Web site spotlight: Meet The Joint Commission standard IC.02.01.01

Staff Development Weekly: Insight on Evidence-Based Practice in Education, May 1, 2009

It’s difficult to establish effective means of communication between the infection control (IC) team and frontline staff members. But that’s what The Joint Commission is asking of facilities in standard IC.02.01.01, particularly in elements of performance (EP) 9–11. These EPs require facilities to communicate IC information among their own staff members, as well as to outside authorities such as federal, state, and local regulators and other healthcare facilities during patient transfers.

The difficult part about meeting some of the EPs in this standard is that to fulfill the requirements, you need the cooperation of many people, particularly frontline staff members who have a variety of other issues to deal with. In almost all circumstances, a nurse, not an IP, will be the one transferring or discharging the patient.

EP 10 requires the hospital to inform the receiving organization when it becomes aware that it transferred a patient who has an infection requiring monitoring, treatment, or isolation. “This actually becomes a little difficult, and it takes a lot of thought and a real team approach,” says Patty Burns, RN, CIC, co-manager of the IC program at St. Elizabeth Medical Center in Edgewood, KY. “It’s generally not the infection control staff. Many times, it’s the discharging nurse who is having a conversation with the next facility where the information needs to be shared.”

Also, it’s helpful if staff members have some sort of checklist to use during discharge, says Gail Bennett, RN, MSN, CIC, owner of ICP Associates, Inc., in Rome, GA.

“If we know about the infection when the discharge is occurring, it’s important to have a good transfer form that gives us a prompt to include infectious diseases,” says Bennett. “And that’s what a lot of hospitals are working on now, just making sure they have the best form so that information cannot be forgotten or overlooked as they are doing the transfer.”

The IP’s responsibility in this case is less hands-on and more in the form of leadership and initiative in terms of educating and preparing staff members.

Editor’s note: This excerpt was adapted fromComply to standard IC.02.01.01 with communicationfound in the Reading Room at Get a free trial membership that will give you 30 days to test drive all the exciting features on the Web site.

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