Transcript Optimizing Outcomes in Ambulatory Surgery Centers

Infection Prevention in the Outpatient
Setting
Ruth Carrico PhD RN FSHEA CIC
Associate Professor
School of Public Health and Information Sciences
University of Louisville
[email protected]
Objectives
 Overview of current regulations pertinent
in ambulatory surgery settings (What I have
to do)
 Basic elements for an effective infection
prevention program in the ambulatory
surgery setting (How to do it)
 Opportunities for practice monitoring
What is an Ambulatory Surgical
Center?
 Any distinct entity that operates exclusively for
the purpose of providing surgical services to
patients not requiring hospitalization and in
which the expected duration of services would
not exceed 24 hours following an admission
 The entity must have an agreement with CMS to
participate in Medicare as an ASC and must meet
the Conditions for Coverage (42 CFR 416.2416.52)
What is Surgery?
 Procedure performed for purpose of structurally altering the
human body by incision of destruction of tissues
 Also: diagnostic or therapeutic treatment of conditions of
disease processes by any instruments causing localized
alteration of transposition of live human tissue which include
lasers, ultrasound, ionizing radiation, scalpels, probes and
needles
 Also: injection of diagnostic or therapeutic substances into
body cavities, internal organs, joints, sensory organs, and the
central nervous system
What Do I Have to Do?
 Comply with regulations
 Demonstrate compliance and adherence
 Educate and train
 Evaluate
 Improve
CMS Conditions for Coverage
 New ASC CfC effective May 18, 2009
 Interpretive Guidelines extensively updated and
reflect the new CfC
 Added a CfC on Infection Control
CMS Conditions for Coverage
 416.51(a): Provide function and sanitary
environment
 Food sanitation
 Cleaning and disinfection of environmental
surfaces, carpet and furniture
 Disposal of regulated and non-regulated waste
 Pest control
 Monitoring compliance is required
CMS Conditions for Coverage
 416.51(b): Infection Control Program
 Designed to prevent, control and investigate infections
and communicable diseases
 Based on nationally recognized guidelines
 Led by individual who has training in principles and
methods of infection prevention and control
 Must be integral part of the ASC’s quality assessment
and performance improvement program
 Provides a plan of action for preventing, identifying
and managing infections and communicable diseases
and for immediately implementing corrective and
preventive measures that result in improvement
CMS IC Surveyor’s Worksheet
 Reviews elements of the program
 Observations
 Tours throughout the facility
 Interviews with staff with focus on those who do
procedures
 Required that surveyor follow at least one patient from
admission, through surgery and recovery, to discharge
 Observe for compliance with multiple CfCs, particularly
at transition points and in the OR
Other Relevant Regulations: OSHA
 OSHA Bloodborne Pathogens Standard
 29 CFR Part 1910.1030. Occupational Exposure to Bloodborne
Pathogens; Final Rule; 12/6/91
 OSHA BBP 1/18/01 revision
 Occupational Exposure to Bloodborne Pathogens: Needlestick and
Other Sharps Injuries; Final Rule 4/18/01
 Hazard Communication
 29 CFR 1910.1200
 Respiratory Protection
 29 CFR 1910.134
 Occupational Injury and Illness Recording and Reporting
 29 CFR 1904
Infection Control Program:
Services Provided
 Anesthesia
 Environmental Services
 Linen
 Nursing Services
 Pharmacy Services
 Sterilization/Reprocessing Services
 Waste Management
Infection Control Program:
Required Elements
 Must have a written plan
 Directed by qualified, licensed professional
 Based upon nationally recognized guidelines
 Evidence of compliance
 Surveillance system
 Notifiable diseases reporting
 Staff education and training
How Do I Do What I Have To Do?
 Begin with risk assessment so you know
what needs to be done and where to focus
efforts and resources
 All things should stem from that risk
assessment
 Provides you with the training, education
and evaluation framework
IP Program Elements
 Risk assessment based upon services and
procedures, patients and community served
 Plan must outline goals and objectives of the
program
 Defined prevention and control strategies
 Written plan includes surveillance as well as
prevention activities
 Authority statement
Based upon information provided by Terrie Lee RN MS MPH CIC, Director, Epidemiology and Employee Health, Charleston Area
Medical Center, Charleston WV
IP Program Elements
 Communication and reporting processes
 Emergency management and planning
 Education of staff
 Education of self
 Evaluation of program effectiveness
Infection Control Practices
 Hand hygiene (including glove use)
 Safe injection practices
 Disinfection and sterilization
 Environmental infection control
 Safe use and handling of Point of Care testing
devices
Infection Control Practices: Hand
hygiene
 Measured by observation, interview
 Cleaning hands after glove removal
 Patient to patient without cleaning hands or changing
gloves
 Use ABHR on gloves
 Gloves not accessible where they are needed/used
 Soap and water as well as ABHR available
 ABHR stations installed correctly (42 CFR 416.44(b)(5)
Infection Control Practices: Safe
Injection Practices
 Needles used for only one patient
 Syringes used for only one patient
 Medication vials always entered with a new needle and

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syringe
Medication prepared in clean area
No community IV bags
No community tubing or components
Can do incremental dosing but must be same syringe, same
drug; required intraoperatively; no opportunity for reuse on
another patient
Acute Hepatitis C Virus Infections Attributed to Unsafe Injection Practices at an
Endoscopy Clinic --- Nevada, 2007. MMWR May 16, 2008 / 57(19);513-517 .
Infection Control Practices: Safe
Injection Practices
 Pre-drawn medications are completely labeled
 Multidose vial use
 Disinfect diaphragm before use
 New needle and syringe
 Vials are discarded within 28 days or manufacturer’s expiration
date WHICHEVER COMES FIRST
 Vials dated when opened
 Not stored or accessed in immediate vicinity of patient
Infection Control Practices: Safe use and
handling of Point of Care testing devices
 Most common example are blood glucose
monitors
 Must clean between uses
 Must use new, autodisabling lancet for each use
 Must follow manufacturer’s recommendations
regarding use and disinfection
 Do not rely upon alcohol as a disinfectant in
shared use situations
Infection Control Practices:
Disinfection and Sterilization
 Pre-cleaning always performed
 Surgical instruments sterilized
 High level disinfection for semi-critical items
 Items coming in contact with non-intact skin or
mucous membranes
 Flexible endoscopes
 Laryngoscope blades
Infection Control Practices:
Disinfection and Sterilization
 Chemical indicators in each load
 Biological indicator run at least weekly and with each implant





load
Mechanical indicators monitoring each load
Documentation maintained for each load
Equipment has routine preventive checks and maintenance
Scopes must be soaked then adequately dried before use
Storage of instruments and scopes prevents contamination
Infection Control Practices:
Environmental Infection Control
 Operative areas cleaned with EPA-registered
disinfectant between cases/procedures
 Operative areas terminally cleaned daily
(including endoscopy suites)
 Special attention to high-touch surfaces
 Procedure in place for cleaning spills
 Must assure services of contract ES personnel
Additional Critical Practices
 Best Practices associated with prevention of
surgical site and other infections
 Skin preparation
 Antibiotic timing
 Elimination of unnecessary devices asap
 Care and maintenance of IV lines
 Look at updated guideline regarding
prevention of device-related BSI
Knowing is not enough; we must apply. Willing is not enough;
we must do.
Johann Wolfgang von Goethe
Do or do not……there is no try.
Yoda
Where the willingness is great, the difficulties cannot be great.
Niccolo Machiavelli