JCAHO's Focus on Healthcare-associated Infections
Increasing attention on healthcare-associated infections (HAIs) has prompted JCAHO to review infection reports related to its sentinel event database. Since the database's 1996 implementation, JCAHO has received only 10 infection-related reports for review under its sentinel event policy. Its belief is that HAI sentinel events are underreported, so the agency released a national patient safety goal for 2004 that addresses HAI risk, says Judene Bartley, MS, MPH, CIC, a clinical consultant for the Premier Safety Institute. Here's a summary of the standards related to the new goal, which takes effect in January 2005.

• Set and prioritize goals for preventing HAIs. Write a policy that includes goals, priorities, strategies to handle the risks and how you will evaluate whether you've been successful.
• Educate all staffers who are part of the infection control process onthe policy to minimize the risk of HAIs.
• Once the policy is implemented, continue to evaluate and re-evaluate all aspects; do a formal review once a year. Revise and revamp as needed.
• Include the CDC's hand-hygiene guidelines in your goals.
• Base your HAI-battling strategies on relevant guidelines, reducing risks at the staff, procedure and device-reprocessing levels, applying the Association for Infection Professionals' universal precautions.
• Ensure your HAI program is effective by choosing leaders from different areas of your facility (for example, the OR, pre-op and the reprocessing room) to work with infection control personnel to review how the program works and where improvements can be made.
• Enlist the infection control leaders from each area to report each year on the program to the patient safety committee. The patient safety committee members can report to the facility's board.

- Stephanie Wasek

Combating Surgical Site Infection

• 99% Percentage of infection control (IC) managers who agree that SSI infection control procedures are important to ensure patient health
• 30% Percentage of IC managers who report moderate or low-level concern about SSIs at their institution
• 58% Percentage of IC managers who report use of active anti-SSI devices (such as anti-bacterial sutures or wound dressings) at their facility
• 45% Percentage of IC managers who cite pre-op hand/forearm antisepsis as an effective way to combat SSIs
• 38% Percentage who believe antibiotic prophylaxis and standard surgical techniques reduce SSIs
• 31% Percentage of IC managers who believe sterilization of medical devices and surgical instruments is effective
• 23% Percentage of IC managers who say their institutions' IC policies go beyond recognized guidelines
• 73% Percentage of IC managers who believe the IC guidelines or procedures used by their facilities are effective

Source: Combating Surgical Site Infection: A Study Among Infection Control Managers (n=301), prepared by Harris Interactive Market Research for Johnson & Johnson