Investigating Nosocomial Infections as Sentinel Events—Algorithm by the C4QI Infection Control Group

ISSUE: Healthcare organizations are required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to “manage as sentinel events all identified cases of unanticipated death or major loss of function due to nosocomial infections.” Because patients at cancer centers are generally at high risk for serious infections, these institutions face unusual difficulty when they must determine whether a morbid nosocomial infection is “unanticipated.” PROJECT: A consortium of quality improvement professionals from comprehensive cancer centers, the C4QI group, formed to address common quality improvement issues. Infection control practitioners (ICPs) from some of the cooperating centers organized to explore benchmarking infection data. When JCAHOʹs Patient Safety Goal #7 was formalized, a subgroup of these ICPs developed a standardized method to comply. A consensus statement and algorithm were created to identify sentinel events caused by nosocomial infections. RESULTS: Data used in the algorithm included: reasons for admission; cancer type and stage; cancer effect on immunity; and anatomic barriers to infection. The influence of these factors on infection likelihood and severity dictated branch points in the algorithm. For example, one patient died of pneumonia but had advanced lung cancer that blocked lung drainage; this patientʹs death was deemed “anticipated.” When death or morbidity is unanticipated, the incident is reported as a sentinel event. The case is referred to Risk Management/Quality Improvement departments for a root-cause analysis. An action plan is implemented and monitored.