medical gas  (example, oxygen cylinders that are not secured when stored, or leaking oxygen lines, and other key systems that all pose hazards and when appropriate, they must be improved
  3. designated individuals or authorities monitor regularly the quality of water received from a source, and the water used in chronic renal dialysis
  4. collection of monitoring data for the utility system management program
    1. monitoring essential systems helps the hospital prevent problems
    2. monitoring data that are collected and documented are used to plan the hospital’s long-term needs on system improvements and in planning for upgrading or replacing utility systems

It is almost to the end of this rather long post.

I think it is also safe to justify from the foregoing discussion on utility system management that when a hospital – which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs, when data is aggregated for utility system management.

This post ends what I wish to share all about the JCI Standard MCI.20.1, ME 1.

References:
Barbara JY 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA

Diane, LK 2007, Applying quality management in healthcare : a systems approach, 2nd edn, Health Administration Press, Chicago, Illinois, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA

Pre-sedation assessment documentation

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Image credit: patientsafetyauthority.org/

My purpose of including this post about pre-sedation assessment is because it warrants a provision to check for compliance against the Joint Commission International (JCI) Standard ASC.3 which requires documentation of a pre-sedation assessment and monitoring of the patient during administration of moderate or deep sedation or anesthesia using the Medical Records Review Tool (MMRT) form, similar to the situation  when the JCI Standard AOP.1.4. which also examines the documentation in a medical record during a Medical Records Review (MMR) session.

Sedation (JCI, 2011 p.245) at three (3) levels of sedation – minimal sedation (patient can respond to command), moderate sedation (depressed level of consciousness; patient can breathe without assistance, respond to pain, and follow some commands. protective reflexes are maintained),  and deep sedation (patient cannot be easily aroused, but can respond after repeated stimulation. respiration may need to be supported), is “the administration of medication to an individual, in any setting, for any purpose, by any route to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure.” as defined in the Glossary  of the JCI Hospital Acceditation Standards For Hospitals, 4th Edition Manual.

So what needs to be checked for compliance against this JCI Standard ASC.3, which states that “Policies and procedures guide the care of patients undergoing moderate and deep sedation.” in the medical record of a patient due for the purpose of conducting an operative or other procedure on the patient.” and specifically its Measurable Element (ME) 3 which requires that “There is a pre-sedation assessment performed that is consistent with organization policy to evaluate risk and appropriateness of the sedation for the patient.?

Such aforesaid policies and procedures of a hospital must define the scope and content of a pre-sedation assessment to guide the care of patients undergoing moderate and deep sedation. A responsible qualified individual competent in (a) techniques of various modes of sedation, (b) appropriate monitoring, (c) response to complications, (d) use of reversal agents, and (e) at least basic life support, conducts a pre-sedation assessment of the patient to ensure the planned sedation and determine the appropriate level of sedation for the patient that is consistent with hospital policy to evaluate risk and appropriateness of the sedation for the patient. Pre-sedation assessment is important in particular for moderate and deep sedation levels because the degrees of sedation occur on a continuum, and a patient may progress from one degree to another, based on the medications administered, route, and dosages.

A pre-sedation assessment will include the following to ensure a patient’s ability to maintain protective reflexes; an independent, continuous patent airway; and the capability to respond to physical stimulation or verbal commands :

a) how planning will occur as I covered in the post Anaesthesia plan in the patient’s medical record (this link will open in a new tab of your current browser window), including the identification of differences between adult and paediatric populations or other special considerations for patients with significant underlying medical conditions (e.g., extremes of age; severe cardiac, pulmonary, hepatic, or renal disease; pregnancy; drug or alcohol abuse, uncooperative patients, morbid obesity, potentially difficult airway, sleep apnea);

b) documentation required for the care team to work and to communicate effectively;

c) informed consent must be obtained for all non-emergency procedures and special consent  for example when informed consent is obtained moments before a patient will undergo a major, potentially life-threatening or disfiguring procedure;

d) frequency and type of patient-monitoring requirements;

e) special qualifications or skills of staff involved in sedation process as I posted under the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current browser window); and

f ) availability and use of specialised equipment.

Recommendations on Pre-Anaesthetic Assessment , one of the six (6) Clinical Practice Guidelines (CPGs) of the Malaysian Society of Anaesthesiologists (MSA) recommends that  “A written summary of the pre-anaesthetic assessment, orders or arrangements should be explicitly and legibly documented in the patient’s anaesthetic record”.

Likewise, another MSA CPG – Recommendations for Standards of Monitoring During Anaesthesia and Recovery, makes special mention on sedation and recommends that (i) A patient who is to be given any form of sedation for a procedure should be assessed by a qualified medical practitioner and his medical status noted.”, and (ii) “A written record of the time and dosages of the drugs used must be kept as part of the patients records. This record must also note the monitored values of the patients vital signs( i.e. blood pressure, pulse rate. respiration, and oxygen saturation) .”

Examples of presedation assessment forms for adults and paediatrics with links from this post are as follows :

Adult Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

Paediatric Sedation Pre-Sedation Assessment Form example (this link will open in a new tab of your current browser window)

It is also possible to find pre-sedation assessment recorded in the anaesthesia record.

Before I close the discussion on pre-sedation assessment in this post, I like to recommend the following based on my experiences:

  1. a special, separate special pre-sedation medication form or the pre-sedation medication form printed on the reverse side of the anaesthetic record form or elements of the pre-sedation assessment included as part of the anaesthetic record form;
  2. team members of a MMR session must be briefed about (a) the pre-sedation assessment process compliance check for JCI Standard ASC.3 in the MMRT form, and (b) about the presence of a pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation;
  3. a medical record is just not complete if there is no pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation, so Health Information Management (HIM) / Medical Records (MR) practitioners must ensure a medical record for such patients is completed with a pre-sedation assessment record;
  4. reporting the presence of a  pre-sedation assessment form in a medical record for patients undergone pre-sedation assessment and monitoring during the administration of moderate or deep sedation is not enough just to satisfy the completion of the process of a MMR session but I believe it is beyond just checking for completeness of the medical record and merely to complete the  MMRT form;
  5. team members of a MMR session must be briefed not only to check for a pre-sedation assessment form in a medical record but also its completeness and team members must notify the MMR session team leader of any incompleteness found; and
  6. the team leader of a MMR session must record such observations of incompleteness found in the pre-sedation assessment form so as to make the MMR session report as value added as possible and to improve the quality improvement activities of the Anaesthesiology Department of the hospital.

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Children’s Hospital Central California, 2013, Paediatric Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.chccsedation.org/downloads/PreProceduralSP.pdf >

Darthmouth-Hitchcock Medical Centre, Adult Sedation Pre-Sedation Assessment Form example, viewed 5 January 2013 < http://www.dhmcsedation.com/as/downloads/PreAssessmentExample.pdf  >

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations on Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations for Standards of Monitoring During Anaesthesia and Recovery, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=180 >

Malaysian Society of Anaesthesiologists (MSA), 2013, Recommendations On Pre-Anaesthetic Assessment, viewed 5 January 2013 < http://www.acadmed.org.my/view_file.cfm?fileid=222 >

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

The frequency of data analysis

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A Health Information Management (HIM) / Medical Records (MR) practitioner at any HIM / MR department in any hospital knows pretty well how often his or her hospital has determined how often different sets of clinical and administrative data that are collected during or in the time closely surrounding the patient encounter, are aggregated and analysed at his or her department or in other relevant departments. Patient records, uniform billing information, and discharge data sets are the main sources of the data that go into the literally hundreds of aggregate reports or queries that are developed and used by care providers and executives in hospitals. The frequency depends on the activity or area being measured, the frequency of measurement, and the hospital’s priorities.

What can these data then tell you about the hospital and the care provided to its patients?

How can you process these data into meaningful information?

The number of aggregate reports that could be developed from patient records or other patient related information – example accounting information, is practically as you already know is limitless.

Data quality management programs are essential for clinical improvement. Thus, HIM / MR practitioners must realise there is a need for the continuous quality improvement to ensure the accuracy and completeness of data collection at their end.  HIM / MR practitioners frequently generate reports that yield data from their data collection. Such reports can then be used to help monitor patient outcomes and identify areas in which improved care is needed. However,  HIM / MR practitioners need to regularly run and act upon them to improve areas of missing or incomplete data. They must also ensure that standard operating procedures in data management processes are in place, remedy inconsistent data collection methods, or minimise missing paper records. So I guess that more training and onsite audits could help facilitate additional improvement in data quality and efficiency.

In the post Data must be aggregated, analysed, and transformed into useful information by expert individuals (this link will open in a new tab of your current browser window), I had outlined the importance of data analysis that must involve individuals who understand information management, have skills in data aggregation methods, and know how to use various statistical tools.

HIM / MR practitioners must ensure that data collection up-to-date (data currency) and must be able to relate the frequency of data analysis (timeliness) appropriate to a process under study and develop processes that match frequency of data analysis to meet the hospital’s requirements.

The categories of statistics that are routinely gathered by  HIM / MR practitioners in a hospital for data analysis include:

  1. Census statistics including the average daily census and bed occupancy rates from data collected in wards to reveal the number of patients present at any one time in a hospital.
  2. Discharge statistics like average length of stay, death rates, autopsy rates, infection rates, and consultation rates calculated from data accumulated when patients are discharged.

HIM / MR practitioners also participate in generating quality reports which may be used for the purpose of improving customer service, quality of patient care, or overall operational efficiency. Examples of aggregate data that relate to quality reports include:

  1. customer service – the average time it takes to get an appointment at a clinic and the average referral volume by the doctor
  2. quality of patient care -clinical laboratory quality control data may be analyzed weekly to meet local regulations, and patient fall data may be analyzed monthly if falls are infrequent, infection rates, unplanned returns to the operating room
  3. overall operational efficiency – cost per case, average reimbursement by Diagnosis Related Groups (DRG), and staffing levels by patient acuity

HIM / MR practitioners in a hospital routinely gather such data to produce easy-to-use ad hoc statistical reports and trend analyses reporting that is available with the hospital’s databases which gives them access to any number of summary reports based on the data elements collected during the patient encounter. Such statistics are frequently used to describe the characteristics of the patients within a hospital and also provide a basis for planning and monitoring patient services.

Here are some examples I can think of when a hospital determines how often data are aggregated and analysed, the frequency depending on the activity or area being measured, the frequency of measurement, and the hospital’s priorities.

The patient census application is needed daily to provide sufficient day-to-day operations staffing, such as nursing and food service. However, annual or monthly patient census data are needed for the facility’s strategic planning.

Hospital management often wants to know summary information about particular diseases or treatment from the disease and procedure index function generally handled as a component of the patient medical record system or the registration and discharge system. Examples of questions that might be asked are: What is the most common diagnosis in the hospital? What percentage of diabetes patients are of a particular ethic group? What is the most common procedure performed on patients admitted with gastritis (or heart attack or any other diagnosis)? Here the process under study is related to the frequency of data analysis of diseases and procedures and the retrieval of information is based on the International Classification of Diseases (ICD) and procedure codes that are collected and entered into discharge system on a daily frequency by  HIM / MR practitioners. Such summary information to meet the hospital’s internal requirements could be required for example on an ad hoc basis or daily or weekly or monthly period – which is the frequency of data analysis.

Another type of aggregate information that can be created on an ad hoc basis are register lists that generally contain the names, and sometimes other identifying information, of patients seen in a particular area of the hospital, for example numbers of patients seen in the emergency department or operating room.

Specialised trauma and tumor registries found in hospitals with high-level trauma or cancer centers are used to track information about patients over time and to collect detailed information for research purposes.

If your hospital is at the point of then what I have tried to bring in this post when (JCI, 2010 p. ) “the aggregation of data at points in time enables a hospital to judge a particular process’s stability or a particular outcome’s predictability in relation to expectations”, is truly relevant to the Joint Commission International (JCI) Standard QPS.4.1 which states that “The frequency of data analysis is appropriate to the process being studied and meets organization requirements.” if your hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status.

Nevertheless, regardless of the type of hospital you work at,  HIM / MR practitioners must perform the frequency of data analysis appropriate to the process being studied and ensure that the data analysis meets their hospital’s requirements.

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Wager, KA, Frances, WL & John PG 2005, Managing health care information systems : a practical approach for health care executives,1st edn, Jossey-Bass A Wiley Imprint, San Francisco, CA, USA

Medical and Nursing assessments in 24 hours, updates if less than 30 days old

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My purpose of writing this post is to highlight that the Medical Records Review Tool (MMRT) form contains a provision to check for compliance to “Medical assessment in 24 hours. Updates if less than 30 days old. Nursing assessment in 24 hours” documentation in a medical record during a Medical Records Review (MMR) session.

Members of a MMR session must be able to connect this provision found in the MMRT form to the Joint Commission International (JCI) Standard AOP.1.4.1 which requires that “The initial medical and nursing assessments are completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.”

However, most members of the MMR session are usually unaware of this requirement, and it is the duty of the team leader to explain this standard which requires that to begin correct treatment for a patient as quickly as possible, the initial assessments must be completed as rapidly as possible.

Members of the MMR session must be breifed that the hospital determines the time frame for completing assessments, in particular the medical and nursing assessments depending on a variety of factors including:

  1. the types of patients cared for by the hospital,
  2. the complexity and duration of their care, and
  3. the dynamics of conditions surrounding their care.

Nonetheless, it is important for the team leader to stress that all initial medical and nursing assessments must be completed within 24 hours of admission to the hospital and available for use by all those caring for the patient.

The team leader must also indentify situations when the patient’s condition indicates, that the initial medical and/or nursing assessment are conducted and available earlier and supported by a hospital policy which define that certain other patient groups are assessed sooner than 24 hours.

Such certain other patient groups who are assessed sooner than 24 hours will include:

  1. emergency patients
  2. patients seen in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient

The above certain other patient groups will be assessed within different time frames as follows :

  1. emergency patients are assessed immediately
  2. when the initial medical assessment is conducted in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient, it must be no older than 30 days but (i) if the medical assessment is more than 30 days old, then the medical history must be updated and the physical examination repeated and (ii) if the medical assessment is less than 30 days old but if at the time of admission there are significant changes in the patient’s condition since the assessment was first done, then they are noted in the patient’s medical record at the time of admission to inpatient status.

The team leader may include to explain the rationale why the above 30 days time frame applies when the assessment is completed in a consultant’s private office or other outpatient setting prior to care in the hospital as an inpatient. Such explanation may include (JCI, 2010 p. 80) “the critical nature of the findings, the complexity of the patient, and the planned care and treatment (for example, the review confirms the clarity of the diagnosis and any planned procedures or treatments; the presence of radiographs needed in surgery; any change[s] in the patient’s condition, such as control of blood sugar; and identifies any critical lab tests that may need repeating)”, findings by any qualified individual (medical, nursing, and other individuals and services responsible for patient care) who usually will update and/or re-examine this patient group.

Reader can relate this post to the previous post Assessments within 24 hours (this link will open in a new tab of your current browser window) on the JCI Standard AOP.1.5 which states that “Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.”

References:
Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.”

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Image credit : http://www.tsft.nhs.uk/

As I had posted in the post JCI Standard MCI.20.1 – patient based data and aggregate data, in a process available to aggregate data to meet the needs of internal and external users (this link will open in a new tab of your current browser window), in this post I shall continue on infection prevention and control. This post is also a follow-up from the previous post on risk management in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).

Infection prevention and control is one of a hospital’s four (4) performance improvement (PI) activities other than risk management, utility system management, and utilisation review PI activities a hospital is required to meet the Joint Commission International (JCI) Standard MCI.20.1, Measurable Element (ME) 1 which requires that a hospital as “The organization has a process to aggregate data in response to identified user needs.”

Although the details of infection prevention control are beyond the scope of this post and blog, I shall embark to highlight some aspects of infection prevention and control here. It is going to be a long post.

Health care–associated infections (HAIs) or also referred to as health care–acquired Infections, are infections acquired in the hospital or other health care facilities that were not present or incubating at the time of the patient’s admission. Hospital (or ‘nosocomial’) infection is infection acquired either by patients while they are in hospital, or by members of hospital staff.  (eds. Adam & Christina 2009) define the term infection as “generally used to refer to the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body with an associated tissue reaction.”

At the time of the patient’s admission due to an illness – which impairs the body’s normal defense mechanisms, often the reason for hospital admission, the patient is in the state of risk for infection in which the patient is at increased risk for being invaded by pathogenic organisms because the patient has not been exposed to in the past what the hospital environment now provides the exposure to a variety of virulent organisms, therefore the patient has not developed any resistance to these organisms.

Health care personnel in hospitals who usually fail (eds. Adam & Christina 2009) to practice proper handwashing procedures or to change gloves between patient contacts, contribute to most HAIs been transmitted  to hospitalised patients who are at risk from the most common HAI endemic infections in hospitals caused by multi-resistant tuberculosis, Clostridium difficile one of the major hospital infections in the elderly, vancomycin-resistant enterococci in some specialised units, and cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) that affect the urinary tract, upper and lower respiratory tracts, gastrointestinal tract, conjunctiva, and skin.

HAIs have received increased attention due to their overwhelming consequences in terms of cost, morbidity, and mortality.  One of the reasons for this increased attention is that these infections which are preventable through the adherence to numerous strict guidelines, legal requirements and other recommendations when caring for patients, is that they frequently occur in people whose health is already compromised by disease, age, or injury.

The data presented in the 1999 Institute of Medicine (IOM) study reported that an estimate of  between 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year and also reported that hospital-acquired infections, many of which can be prevented, take another 100,000 lives.

In the United States of America, payers have begun to refuse reimbursement for additional care resulting from treatment for an infection not present on admission with the underlying rationale that HAIs are preventable complications and denying reimbursement provides a strong incentive for quality improvement actions to avert them.

Then there are site-specific infection prevention to reduce (i) postoperative surgical wound infections through the use of appropriate surgical site preparation and also prophylactic antibiotic therapy, (ii) ventilator-associated pneumonia by for example minimizing the duration of intubation, (iii) central venous catheter infections for example with the use of sterile technique and full barrier precautions, (iv) urinary tract infection by avoiding unnecessary or prolonged use of indwelling bladder catheters, and (v) resistant organisms for example methicillin-resistant Staphylococcus aureus (MRSA) by employing (a) active surveillance procedures in which cultures are routinely obtained at scheduled intervals to promote earlier identification of resistant organisms, and (b) careful management of antibiotic use.

To address each type of HAI, many hospitals have adopted a series of practices called a “bundle” at a significant cost,  failure to use all the measures prescribed in the “bundle”, for example in the approach to preventing central line-associated bloodstream infections  (CLBSI) (this bundle includes the entire procedure for insertion, the daily cleaning protocols, and the protocols for use of the central line catheter) may adversely affect patient outcomes but adopting a “bundle” has been shown to decrease the incidence of the target infection, and thus been effective  in improving quality of care which may then offset the significant cost.

Transmission of infection as an occcupational hazard in all hospital settings is a major concern when caring for infected patients made worse by the presence of resistant organisms which causes extra concern and makes treatment difficult.

Universal precautions are usually mandated for use with patients who pose the hidden danger when they have not been diagnosed as having an infection and for whom specific infection control measures have therefore not been prescribed. Universal precautions is a critical protective strategy with measures that include hand decontamination upon entering and leaving every patient encounter, isolation and the use of disposable gowns and gloves in addition to hand decontamination for patients with certain particularly dangerous types of infections. Provision of sharps containers wherever needles were used and the provision of a supply of gloves and protective eyewear for employee use are some other measures as part of universal precautions.

Blood-borne pathogens are not the only pathogens of concern in the healthcare environment. Body Substance Precautions are also used in all hospital settings to protect patients and staff members from infections that might be transmitted by any body substance, for example to protect staff members from the tuberculosis (TB) organism.

Confidentiality should be maintained at all times by Health Information Management (HIM) / Medical Records (MR) practitioners who may be needed to provide medical records of staff members exposed to HBV, HCV and HIV infection for review at the time of exposure of the source of their occupational exposure to the bloodborne pathogens including results of blood tests, admitting diagnosis and past medical history.

HIM / MR practitioners may be needed to work closely with an infection control officer at most hospitals which usually designate this officer who has the expertise to guide the staff in planning appropriate infection control procedures to protect staff members from blood-borne pathogens to prevent the spread of HIV, hepatitis B, and other such blood-borne pathogens.

HIM / MR practitioners may be involved in the development of policies and procedures is a key role for any infection control team. The central document is a collection of procedures (sometimes called an infection control policy or infection control manual).

As I have said in my previous posts, most hospitals today are involved in processes of quality improvement.

In the context of HAI, (eds. Adam & Christina 2009,  p. 5) defines ‘surveillance which is a vital component of infection control as ‘the ongoing systematic collection and analysis of data about a disease (or organism) that can lead to action being taken to control or prevent the disease.’

As part of these processes, ongoing data are collected and analysed for problems or opportunities for improvement including using infection control and quality improvement data to improve care. An example of the use of infection control data reviewed from interviews in regard to care practices for patients with catheters in an intensive care unit (ICU) about the series of urinary tract infections for example by the same strain of Serratia as the infective agent that had been identified in all patients in that unit, showed that a deviation from the standard protocol for the unit with the use of one measuring container used by an infected patient cultured positive for the Serratia, and using it from patient to patient easily had transmitted the organism to another patient’s catheter, and the infectious agent could have been spread from patient to patient in this manner.

Quality of care aggregate data takes many forms, revealing such things as infection rates and unplanned returns to the operating room. Infection rates for example MRSA wound infections per 1000 bed days or per 1000 admissions are commonly computed rates like other rates for example average length of stay, based on discharge statistics data that are accumulated when patients are discharged. At the local level, (eds. Adam & Christina 2009) infection rates from surgical wound infections fed back to practising surgeons can demonstrate results in lowering infection rates.

Other forms quality of care aggregate data on HAIs is the reporting of infections.

A daily report generated by a laboratory-based system is able to give information based around ‘alert’ organisms that have the potential to cause outbreaks, for example the percentage of Staphylococcus aureus that are methicillin resistant and/or the percentage of wound swabs showing S. aureus.

Reporting is generated as recommended by (eds. Adam & Christina 2009) through (i) weekly reports by the Infection Control Nurse (ICN) and sent to the wards, departments and clinicians containing  information on alert organisms and infectious patients including simple graphs that provide rapid feedback on current issues while they are still fresh, (ii) monthly reports sent to all members of the Infection Control Team (ICT) within two or three days of the new calendar month, (iii) quarterly reports that includes recommendations to management and education data on who attends the sessions, and (iv) a comprehensive annual report intended for the board members.

Local data must include ‘details’ of wards and consultants – to establish the ‘ownership’ of the data as well as the competitive element,  needs to be analysed promptly and sent to the ward/clinician as daily and weekly reports.

All of the above are my observations, experiences and readings on infection prevention and control activities and processes in a hospital setting to aggregate data in response to identified user needs. They are by no means complete, in future posts I shall document on latest trends and developments in infection prevention and control activities.

In my next post on JCI Standard MCI.20.1, ME 1 I shall dwell on utilisation review PI activities a hospital is required to meet the JCI) Standard MCI.20.1, ME 1.

References:
Adam, PF & Christina, B (eds.) 2009, Ayliffe’s Control of Healthcare-Associated Infection A practical: handbook, 5th edn, Hodder Arnold, London, UK

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Janice, RE, Celia, LH 2012, Nursing in todays world : trends, issues & management, 10th edn, Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia, PA, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA