Healthcare associated infections have long been considered a hospital problem, but with 75 percent of surgical procedures in the United States being performed on an outpatient basis, ASCs need to address the issue of HAIs as well. HAIs are responsible for 1.7 million deaths per year, one-third of which are preventable. ASCs are built on the reputation of being a superior option to hospitals and if this is the case ASCs must not only meet, but exceed hospital standards for infection prevention.
Chuck Peck, MD, managing director of Navigant Consulting and leader of clinical and operational effectiveness, and TK Miller, MD, associate professor of surgery at Virginia Tech/Carillion School of Medicine and medical director of Roanoke Ambulatory Surgery Center and Carillion Outpatient Surgery, discuss 10 tips for ASCs to build and implement a standardized infection prevention program.
1. Be aware of current guidelines and regulations. Before creating a program, ASCs need to know the current guidelines and regulations dictating proper infection prevention and control in a healthcare setting. Compliance with current guidelines and regulations will create the basis of your infection prevention program.
Current Centers for Disease Control guidelines state:
• Patients should take an antiseptic shower the day before arriving at surgery center
• Any necessary hair removal should be done immediately before the procedure
• The surgery site should be prepared with an antiseptic; preferred agents should provide rapid, persistent, broad-spectrum antimicrobial activity (e.g., 2 percent Chlorhexidine Gluconate/70 percent Isopropyl Alcohol formulation)
• The surgical team should wash their arms and forearms before the procedure
• ASCs and all healthcare organizations must have established protocols to prevent the transmission of infection from staff to patients
• Patients should be given an antimicrobial prophylaxis prior to the procedure
In 2009, CMS began enforcing new conditions for coverage of ASCs. The most important CMS conditions include having written policies and procedures that minimize communicable infections and maintaining contact with a trained infection prevention individual. 
2. Regularly work with a licensed and trained infection prevention and control individual or team. CMS guidelines stress the need for ASCs to work with at least one person licensed and trained in infection prevention and control, if not an infection prevention team. ASCs should require that an individual or team assisting with infection prevention have documentation proving qualifications.
"Certification is not required unless specified by state laws, however the better you do at showing that your infection control officer has the best possible certification and training, the better you do if there is ever discussion about problems that occur," said Dr. Peck. A verified infection prevention expert will be able to facilitate the creation and realization of an effective program.
3. Know your patient base. Each ASC needs to be familiar with the culture of the patient population it serves. A patient community can constitute an at-risk population before any individual even enters the surgery center. If this is the case, institute protocols to mitigate the risk of patients bringing infection to the center or catching an infection at the center. The CDC requiring patients take an antiseptic shower the day before surgery "is much more difficult in an ambulatory setting to get patients to buy into," said Dr. Miller. "Assume patients won't, even given directions. Give an onsite chlorhexidine scrub the day of surgery."
4. Know your environment. Each ASC is going to have a unique environment and it is vital to understand this environment in order to create a standardized program that will work for your ASC. External housekeeping services should be spot checked to ensure outside staff is in compliance with current guidelines and regulations. Monitor the positive and negative air pressure gradients, temperature and humidity levels, number of air changes per hour and potential security risks. Ensure none of these factors contribute to an environment conducive to spreading infection.
5. Strengthen your first line of defense. Infection prevention begins with your staff. Hand hygiene and employee health are the first steps in assembling a successful infection prevention program. According to Dr. Peck, regulatory agencies prefer alcohol-based hand rubs. Dr. Miller explained that the "use of an alcohol-based hand rub can increase compliance with recommended hand hygiene practice by requiring less time and irritating hands less." Instruct your staff to begin each day with a hand scrub and place scrub stations throughout the ASC.
Enforced employee health protocols are one of the most important first steps in infection prevention. In addition to basic hand hygiene, staff should be aware of potential risks and how to mitigate these risks. A recent study of ICU nurses found that the skin beneath rings represented an area of substantial risk for gram-negative bacteria growth. Staff should always change their gloves, be aware of the risks jewelry can entail and avoid artificial nails.
The number one violation recently found in ASCs and an area CMS is heavily focusing on is the use of single-use vials for more than one patient. Your staff should strictly adhere to safe injection, infusion and medical vial practices.
6. Create a culture of infection prevention. Create and reinforce specific protocols for infection prevention that become a part of the staff's daily routine. Cleaning, disinfection and sterilization protocols, once learned, will be both easy to follow and a strong element of your ASC's program.
Before sterilization, instruments should be decontaminated with detergent, enzyme cleaner and water. "Effective sterilization cannot occur without effective cleaning," said Dr. Miller.
Sterilization should be done with an FDA approved chemical agent and flash sterilization should be kept to a minimum. Your staff should label sterilized items with the date of sterilization, the sterilizer used and the controlled conditions in which it was done.
Once items are properly sterilized, it is important to follow proper storage guidelines to ensure supplies remain sterile. Your storage area should never be over 75 degrees Fahrenheit or over 75 percent humidity. All items should be kept 8" to 10" off the floor and 18" away from sprinkler heads. Avoid using cardboard, which can be accidentally penetrated. Train your staff to rotate supplies in order to track what the center has and quickly notice any compromised items.
7. Involve your physicians. Physicians, as well as your healthcare staff, need to participate in the prevention program. "There has to be an active surveillance program. This means monitoring and feedback from staff and physicians," said Dr. Peck. Require patients to give feedback so you can effectively track postoperative infections. Physicians follow up with their patients and flag any potential risks.
A case study revealed that Lakeland Surgical and Diagnostic Center had two physicians and an epidemiologist staffing an infection control committee. The case study found that increased physician involvement on the front end led to fewer infections.
8. Provide administrative support. Administrative support is key to maintaining effective infection prevention, and Dr. Miller and Dr. Peck suggest holding obligatory recorded staff-wide meetings at least once every quarter. At these meetings, ASC administrators can outline the prevention program, highlight staff strengths, go over any areas that need improvement and discuss any updates in regulations that would necessitate a change in the program. "Each staff member is required to be present or review the recording," said Dr. Peck of physicians at his center.
9. Constantly document and track. "Tracking results is critical to demonstrating effectiveness," said Dr. Miller. Your staff should be responsible for documenting each step taken to prevent infection.
"Record keeping is an absolute must. If it is not documented and written down then assume no one will believe it happened," said Dr. Peck. Two important areas to document are bacterial reduction due to employees adhering to hand hygiene protocols and the amount of time your infection control officer spends on the program at your ASC.
CMS requires ASCs to maintain a four-week tracking period for infections, but for an excellent program Dr. Miller and Dr. Peck recommend a six-week tracking period.
Your staff should be instructed to track all product lot numbers, from the larger items all the way down to sutures. At an ASC where patients had a soft tissue reaction to sutures, the center's staff was able to track an outbreak of patient infection back to a specific group of sutures.
10. Update the program. Your infection prevention program should be designed with adaptability in mind. Regulations and guidelines are not static and once you implement a standardized program you may need to adjust the program tailored for your ASC. "You have to have a means of evaluating and following up on your infection control policies. Revise them when indicated. They are not carved in stone and actually has things evolve there has to be a policy to update and bring everybody on board," said Dr. Peck.
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