Historically, ASCs demonstrate very low surgical site infection rates. One study found a surgery site infection rate that ranged from 0 to 3.2% for common procedures.1
Because ASCs experience high patient volumes, any lapse in infection control best practices at an ASC can create major problems. The way to prevent a post-surgery infection outbreak is to follow quality improvement steps in surveillance, detection, analysis, and process changes, says Elethia Dean, BSN, MBA, PhD, chief executive officer of ASC Compliance, an organization that works with ASCs on accreditation and regulatory compliance. Dean offers the following best practice steps in infection surveillance, control, and compliance:
1. Conduct active surveillance to identify post-surgery infections.
“The incubation period for bacteria is usually days or weeks after surgery, so it’s not always possible to identify infections prior to the patient leaving the ASC,” Dean says.
ASCs must actively identify these post-surgery infections, typically up to 30 days out.
One option for infection surveillance would be to ask the patients if they have experienced an infection after the procedure. Some ASCs call patients directly, but there is a drawback: “Some patients interpret redness as a sign of infection,” she notes. “You get better data if you go directly to the physicians.”
2. Look for infection trends.
There are a lot of potential trends, including two or more infections with a common medication, operating room team, specific surgical equipment, equipment sterilization methods, and recovery practices.
“Did you look at when the infections occurred, which day, week, month? Is there a trend where something is happening every Tuesday? Is there a particular physician who has infections?” Dean asks. “Look at everyone who [is involved with] the patient to see if there is a commonality. Look at all staff, instruments, medications given, anything and everything that touched the patient.”
ASCs must ask these questions and investigate every single infection.
“What is required by CMS is that you do active surveillance, and then you will want to make that a part of your quality assurance/performance improvement [QAPI] program,” Dean explains. “Every problem reported into QAPI should be investigated, and infections should definitely be part of QAPI.”
The more data collected and reported, the easier it will be to find trends. For instance, there is not a regulation that requires someone record lot numbers of medications in the medical record. However, if there is an infection outbreak and the causative agent is a particular medication, it will be almost impossible to trace it to a certain lot number, Dean cautions. In this situation, the ASC is at higher risk of taking responsibility for the infection when the problem was actually caused by the medication manufacturer. Therefore, every ASC should keep up to date on medication recalls, regardless of whether patients exhibit infections, Dean recommends.
3. Take action, depending on findings.
If there is no discernible trend, then the ASC could look at differences between the patient who exhibited the infection vs. patients who underwent the same surgery without an infection. This assessment also might show a trend that could suggest better practices.
“Once a comparative analysis has been performed between infectious and noninfectious cases, changes can be made in order to achieve best practice,” Dean says. “This may be a change in medication lot numbers, training of staff, housekeeping changes, etc.”
Some of the usual infection control retraining strategies might include checking staff’s hand hygiene practices as well as cleaning and sterilization procedures.
“Make sure staff are aware of cleaning the OR and know how to maintain a sterile field,” Dean suggests.
4. Follow up on the QAPI process.
“Go back and check to see if there are any more infections and check for trends again,” Dean says.
For example, an ASC might register one infection. Then, the next month, there is another one. The month after that, there’s a third infection. “That’s trending, and you have to look at commonalities between the three,” Dean says. “It’s not that once you finish it, you’re done. Sometimes, you make a corrective action, and that may or may not solve the problem.”
The QAPI process requires restudy of the problem to make sure the corrective action solved the problem effectively. If it doesn’t solve the problem, it could be that there was more than one factor that led to the original infection case, Dean notes.
Although there is not a national infection reporting requirement for ASCs, some states require reporting. When ASCs are inspected, most surveyors will look at reported infections to see if there is a trend and to make sure quality of care is maintained, Dean says.
1. Rhee C, Huang SS, Berríos-Torres SI, et al. Surgical site infection surveillance following ambulatory surgery. Infect Control Hosp Epid 2015;36:225-228.