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Wednesday 6:27 CST, February 10, 2016

Standards FAQ Details


National Patient Safety Goals (NPSG) (Critical Access Hospitals / Critical Access Hospitals)

Surveillance Requirements for CAUTI
Current | July 18, 2011
My facility performs a risk assessment every year as required by IC.01.03.01. We consider a wide range of infection risks, and we rank them per IC.01.03.01 EP 5. Our risk assessment shows CAUTI is a very low patient risk; there are many other higher priorities. Must I perform surveillance for CAUTI because of the new NPSG.07.06.01 even though my risk assessment does not identify it as a priority?

A. NPSG.07.06.01 is a new goal on catheter-associated urinary tract infection (CAUTI) that was published in the July 2011 edition of Perspectives.  Reasons for this goal are captured in the following quote from the Perspectives article:

“The Joint Commission’s Patient Safety Advisory Group, a group of external national experts on patient safety issues, recommended that NPSG.07.06.01 for CAUTIs be considered for adoption. CAUTI is the most frequent type of health care–acquired infection (HAI), and represents as much as 80% of HAIs in hospitals. The frequency of CAUTIs creates a patient safety and quality concern.”

The Joint Commission recognizes that a variety of surveillance approaches are appropriate for various types of infections.   For example, NPSG.07.04.01 on catheter-associated bloodstream infection requires that all catheters be monitored; EP 4 states surveillance must be “hospital-wide, not targeted”.  However, NPSG.07.03.01 on multi-drug resistant organisms allows for the risk assessment to drive surveillance, hence EP 4 says surveillance may be “targeted rather than hospital-wide”.  In a similar fashion, NPSG.07.05.01 on surgical site infection allows organizations to determine which surgeries to monitor, and EP 5 states, “Surveillance may be targeted to certain procedures based on the hospital’s risk assessment.”

NPSG.07.06.01 on CAUTI does not specify either hospital-wide or targeted surveillance.  In fact, it does not specifically require that surveillance for CAUTI be performed at every accredited hospital.  Rather, it allows for each organization to decide, based on its risk assessment (IC.01.03.01) whether CAUTI is a priority warranting surveillance.

Having said this, The Joint Commission urges organizations to review the scientific literature and consensus-based guidelines when considering CAUTI surveillance.  One summary of the epidemiology of CAUTI that bears consideration is the following excerpt from the CDC/HICPAC document entitled “Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009”.

Urinary tract infections are the most common type of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals. Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients.”

For more information see:  R3 Report Issue 2 - Catheter-associated urinary tract infections

Survey process note: This new NPSG has a phase-in period during 2012, during which surveyors will be ensuring that hospitals are planning and preparing for full implementation in 2013.  Starting in January 2013, a hospital that has decided, based on its risk assessment, that CAUTI surveillance is not indicated should be prepared to discuss this decision with its survey team and provide a clear rationale.  Even if surveillance is not performed, the insertion and management requirements of the goal must still be implemented.