EXECUTIVE SUMMARY

Infection control and prevention measures, along with using the most effective filters, can help prevent aerosol infectants, including prions.

• One surgery center encountered a major problem when a patient was diagnosed with Creutzfeldt-Jakob disease post-surgery.

• Minimize risks by instituting thorough infection control policies and procedures.

• Every ASC should obtain the manufacturer’s instructions for each instrument used and document the time, temperature, and method for sterilization.


Prions and Creutzfeldt-Jakob disease are two issues surgery center administrators rarely consider when reviewing infection control and prevention policies and procedures. But these are part of a cautionary tale of why all surgery centers are better off spending extra time and money to develop the best filters and infection prevention equipment and processes.

“I was doing grand rounds for a university in the Southwest, talking about aerosols, when a CEO came over to me and said, ‘Did I understand you that filters can stop prions?’” says James M. Maguire, PhD, who has served as a surveyor for The Joint Commission, provides health education, and is with Maguire Healthcare Consulting in Norwich, VT. Maguire also speaks at national surgery center conferences on operating room aerosols.

Prions cause Creutzfeldt-Jakob (CJ) disease, a condition that results in irreversible and serious brain tissue damage. CJ disease is similar to bovine spongiform encephalopathy, colloquially known as mad cow disease.

Maguire told the CEO that one company claims its filters can stop prions. Then, the CEO told him a story about a surgery patient who was discharged without incident — but two weeks later, the facility heard that the patient had contracted CJ disease. After meeting with risk planners and attorneys, facility administrators realized that they had to contact all patients who had used the same ventilator during the two-week period to notify them of possible exposure to prions.

“They’ll have to follow them medically for the next 25 years because that’s how long it takes,” Maguire says. “And they’ll have to throw away the anesthesia machine, and in the long run it will cost them hundreds of thousands of dollars.”

If any patients develop CJ disease, it will cost them even more, Maguire adds. This could have been avoided if the surgery center had purchased the most effective filters. Better filters might increase supply costs, but the tradeoff is better infection prevention and control.

“The price of these filters is $3 or $3.50 for the best ones,” Maguire says.

Risk of exposure to prions might be remote, but there are plenty of reasons why ambulatory surgery centers (ASCs) must pay greater attention to sterilization processes, infection control rules and regulations, and staff workflow habits.

The chief reason to focus on infection prevention and control is that infections can be devastating to patients and their families. Knowing that a patient became infected post-surgery also can affect staff morale, says Tammeria Tyler, RN, CIC, infection preventionist and quality, and chief post-acute care unit nurse at Southeastern Spine Institute Ambulatory Surgery Center in Mt. Pleasant, SC.

“We try so hard to do everything right,” Tyler notes. “If there’s a patient infection, we all get bummed.”

To ensure best practice and maximize outcomes, it is important that optimal infection control practices are implemented in every ASC. While it is true that ASCs demonstrate very low infection rates, quality demands that all infections are investigated to identify and implement corrective actions to improve outcomes.

“For every action taken within the ASC, it is important that the staff knows why they do what they do and what is the regulation or rule that governs each action,” says Elethia Dean, RN, BSN, MBA, PhD, chief executive officer of ASC Compliance in Columbus, OH.

Understanding the reasoning behind each action and effort in the ASC will assist in adjusting practices to become a best practice in the industry, Dean adds. A few of the most frequent infection control areas of concern are infection control training, instrument care and handling, and hand hygiene, she says.

“Everyone in the ASC must have infection control training, including physicians,” Dean says. “Where infection control can lapse is when everyone has had training, except the physicians. ASCs might feel physicians can have the requirement waived, but they cannot — everyone needs ongoing infection control training.”

Maguire, Tyler, and Dean suggest ASCs improve infection control and prevention by following these steps:

• Use the Centers for Medicare & Medicaid Services (CMS) infection control guide. ASCs should approach infection control from the perspective of a CMS surveyor, Tyler suggests. The CMS ASC infection control surveyor worksheet is helpful. Administrators can use this worksheet annually to check off their own adherence to regulations and standards. (See story in this issue on following the CMS infection control checklist.)

“Use the checklist and go through it as if you were the surveyor, and you’d be surprised at how many things you overlook,” Tyler says. “Everything you do should be policy-based.”

• Follow regulations related to instrument cleaning and sterilization. Surgery centers run into potential infection control problems when instruments are not cleaned and sterilized according to the manufacturer’s directions for use.

“It is imperative that every ASC get the manufacturer’s instructions for each instrument used and document the time, temperature, and method for sterilization, as well as compliance with manufacturer’s recommendations,” Dean says.

Manufacturer requirements for sterilization containers are required, as are the instructions for each type of autoclave present in the ASC, Dean adds. It might be tempting, in an effort to save time, to clean only the instruments that were used during the case, but regulations and industry standards require that every instrument opened during a case must be cleaned and disinfected prior to sterilization, Dean explains. Also, there must be documentation of the time and temperature required for each instrument tray, and there should be evidence of compliance.

“Surveyors will ask for this information during both federal and accreditation surveys,” Dean warns.

• Improve filtration and cleaning procedures. As a surveyor, Maguire would ask to see surgery centers’ procedures for cleaning equipment. He quickly found that only machine exteriors were cleaned.

“When we looked at the machines, it became apparent that you can’t clean the inside of the machines,” he says. “I thought there was something wrong here, something we’re not paying attention to.”

Infectious agents could grow inside equipment, and filters were a main line of defense to keep them from becoming aerosol and infecting staff and patients.

“In these operating room theaters, there is significant airflow,” Maguire says. “Even in rooms with high airflow, there are pockets where air is barely moving.”

Stagnant air can hold aerosol agents. These bacteria and viruses can spread and colonize. Infectious organisms also can spread via air from humans to equipment, even during cleaning procedures. For instance, investigators have found that tap water faucets in healthcare facilities sometimes contain drug-resistant organisms, Maguire explains.

“It turned out the taps were getting contaminated, not from water coming in, but from aerosols coming in contact with the taps,” he says. “When people wash their hands, water can splash up and hit the tap. So whatever is on their hand will get into the tap.”

Also, when cleaning crews sanitize and clean patient rooms and the operating room, there’s always the chance of lax procedures, like someone using the same cloth to clean the bottom of the sink and to wipe the tap, Maguire notes.

“A colony forming in tap water can be huge,” he notes. “Anytime someone turns on that tap, the water, as it rushes past this colony of organisms, has some organisms that slough off and go downstream, and if you wash your hands you come into contact with these organisms.”

Once a tap is infected with a colony of drug-resistant organisms, the only way to get rid of it is to turn up the hot water to a high temperature and hyper-chlorinate the building’s water system over a weekend or in the evening, when fewer people are using the water, Maguire advises. After wiping out the colony, then a filter on the tap can prevent future colonization.

• Improve hand hygiene. “Hand hygiene is the single most important method of reducing infections in the healthcare setting,” Dean says. “So is the problem of wearing masks hanging around the neck.”

ASCs can target hand hygiene with a quality assessment and performance improvement (QAPI) project, Dean suggests. (See the brief on performing QAPIs in this issue.)

The surgery center’s governing body should set standards for its hand hygiene compliance, such as setting a rate of following all hand hygiene policies and procedures at 95% or whatever percentage is greater than what the ASC already achieves, she says.

Surgery centers can focus on staff education, monitoring hand hygiene procedures, and using peer pressure to encourage greater effort and compliance. For instance, an ASC can post a list of staff percentages on hand hygiene adherence in the break room. The list would not include staff members’ names, but each employee would know his or her own adherence percentage. Seeing the high achievers’ results would give staff an incentive to reach for that goal, Dean explains.

“I’d tell an employee, ‘Your number is too low; you’re not washing your hands enough,’” she says. “Then, I’d say that we’re going to check hand hygiene monthly, and the governing board will have different people monitoring on different days.”

Monitors can use their cellphones to record handwashing rates. This is less obvious to employees than if the monitor used a clipboard to record data, Dean adds. Once an audit is complete and data collected, the ASC can use the information to set a baseline for hand hygiene adherence and set improvement goals.

“Keep the information on the wall. Post actual results of where the staff stands with hand hygiene right now,” Dean suggests. “When everyone shows improvement, you can give an incentive, which can be financial or even buying lunch on a surgery day.”

The right incentive will lead to success in achieving compliance. Also, with peer pressure, if the incentive is tied to improvement by every staff member, if there is a member who is not participating, other staff can work with that member to achieve the goal set by the governing body, so that the incentive can be achieved, Dean says.

Providing quality care in the ASC is critical in obtaining optimal outcomes, as well as achieving financial success. Infection control practices implemented within the ASC can lead to positive outcomes and higher patient satisfaction levels, Dean adds.