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Ambulatory surgery found lacking in proper infection control procedures
Experts offer advice on being prepared for your survey
[This special issue of Same-Day Surgery focuses on the most significant infection control issues facing ambulatory surgery managers. In our cover package, we tell you about a recent pilot study that found infection control practices were lacking, and we share lessons learned. Also in this issue, we tell you about a new guideline from the Society for Healthcare Epidemiology of America (SHEA) regarding the management of providers who are infected with hepatitis B, hepatitis C, and HIV. We let you know how this guideline will impact your day-to-day practice.]
Just when you thought it was safe to go back in the OR ... ambulatory surgery has come under the microscope yet again for its infection control practices.
Research presented at a recent international conference showed that in a pilot test of a new audit tool, two-thirds (68%) of the 68 surveyed ambulatory surgery centers (ASCs) had one or more lapses in infection control. Almost one-fifth (18%) had lapses in three or more of the five categories that were evaluated.1 The infection control lapses and percentage of ASCs that experienced them were:
"The findings of this study serve as a wake up call, a reminder, to all health care facilities," says Melissa Schaefer, MD, medical officer in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta and lead author of the study. "We looked at ASCs in particular, but for all providers there are guidelines, and they need to take responsibility for their practices, review the guidelines, and make sure their staff are [following] them," Schaefer says. (For a list of evidence-based guidelines, see below.)
Ambulatory surgery doesn't mean lesser quality of care, she emphasizes. "It doesn't make unsafe care," Schaefer says. "They're held accountable to the same standards as hospitals and other health care facilities."
However, hospital-based programs also have their issues. A quality report from the Agency for Healthcare Research and Quality (AHRQ) says that little progress has been made in eliminating health care-associated infections.2 The report says that postoperative sepsis showed an annual increase of 8%, and postoperative catheter-associated urinary tract infections showed an increase of 3.6%.
Use the audit tool to self-assess
For surgery centers, the infection control audit tool used in the pilot test has been refined and is now part of the Medicare survey. About one-third of non-accredited surgery centers will be surveyed this year by the Centers for Medicare and Medicaid Services (CMS).
Researchers who reported on the pilot test say, "ASCs are encouraged to review the new audit tool, related requirements, and evidence-based guidelines as part of efforts to ensure adherence to basic infection control and enhance patient safety."1 [A copy of that survey tool is included.]
Ambulatory surgery mangers can use the survey tool to perform a self-assessment, says a CMS official, who spoke on condition of anonymity, according to department policy. "It's been very helpful to use and identify where some of their weaknesses are or where they have a lot of questions," she says. Providers should pay special attention to the areas of the survey that showed lapses in the pilot test: medication and injection safety, disinfection and sterilization, environmental cleaning and sanitation, and point-of-care devices (glucometers), the official says.
One of the biggest challenges
One of the major problem areas for outpatient surgery infection control is improper hand hygiene, including failure to wash hands after contact with body fluids. According to CMS, surveyors will evaluate correct installation of alcohol hand rub dispensers and correct use of soap and water, alcohol hand rubs, and gloves. (For more information on gloves and other problem areas in outpatient surgery, see story, p. 64.)
Improper hand hygiene is "ever our challenge," says Marcia Patrick, RN, MSN, CIC, director of infection prevention and control at MultiCare Health System, Tacoma, WA, and a member of the board of directors for the Association for Professionals in Infection Control and Epidemiology (APIC). "Hand hygiene is the cornerstone of good infection prevention," Patrick says.
The ASC pilot study indicated a lack of hand hygiene when people were in contact with blood and body fluids and between patients, she says.
"We just can't do that," she says. Staff members have to sanitize their hands by washing or with an alcohol-based gel between patients and between tasks on a patient, if they are going from a dirty to a clean task, Patrick says. .
Ambulatory surgery managers might particularly struggle with getting their staff to use proper hand hygiene because of the perception that their patients are mostly healthy and, thus, aren't particularly at risk, she says. Other issues might be the busyness of the outpatient setting and also availability, she says. "If you only have one sink back in a corner behind some equipment, it's not going to get used because it's not convenient," Patrick says. That problem can be common in surgery centers and office-based suits because the buildings might not have been originally intended for medical use, she says.
In such environments, alcohol-based hand products can be boon, Patrick says. When hands are visibly clean, just contaminated, alcohol-based products work well, she says. Ensure the products have at least 60% alcohol, she advises. Many products on the market have good emollients in them, which makes them easier on skin then soap and water, and faster, Patrick says.
Staff who wash their hands should scrub with soap for 15-20 seconds, then rinse and dry, she says. "The average hand wash of a health care workers is about 7 seconds," Patrick says. "Running hands under water with a little soap doesn't accomplish much."
This area is 'absolutely huge'
Another problem area for reducing health care infection is injection safety, Patrick says.
"This is absolutely huge," she says.
The 2008 case at a Nevada endoscopy clinic brought this issue to the forefront in ambulatory surgery, Patrick says. In one facility, staff would draw propofol from a single-user vial and then inject the propofol into an IV line some distance from site, she says. "If they needed more propofol, they would use the same needle and syringe and get propofol, which is fine if they threw the vial out at the end of the case," Patrick says. "But they would continue to use that vial on the next patient. The vial was contaminated because it was re-entered."
Additionally, at the end of each day, there would be some propofol left in the vials, she says. A staff person collected all the leftover propofol and put it into a single bottle, which was used for patients the next day, and it was all contaminated. "They're testing 63,000 patients for hepatitis because of this," she says.
And the problem continues, Schaefer reports. The ASC pilot study found 18 facilities where single-dose vials were being used for more than one patient, she says.
HONOReform (www.honoreform.org) is an organization dedicated to safe injection practices by advocating "one needle, one syringe, one patient," Patrick says, "and we probably could add `one time' to that," she says. Don't be penny wise, and pound foolish, Patrick warns. "Propofol is expensive, but giving someone hepatitis C is morally irresponsible and causes lifelong problems for that patient," she says. "It's the leading reason for liver transplants."
In summary, ensure you're providing thorough training and oversight about evidence-based guidelines, and follow up, Schaefer emphasizes.
"You might have adequate policies and procedures, but if that doesn't translate down to the staff level to a person performing them, it's not being done," Schaefer says.
Evidence-Based Infection Control Guidelines
Stumbling blocks include equipment reprocessing
Other woes: gloves, glucometers, SUDs, and cleaning
Five hundred patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at a hospital in British Columbia, Canada, have been warned that they might have been infected with a bloodborne pathogen after instruments were improperly cleaned, according to published reports.1
Equipment reprocessing is one of the major problem areas in outpatient surgery infection control. A recent survey conducted by Millennium Surgical Corp. in Narberth, PA, said "a variety of staff members with different levels of sterilization training and experience" is the overwhelming obstacle to proper instrument reprocessing.2
One critical step is thorough cleaning before high level disinfection or sterilization, says Marcia Patrick, RN, MSN, CIC, director of infection prevention and control at MultiCare Health System, Tacoma, WA, and a member of the board of directors for the Association for Professionals in Infection Control and Epidemiology (APIC). Additionally staff should take the time to ensure sterilizers have annual maintenance, that they are calibrated and working properly, and that spore testing is being performed, Patrick says. For high level disinfection, perform a dip stick prior to each use, she says.
According to the Centers for Medicare and Medicaid Services (CMS), flash sterilization should not be the routine method of unwrapped/uncontained processing.3 If an ambulatory surgery program routines performs flash sterilization, they will be cited, says a CMS official, who shared information on condition of anonymity, according to department policy. Two question to ask yourself, according to the official:
With disinfection and sterilization, shortcuts lead to citations, says the official, who lists the following warning flags:
Other problem areas in ambulatory surgery infection control are:
Because of problems with hand hygiene compliance, it's particularly important to wear gloves, Patrick says.
"That's standard precautions," she says. "If it's wet, they should have gloves on."
Education is key to "getting people to understand, even though these are relatively healthy people, you never know when someone might have HIV or hepatitis B or C," Patrick says. "You don't want that on your hands and cuts and sores. The risk is quite low for bloodborne pathogenshepatitis or HIVbut it's not zero."
Additionally, staff members need to gel or wash their hands when they take off their gloves, because gloves "are not perfect," she says.
While bite blocks probably are sturdy enough to reuse and don't look disposable, anything labeled single use cannot be reprocessed and reused by a facility that isn't licensed by the Food and Drug Administration as an approved third-party reprocessor, says Patrick. "It's against the law," she says.
If a surgery program uses a glucometer, the manufacturer's directions indicate that it can be used on more than one patient, according to the CMS official. A single use, auto-disabling lancet is used for each patient, she says. Additionally, the device should be cleaned and disinfected after each use, the official says.
After a surgery, use disinfectant to clean, Patrick says. If someone touches the patient, then touches a drawer or cabinet, the handle needs to be wiped, she says.
Anesthesia carts are one of the "gaps" in the infection control process, Patrick says. When the anesthesia provider has become contaminated with saliva after intubation, and he or she takes items on and off the cart, the cart is contaminated, she says. "It shouldn't be used with another patient," she says.
Items that should be cleaned between patients include blood pressure cuffs, pulse oximetry problems, gurneys, and wheelchairs, Patrick says.
"A lot of this is very basic," she says.
Providers can request a free reprocessing poster from Millennium Surgical Corp. in Narberth, PA. The posters contain the critical steps of instrument sterilization as outlined by the Association of periOperative Registered Nurses (AORN), American National Standards Institute/Association for the Advancement of Medical Instrumentation (ANSI/AAMI), The Joint Commission, and the Centers for Disease Control and Prevention (CDC). The posters were developed with former AORN board member Rose Seavey, RN, MBA, CNOR, CRCST, CSPDT, to serve as a reminder of accreditation standards. Facilities can request the posters by filling out an 11-question survey at www.millenniumsurgical.com/poster.