infection prevention
By Sylvia Garcia-Houchins , MBA , RN , CIC
The Role of Evidence-Based Guidelines and Consensus Documents : What is Required ?
Healthcare organizations ( HCOs ) preparing for survey understand they will undoubtably be asked to reveal which evidence-based guidelines ( EBGs ) their facility uses . This is a staple of survey , whether conducted by The Joint Commission , the Centers for Medicare and Medicaid Services ( CMS ) or a state , since all require the use of EBGs .
The most accurate way to prepare for and respond to this EBG inquiry during survey is to :
● Identify which EBGs and consensus documents are required vs . those that are optional
● Document and disclose basic processes used for determining required elements
How many EBGs are required ?
The Joint Commission does not require a minimum number of EBGs . HCOs that receive CMS deemed status through The Joint Commission can locate required EBGs within program-specific CMS State Operations Manuals . For example , the
Ambulatory Surgery Center ( ASC ) State Operations Manual states , “ The infection control and prevention program must include documentation that the ASC has considered , selected and implemented nationally recognized infection control guidelines .”
During an ASC deemed status survey , Joint Commission surveyors complete a
form to identify selected guidelines and must confirm a selection or score non-compliance “ even if the ASC ’ s infection control practices comply with generally accepted standards of practice / national guidelines .”
The survey form lists potential guidelines ASCs may select , including :
● The Centers for Disease Control and Prevention ’ s ( CDC ) isolation , hand hygiene , environmental , or disinfection and sterilization guidelines
● The Association of periOperative Registered Nurses ( AORN ) Perioperative Standards and Recommended Practices
● Specialty surgical societies ’ guidelines
Each surveyor must indicate at least one infection control-related EBG by name during survey .
During the guideline selection process , while it is critical infection preventionists understand there is no specified number of EBGs to consider , they must demonstrate their facility has reviewed and selected EBGs to implement . Additionally , they must maintain an active and organization-wide infection control program consistent with nationally recognized infection prevention standards .
Which EBGs are required by The Joint Commission and / or CMS ? During every Joint Commission survey , compliance is evaluated with :
● CDC and / or World Health Organization ( WHO ) 1A , 1B and 1C hand hygiene guidelines ( NPSG . 07.01.01 EP1 )
● CDC isolation guidelines ( IC . 02.01.01 , EP 2 and 3 on standard and transmission-based precautions )
Joint Commission standards and CMS requirements are not prescriptive regarding other EBGs or consensus documents that HCOs must consider or implement . CMS recently clarified this within its interpretive guidance chapters :
● Hospitals have ample recognized evidence-based approaches to select from in order to adhere to nationally recognized guidelines without impeding their ability to otherwise make progress in infection prevention and control .
● ASCs must select one or more sets of guidelines that enable them to address the key functions of an effective infection control program .
Joint Commission standards contain general wording that specifies an HCO should “ measure and monitor its infection prevention processes , outcomes and compliance using EBGs or best practices , and consider EBGs when implementing evidence-based practices .”
Are there any other requirements for EBGs ?
Joint Commission-accredited HCOs that have considered , selected and implemented nationally recognized infection control guidelines should be considered compliant as long as there are not manufacturer instructions for use ( IFUs ) or state regulations that otherwise specify compliance with a particular EBG or consensus document .
Joint Commission standards require HCOs comply with state law and regulation and follow manufacturer IFUs as part of a
hierarchical method to address infection control-related requirements .
Several states have adopted specific EBGs or consensus documents by incorporating them into healthcare code requirements . It is key HCOs access their specific state requirements as they vary from state to state . For example :
● Illinois : Requires long-term care ( LTC ), ASCs and hospital settings to adhere to specific CDC guidelines ,
● New Jersey : Provides an exception to the adoption of specific CDC guidelines by LTC if there is sound infection control rationale based upon scientific research or epidemiologic data . Additionally , specific Advancement of Medical Instrumentation ( AAMI ) and Society of Gastroenterology Nurses and Associates ( SGNA ) standards are required for central services .
● Texas : Requires ASCs to develop policies and procedures for sterile supplies based on standards , guidelines and recommendations by AORN , Association for Professionals in Infection Control and Epidemiology ( APIC ), CDC , and if applicable , SGNA .
Infection preventionists may access statutes , codes and regulations by
state but should be cautious to ensure they have considered all applicable requirements based on their unique healthcare setting and confirm requirements with the source and / or legal counsel .
Additionally , manufacturer IFUs may direct users to reference EBGs and consensus documents for further information . HCOs