Goal Revisions for Healthcare-Associated Infections NPSGs from The Joint Commission

APPLICABLE TO HOSPITALS AND CRITICAL ACCESS HOSPITALS Effective January 1, 2018
National Patient Safety Goals (NPSG)
Standard NPSG.07.03.01   Implement evidence-based practices to prevent health care– associated infections due to multidrug-resistant organisms in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillinresistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), carbapenemresistant enterobacteriaceae (CRE), and other multidrugresistant gram-negative bacteria.
Elements of Performance for NPSG.07.03.01  Based on the results of the risk assessment, eEducate staff and licensed independent practitioners about  health care–associated infections, multi-drug-resistant organisms and prevention strategies at hire and annually thereafter. Education occurs upon hire or granting of initial privileges and periodically thereafter as determined by the organization.  Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the [critical access] hospital organization.  Implement a surveillance program for multidrug-resistant organisms based on the risk assessment.  Note: Surveillance may be targeted rather than [critical access] hospital-wide.  Measure and monitor multidrug-resistant organism prevention processes and outcomes, including the following:   Multidrug-resistant organism infection rates using evidence-based metrics    Compliance with evidence-based guidelines or best practices    Evaluation of the education program provided to staff and licensed independent practitioners Note: Surveillance may be targeted rather than [critical access] hospital-wide.
Standard NPSG.07.04.01 Implement evidence-based practices to prevent central line– associated bloodstream infections.    Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.
Element of Performance for NPSG.07.04.01 1.  Educate staff and licensed independent practitioners who are involved in managing central lines about central line– associated bloodstream infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities or granting of initial privileges and periodically thereafter as determined by the organization.    Conduct periodic risk assessments for central line– associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the [critical access] hospital, and this infection surveillance activity is [critical access] hospital-wide, not targeted.
                 Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters.   Perform hand hygiene prior to catheter insertion or manipulation.  .  Use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion. .  For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.   Use an alcoholic chlorhexidine antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations. *unless contraindicated.
    *: A limited number of National Patient Safety Goals contain requirements for practices that reflect current science and medical knowledge. In these cases, the element of performance refers to a practice that is cited in scientific literature or endorsed by professional organizations. This means that the practice used by the hospital must be validated by an authoritative source. The authoritative source may be a study published in a peer-reviewed journal that clearly demonstrates the efficacy of that practice or endorsement of the practice by a professional organization(s) and/or a government agency(ies). It is not acceptable to follow a practice that is not supported by evidence or wide-spread consensus. During the on-site survey, surveyors will explore the source of the practices the hospital follows

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