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Comply to standard IC.02.01.01 with communication


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It’s difficult enough to establish effective means of communication between the infection control (IC) team and frontline staff members in the same hospital, let alone other facilities.

But regardless of how difficult it may be, that’s what The Joint Commission (formerly JCAHO) is asking of facilities in standard IC.02.01.01, particularly in elements of performance (EP) 9–11. These EPs require facilities to communicate IC information among their own staff members as well as to outside authorities such as federal, state, and local regulators and other healthcare facilities during patient transfers.

Looking at state requirements

Each state is going to have a different set of requirements concerning reporting, but rest assured that a surveyor will know what standards your state has in place and whether you are following them, says Patty Burns, RN, CIC, comanager of the IC program at St. Elizabeth Medical Center in Edgewood, KY.

“I think they vary a lot,” Burns says of the state requirements. “So I think the very first thing The Joint Commission [surveyors are] going to do is prep themselves on what the regulations are in your state to make sure you are doing that.”

Pennsylvania state laws mandate hospitals report healthcare-associated infections (HAI) through Act 52. As a result, Pennsylvania hospitals report infections electronically through the National Healthcare Safety Network, with authority granted to the Pennsylvania Health Care Cost Containment Council and the Pennsylvania Patient Safety Authority to access that information.

Although it was a rocky start at first, the reporting requirement actually made things a lot easier in the long run, says Deborah Frye, MT (ASCP), MBA, CIC, an infection preventionist at Lehigh Valley Hospital and Health Network in Allentown, PA.

This year, Lehigh Valley is up for its Joint Commission accreditation survey, and Act 52 has made that part of the preparation process easier because EP 9 is already met. “It sort of softens the burden of the Joint Commission requirements because you have all that data and you are able to identify areas of improvement,” says Frye.

Transferring a patient

The difficult part about meeting some of the EPs in this standard is that to fulfill the requirements, you need the cooperation of many people, particularly frontline staff members who have a variety of other issues to deal with. In almost all circumstances, a nurse, not an IP-, will be the one transferring or discharging the patient.

EP 10 requires the hospital to inform the receiving organization when it becomes aware that it transferred a patient who has an infection requiring monitoring, treatment, or isolation.

“This actually becomes a little difficult, and it takes a lot of thought and a real team approach,” Burns says. “It’s generally not the infection control staff. Many times, it’s the discharging nurse who is having a conversation with the next facility where the information needs to be shared.”

Also, it’s helpful if staff members have some sort of checklist to use during discharge, says Gail Bennett, RN, MSN, CIC, owner of ICP Associates, Inc., in Rome, GA.

“If we know about the infection when the discharge is occurring, it’s important to have a good transfer form that gives us a prompt to include infectious diseases,” says Bennett. “And that’s what a lot of hospitals are working on now, just making sure they have the best form so that information cannot be forgotten or overlooked as they are doing the transfer.”

The IP’s responsibility in this case is less hands-on and more in the form of leadership and initiative in terms of educating and preparing staff members.

“I think the infection preventionist has to take charge of the standard and put the right people together in a room and discuss how are we going to do this,” says Burns. “What I think is a great idea might be a terrible idea for the bedside nurse, so you have to have those people in the room helping to make those decisions.”

The future: Electronic records

EP 11 states that when a hospital becomes aware that it received a patient from another healthcare organization who has an infection requiring action, and the infection was not communicated by the referring organization, the hospital informs that facility. The Joint Commission defines what it means by infections “requiring action,” noting that it includes infections requiring isolation and/or public reporting or those that may aid in the referring organization’s surveillance.

“I think we’ve really needed that communication for a long time and putting strength of standard behind it has really forced us to focus on it,” says Bennett. But there is a possible savior on the horizon: electronic medical records, which would essentially cut out the need for phone calls.

“Then it won’t be like the tattletale accusatory phone call,” says Burns. “We are all going to be sharing the same data, and it will be right there in front of us, and the information just lives with the patient.”