ASCs need to build an infection prevention program that is managed by someone with knowledge and training in infection control.
Some states mandate that ASCs employ a certified infection preventionist or a nursing certified infection prevention consultant. The Centers for Medicare & Medicaid Services (CMS) requires surgery centers to develop a plan for preventing infections and to designate someone to be the quality and infection prevention officer, says Donna Nucci, RN, MS, CIC, infection preventionist at Yale New Haven Hospital and owner of Educated Nurses LLC.
“In ambulatory surgery, one of the challenges is that a lot of surgery centers have nurses taking care of the infection prevention portion and also working in the operating room or recovery room on a daily basis,” Nucci says. “What Medicare is trying to say is that it’s not enough to say that Mary who works in the OR is in charge of the infection prevention and quality program.”
ASCs must be able to answer these questions:
- How are you preventing infections?
- How are you preventing skin abrasions?
- Who is going to be your quality and infection prevention officer?
- Who is taking charge of determining why there were three needlesticks in the past month?
- Who will conduct a root cause analysis and put a process in place to prevent it?
- Who investigates incidences of infection?
- Who has adequate experience and tools to complete an investigation?
“I think there’s a push from Medicare to say that if you’re a single ASC, then you have to think about what kind of infrastructure you’re going to build to ensure the same kind of patient safety that a larger organization is doing,” Nucci explains. “The pushback I hear from physicians is, ‘They don’t pay us the same as hospitals,’ but Medicare does not take that into account.”
A first step for ASCs is to decide on the duties for an infection preventionist. Many ASCs could combine the roles of infection prevention and quality improvement.
“They go hand in hand, and the type of training is similar,” Nucci says. “Quality care is about preventing infections.” Also, the role of a quality improvement director is not as complicated in an ASC as it would be at a hospital system, Nucci notes. “You don’t have admissions to the emergency room, and you don’t have exactly the same types of things for quality measures in an ambulatory setting, so it’s easy to merge them together,” she says. “In surgery centers with under five employees, their nursing director can do infection prevention and quality improvement as well.”
For larger ASCs, one nurse could dedicate six to seven hours a week to quality improvement and infection prevention, Nucci adds. ASCs also could contract with an infection preventionist to conduct training, formulate a risk assessment plan, and monitor processes.
Accreditation organizations require ASCs to conduct quality projects annually, and some want the surgery center to show a quantifiable improvement in patient outcomes. Such projects could involve hand hygiene monitoring, surgical site infection prevention, and reducing occupational exposures.
Results of QI projects are reported to the surgery center’s medical board in an annual report. Infection preventionists also must keep up on product and process updates from regulatory agencies, accreditation organizations, and device and equipment manufacturers.
For instance, Nucci, who follows changes for her ASC clients, recently sent an alert on reprocessing endoscopes. She also published a newsletter on her website about infection prevention tips, including:
- Evaluate exposure risks. Choose gloves, gowns, eye, face protection for durability, and appropriateness for the task;
- Droplets of blood or other potentially infectious material pose a hazard to the eyes, nose, or mouth. Wear masks in conjunction with eye protection, such as goggles or glasses with solid side shields or chin-length face shields to reduce risk of exposure.
Each surgery site’s infection prevention liaison will need training and access to regulatory and accreditation updates. “They should review it, and then provide information at staff meetings, making sure the information is well documented,” Nucci suggests.
Nucci outlines other ways to ensure an ASC’s infection prevention liaison can fulfill the job adequately:
• Find the right person for the job. The infection preventionist should be detail-oriented, well-organized, pragmatic, and a good communicator, Nucci says. “The person has to be a good educator and willing to educate staff,” she says. “The person needs to be a quick learner or lifelong learner, someone who likes to learn new things and stay up to date on new guidelines.”
Infection preventionists need to increase their knowledge base by attending conferences and other venues to learn more.
• Dedicate hours for the role based on ASC’s volume. A surgery center’s need for infection prevention work depends on its size and volume, which determine patient risk.
“Think about how many surgeries the center is doing in one year, and how many employees the infection preventionist will be in charge of training each year,” Nucci says. “For smaller centers of under 100 cases a month, it might be OK for the nursing director to do that role because she has only one other nurse and a handful of physicians to train. Those with 40 to 60 procedures a day will need someone who can devote eight hours a week to the job.”
• Outline the preventionist’s tasks. Infection preventionists will train staff on infection prevention, conduct surveillance, and monitor staff for hand hygiene compliance.
They also will conduct prevention improvement projects, develop competencies, and keep up with the newest methods for preventing infection.
“The staff member needs to develop and maintain a program that actively prevents infection for each patient who walks through the door,” Nucci says. “They do valuable risk assessment for the facility, including looking at the types of surgeries, volume of surgeries, and the post-op infections that might be involved in those types of surgeries.” Then, this staff member formulates a plan to educate staff, physicians, and patients on what to do to prevent specific infection risks.
• Work with ancillary staff. “Infection preventionists work with ancillary, nonlicensed staff in the facility, providing education and, in the wording from Medicare, ‘consistent and comprehensive education update for licensed staff, physicians, and nurses ... and persistent competency and audit for nonlicensed staff,’” Nucci says.
For instance, if a surgery center is reprocessing a few thousand instruments per week and turns over 20 to 40 cases a day, then two additional members of the staff will need competency training in infection prevention, she adds.
• Formulate a plan. The infection prevention liaison should be an LPN or RN, and the person should have some amount of designated time to formulate an infection prevention plan, come up with a consistent message, and conduct audits, Nucci says.
“Auditing is very important with The Joint Commission, AAASC, other accreditation organizations, and state surveyors,” she says. “They want to see someone who is not working in the operating room or sterile processing area actually auditing what staff members are doing.”
Liaisons might want to watch employees scrub their hands, ensuring everyone is scrubbing into surgery, according to national guidelines, and monitoring how surgeons prepare the surgical site with a single-use sterile prep, according to manufacturer instructions.
“Are they using DuraPrep appropriately or the waterless scrub appropriately? Audit, monitor, and document staff members to make sure they’re competent on those high-risk prevention methods,” Nucci says. “They should also do chart reviews for antibiotic prophylaxis and perioperative normothermia prophylaxis. Those are two other quality measures that you can’t do while working in the OR, so schedule time off to do the chart reviews, and make sure those measures are meeting national standards.”