Joint Commission Online - Aug. 11, 2021
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
August 11, 2021
The application period for the 20th John M. Eisenberg Patient Safety and Quality Awards is open now through Sept. 30. The annual awards program from The Joint Commission and the National Quality Forum (NQF) recognizes major achievements by individuals and organizations to improve patient safety and health care quality.
Awards are presented in three categories:
- Individual Achievement
- National Level Innovation in Patient Safety and Quality
- Local Level Innovation in Patient Safety and Quality
Initiatives or projects eligible for the National and Local Level awards will have involved successful system changes or interventions that make the environment of care safer or that advocate on the patient’s behalf. These innovative efforts may address new technologies, protocols, procedures, education, organization culture, legislation, the media, patient advocacy, systems theory or another area. Organizations applying must have at minimum one year (12 months) of data supporting the improvement made by the featured initiative.
Please note that organizations or individuals applying must submit their $400 payment by Sept. 30 to be considered.
Learn more about the application process and to access the application form. Interested parties can inquire about eligibility and the application process by contacting EisenbergAwards@qualityforum.org.
August 11, 2021
A recent issue of Perspectives featured a “Consistent Interpretation” column on two Infection Prevention and Control (IC) requirements as they relate to reprocessing ultrasound transducers. They were for IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
The U.S. Food and Drug Administration (FDA) uses the Spaulding Classification System to instruct manufacturers on appropriate reprocessing instructions for medical devices based on the intended use of the device. Surface ultrasound transducers are classified as noncritical, semi-critical, or critical, based on their intended use, and require the following minimum level of reprocessing:
- Noncritical items which come in contact with intact skin only require low- or intermediate-level disinfection
- Semi-critical items which contact mucous membrane require high-level disinfection
- Critical items require sterilization
Manufacturers of medical devices should comply with the FDA-published guidance on the minimum level of reprocessing when providing instructions, however some manufacturers may choose to require a higher level of reprocessing based on their knowledge and specifications of the device they produce. Health care organizations must follow the minimum level of device reprocessing based on its intended use, as well as the manufacturer’s instructions for cleaning and reprocessing a device unless it doesn’t meet the minimum reprocessing requirement. Health care organizations must determine intended use(s) based on how the surface ultrasound transducers and endocavity probes are used within their organization and resolve any discrepancies with the manufacturer.
The observations and guidance for the elements of performance were for:
EP 1 — The hospital implements infection prevention and control activities when doing the following: Cleaning and performing low-level disinfection of medical equipment, devices, and supplies. For more information, visit https://www.cdc.gov/infectioncontrol/guidelines/disinfection/#r3.
In 2020, the noncompliance percentage for this EP was 21.63% — 122 of 564 hospitals surveyed.
- A surface ultrasound transducer used on intact skin was not reprocessed in accordance with the manufacturer’s instructions for use, as evidenced by the following:
- Low-level disinfection was performed on a surface ultrasound transducer contaminated with blood and/or body fluid that required high-level disinfection in accordance with the manufacturer’s instructions for use.
- A surface ultrasound transducer used on intact skin was neither cleaned nor disinfected, in accordance with the manufacturer’s instructions for use.
EP 2 — The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. (See also Environment of Care (EC) Standard EC.02.04.03, EP 4).
High-level disinfection is used to reprocess items that come in contact with non-intact skin and mucous membranes, such as endoscopes and endocavity probes. Sterilization is used for items such as implants and surgical instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes.
In 2020, the noncompliance percentage for this EP was 46.28% — 261 of 564 hospitals surveyed.
- An ultrasound transducer or probe used in a sterile body cavity was not sterilized in accordance with the manufacturer’s instructions for use, as evidenced by the following:
- An intra-abdominal ultrasound transducer was reprocessed using high-level disinfection rather than sterilized in accordance with the manufacturer’s instructions for use.
- An ultrasound transducer used on mucous membranes was not reprocessed using high-level disinfection in accordance with the Spaulding Classification System (FDA requirement) or the manufacturer’s instructions for use, as evidenced by the following:
- A vaginal (rectal or oral) ultrasound transducer was reprocessed using low- to intermediate-level disinfection rather than high-level disinfection as required by the manufacturer’s instructions for use.
- The organization did not follow the manufacturer’s instructions for use of an ultrasound transducer sheath, as evidenced by the following:
- A sterile sheath was required in accordance with the manufacturer’s instructions for use; however, the organization used a product that was not intended to be used as a sterile sheath. Note: Sterile sheaths are medical devices that are approved by the FDA.
- After using an ultrasound transducer sheath, the organization did not reprocess the transducer at the minimum level based on intended use or required by the manufacturer’s instructions.
They offered the following guidance and interpretation for the two EPs:
- Confirm that the Requirement for Improvement (RFI) accurately captures the device out of compliance.
- Surface ultrasound transducers should be reprocessed according to their intended use, which is commonly low- to intermediate-level disinfection; however, high-level disinfection should be used if this is required based on intended use or by the manufacturer’s instructions for use.
- Noncompliance with reprocessing medical devices will be scored at IC.02.02.01 (EP 1 or EP 2) when the following two criteria are observed:
- An organization is noncompliant with reprocessing medical devices according to the manufacturer’s instructions for use.
- An organization does not meet the minimum reprocessing requirements based on intended use.
- Using a protective sheath does not negate the need to follow the ultrasound transducer’s manufacturer’s instructions for use when reprocessing unless the instructions specifically state it.
August 11, 2021
In April 2014, the now-retired first issue of Quick Safety addressed the care of psychiatric patients boarded in emergency departments (EDs) — particularly those patients at risk for suicide and other acts of harm, including self-harm. In December 2015, another Quick Safety covered the challenge of providing appropriate and timely care to psychiatric patients.
In a new update to Quick Safety Issue 19, current information on and strategies to address ED boarding is given, as it continues to be a significant problem in health care. The problem of ED boarding stems not – or not only – from a lack of inpatient beds, but as psychiatric patients also seek care in EDs because they often have nowhere else to go.
Read the updated Quick Safety.
August 11, 2021
The Joint Commission is seeking feedback on new and revised antibiotic stewardship requirements for the Hospital (HAP) and Critical Access Hospital (CAH) accreditation programs. The proposed requirements expand upon the current expectations for antibiotic stewardship programs and include updates to align with current recommendations from scientific and professional organizations.
According to the Centers for Disease Control and Prevention, there are at least 2.8 million antibiotic-resistant infections each year. Optimizing the use of antibiotics is a patient safety priority, and antibiotic stewardship programs play a critical role in promoting appropriate antibiotic prescribing practices and reducing antibiotic resistance.
We are seeking input from the field on the proposed revisions to Standard MM.09.01.01.
August 11, 2021
- Leading Hospital Improvement — Preparing for Extreme Temperatures: With temperature events occurring worldwide, emergency management teams should start planning for extreme temperatures. To prepare for temperature extremes — heat or cold — as well as storms, health care organizations need to assess the impact of a power outage and how the electrical grid system could affect their facilities, writes Angela Murray, MSN, RN, Project Director.
- Improvement Insights — Just Do It: Rapid Naloxone Initiative is Needed Now: The Department of Veterans Affairs (VA) was recently honored with the 2020 John M. Eisenberg National Level Innovation in Patient Safety and Quality Award for its Rapid Naloxone Initiative. This effort works to prevent opioid overdose deaths among veterans, writes Elizabeth Oliva, PhD, National Opioid Overdose Education and Naloxone Distribution (OEND) Coordinator, Investigator, VA Center for Innovation to Implementation.
- Improvement Insights — Translating Safety II Theory into Practice: The Safety II approach to improving patient safety acknowledges that things go right far more often than they go wrong. Because of this, various learning opportunities exist regarding how individuals and systems make things go right. As we looked around our organization at Nationwide Children’s, we found multiple microsystems had intuitively applied Safety II strategies to their safety work, resulting in improved outcomes, writes Jenna Merandi, PharmD, MS, CPPS; Stacy Kuehn, RN, BSN; Tensing Maa, MD; and Richard Brilli, MD, FAAP, MCCM.
- Quality in Nursing Center Care — New Assisted Living Communities Accreditation Program Accepting Applications: The Joint Commission is now accepting applications for its Assisted Living Communities (ALC) Accreditation Program, writes Gina Zimmermann, Executive Director, Assisted Living Accreditation Services.