The Joint Commission held one of its periodic “Consultant Forums” in August. They conduct group meetings with interested parties about changes and new initiatives. The recent forum covered a topic that befuddled many. It’s the mandate to pre-clean all surgical instruments at the “point of use” in the procedural area and the scoring revisions that follow.
They also hinted that they will train surveyors to the new expectations. And, they would publish an announcement in the September Perspectives.
This announcement was not published in the September Perspectives. But, they did issue one of their 411 publications on “Scoring Revisions for IC.02.02.01.” The 411 publication states that they previously scored visible bioburden and dried blood found on instruments. Also, they used to score if an enzymatic solution was not applied to maintain moisture on instruments. Now, the new scoring would occur only if the organization did not have a process for keeping used instruments moist.
That is nice, simple and does not mandate use of any sort of spray or enzymatic solution. Now the 411 states that surveyors will score if “wiping/flushing of soiled instruments is not observed during a case in the OR or procedure room and it is clinically appropriate.” So, the term “not observed” is interesting phrasing as is the new phrase “clinically appropriate.” What is clearly missing is the notion of strict adherence to a single evidence-based guideline such as AAMI.
We also noted that TJC has pulled down the FAQ they had on the website that mandated pre-cleaning at the point of use. Unfortunately, removal of an FAQ is not easily noticed and does not adequately disseminate new information.
Our Advice Is…
Our newsletter strives to cut through the fog and help advise readers on what they need to do. But, at this time there are too few details from TJC to give clear advice. Until they publish those details, we advise readers to refrain from changing policy or procedures. In fact, in advance of those details, we advise you to send any proposed change to policy or procedure to SIG at the Joint Commission. This will allow them to vet your changes before you put them in place.
Infection Control Changes
The September issue of Perspectives also announced a second critical infection control change. This deals with the storage of semi-critical items. In this new advisory TJC states that semi-critical items processed in a peel pack such as a speculum, may be “opened and distributed safely to multiple clean drawers.”
This is a very significant departure from earlier guidance. For example, for other semi-critical items like laryngoscope blades, TJC mandated keeping them protected in some outer wrapping prior to use.
We looked for that FAQ and noted it too is missing from the website. However, we saved that FAQ in our files and we noted the date of publication was October 2013.
In that FAQ, TJC stated the storage requirement as: “Laryngoscopes should be kept free from contamination until the time of use. Once opened, there is potential for microorganisms to settle on the equipment the longer it remains open and unused.
Consider This Option
One option is to contain the individual blade in a closed plastic bag, placed in a clean storage location and use a peel pack only if steam sterilized.
We did note an FAQ that is still available on their website about storage of ETT tubes. Here they state there is no evidence that opening them ahead of time actually causes a problem. Thus, it is acceptable for the organization to develop a risk assessment and policy that permits the pre-opening of these packaged items.
The 411 article also references equipment processed using high level disinfection. Here again the guidance in the 411 is ambiguous. They mention containers or storage locations that might be or are contaminated as a problem. However, they don’t say if wrapped or unwrapped items stored in a dirty container is a problem.
They also mention if storage is not consistent with the intended use it is scorable as non-compliant. (e.g. storing items that require minimum HLD in a way that protects from contamination, even if sterilized). Unfortunately, the meaning of that sentence is far from clear.
TJC Philosophical Changes
So, it looks like there is a philosophical change happening at TJC on some very difficult infection control requirements. Some of the issues in the 411 seem straight forward like the new guidance on transporting instruments in the building. Previously we saw surveyors scoring a failure to transport a non-sharp like an endocavity probe in a rigid container with a top. Now TJC makes it clear that a rigid container is not a requirement if you are not transporting sharps. They also clearly state TJC will not score issues relative to hang time for processed scopes. But, if that is already in your hospital policy, we imagine they will still score it if you are not following your policy.
Are We Headed In A New Direction?
It looks like this may be headed in a direction that will focus less on minutia. And, based on what we heard at the consultant forum, we think hospitals will like the planned changes.
When we see newly published information like this we act much like our readers do by vetting it with content experts. We distribute and discuss it with our consultants to make sure we our interpretations are correct. Unfortunately, based on what we have read thus far, we are getting divergent opinions. We don’t yet see clear guidance on the new direction where we can advise specific actions. We hope to read the details about these changes in an upcoming edition of Perspectives or hear about them at this falls Executive Briefings.
Before taking action on the new direction, we encourage the Infection Preventionists in your hospital review the recent 411. Then prepare your own analysis on what you believe TJC is saying, and seek confirmation before changing policies.
Patton Healthcare Consulting provides Joint Commission Compliance Assistance. In addition, we offer a full range of pre-survey and post survey services to healthcare organizations. Contact us to learn more.