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Wednesday 10:30 CST, July 23, 2014

Standards FAQ Details

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Infection Prevention and Control (CAMCAH / Critical Access Hospitals)


Screening patients for MRSA with Active Surveillance Cultures
New | July 18, 2011
Is MRSA screening required for all patients? If not, are there certain high-risk patients that must be screened?

IC.01.05.01 EP 1 requires that, "When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or, in the absence of such guidelines, expert consensus."  Also, NPSG.07.03.01 EP 7 states, "Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines)."  Please refer to the CDC/HICPAC guideline entitled "Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006".

The HICPAC guideline lists two sets of interventions, designated as "general" and "intensified, tier 2".   Tier 2 interventions are not recommended of all facilities, but rather just those that meet criteria listed in the guideline.  These criteria include failure to decrease MDRO rates as well as the first occurrence of an epidemiologically significant organism.  Screening, also known as active surveillance cultures (ASC), is listed under the category of "intensified interventions" (recommendation V.B.5.b).

Therefore, unless an organization meets the criteria for "intensified, tier 2" interventions, Joint Commission surveyors would not expect these to be in place.  Consequently, active surveillance cultures are not required at all accredited facilities.

However, please note that LD.04.01.01 EP 2 requires compliance with applicable law and regulation.  Many state legislatures have enacted law or regulation that requires active surveillance cultures for particular patient populations. The Joint Commission would expect these to be done per LD.04.01.01.

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