Joint Commission National Patient Safety Goal Focuses on CAUTI Prevention

PUBLISHED: Jan 3, 2017

The Joint Commission is reminding organizations in a new R3 Report that informs organizations that, effective January 1, 2017, there is a new National Patient Safety Goal (NPSG) on catheter-associated urinary tract infections (CAUTIs) for accredited nursing care centers and a revised NPSG applicable to accredited hospitals and critical access hospitals. The revisions were made to align the NPSGs with the 2014 update to A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. The original requirement was released in 2012.

The Joint Commission NPSG.07.06.01 requires accredited organizations to implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections. In order to comply with NGPS.07.06.01, organizations must use evidence based guidelines to develop policies and procedures aimed at decreasing or eliminating catheter-associated urinary tract infections.

In the NPSG, TJC refers organizations to two evidence based guidelines for CAUTI: Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals and the Center for Disease Control's Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Links to each of these resources is provided in the references.

According to the evidence-based research, a comprehensive CAUTI prevention program should include:

  • Education on evidence-based best practices for licensed independent practitioners and clinical staff inserting and or maintaining urinary tract catheters. Education should be provided upon hire and/or granting of privileges and at regular interval thereafter.
  • Education for patients and/or residents who have an indwelling catheter, and their families as needed, on CAUTI prevention and the symptoms of a urinary tract infection.
  • Written criteria, based on evidence-based guidelines, outlining when an indwelling catheter should be placed.
  • Written procedures, based on established evidence-based guidelines, for inserting and maintaining an indwelling urinary catheter. The following should be specifically addressed:
  • Limiting use and duration
  • Hand hygiene prior to catheter insertion or maintenance care
  • Aseptic techniques for site preparation, equipment, and supplies
  • Securing catheters for unobstructed urine flow and drainage
  • Maintaining the sterility of the urine collection system
  • Replacing the urine collection system when required
  • Collecting urine samples
  • Performance measurement including:
  • Selecting measures using evidence-based guidelines or best practices
  • A consistent method for medical record documentation of indwelling urinary catheter use, insertion, and maintenance
  • Monitoring compliance with evidence-based guidelines or best practices
  • Evaluating the effectiveness of prevention efforts

Included with this notice are example evidenced-based policies and procedures for a CAUTI prevention program.

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