Pilot Study Method for Compliance with JCAHO “Reporting of Nosocomial Deaths”

ISSUE: Two million patients acquire infections in hospitals annually, and 90,000 die as a result. Despite this, only 10 infection-related reports have been reviewed through the Sentinel Event Database since its implementation in 1996. In response, in January 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) promulgated a hospital requirement to report the number of patient deaths due to healthcare-associated infection. The directive called for the review of infection-related deaths according to specific criteria and performance of root-cause analysis to identify risk-reduction strategies. Institutions were also asked to consider reporting to JCAHOʹs Sentinel Event Database to expand knowledge about the scope and characteristics of serious nosocomial infections. PROJECT: To develop a workable method, Infection Control management met with clinical and administrative management from Quality Assessment (QA) to develop a pilot program for chart review. We conducted medical record reviews of 10% of patient deaths that occurred during 2003. The following exclusion criteria were used: 1) death within 72 hours of admission, 2) admissions with fever and chemotherapy-related neutropenia, 3) stage IV incurable metastatic cancer, 4) positive microbiology culture obtained within 72 hours of admission. RESULTS: 1) The median and mean time between death and electronic sign out of the discharge summary was 21 days. 2) Five deaths did not meet exclusion criteria and were referred for formal review by an infectious disease physician. 3) Based on this review, no deaths meeting sentinel event criteria were identified. LESSONS LEARNED: Determining nosocomial infection–related death is a complex endeavor particularly in a tertiary-care cancer center. Our approach may not be useful at community hospitals. Based on the results of this pilot, we have implemented this approach. QA now reviews all in-hospital deaths to identify patients whose deaths may have been due to hospital-acquired infection. Each identified chart is then reviewed by an infection control practitioner and, if indicated, an infectious disease physician. Any death occurring due to nosocomial infection will be treated as a sentinel event and subjected to multidisciplinary review and root-cause analysis.