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There’s a New ASC Infection Control Worksheet

October 12th, 2016

The first worksheet on infection control for ambulatory surgery centers was created in 2009. It lead to the implementation of the final infection control worksheet for hospitals published in November 2014. Now the ASC infection control worksheet, exhibit 351, has been revised again.

CMS says the changes were made to bring the infection control worksheet into alignment with current standards of practice. In fact, the worksheet emphasizes that ASCs must follow nationally recognized infection control guidelines. It is also amended to reflect some of the recently issued survey memos and guidance. This worksheet will continue to be used by state and federal surveyors on all survey activity for ASCs when assessing compliance with infection control standards in the conditions for coverage. Therefore, all ASCs should have a copy of this document and should review closely the changes, which are highlighted in yellow.

CMS recommends that all ASCs use this as a self-assessment tool.

The updates focus on many issues including safe injection practices, including disinfecting the rubber septum with alcohol before piercing.

Many ASCs in the past have been cited for unsafe injection practices. If the manufacturer makes it as a single-dose vial then the ASC needs to buy it. If it only made as a multi-dose vial, then try to use it only one patient and never take it into the patient’s room. This includes taking the vial into an immediate care unit such as the operating room, unless it will be used on that patient and discarded afterward.

The worksheet includes a recommendation for the ASC to voluntarily adopt a policy that multi-dose vials will be used for only one patient.

CMS had issued an infection control breach memo May 30, 2014, and if four specific breaches were noted another knock at the door could occur from the state epidemiologist. Here are four of the 10 CDC unsafe injection practices:

  • Using the same (pre-filled/manufactured/insulin or any other) syringe, pen or injection device for more than one individual.
  • Re-using a needle or syringe that has already been used to administer medication to an individual to subsequently enter a medication container (e.g., vial, bag), and then using the contents from that medication container for another individual.
  • Using the same lancing or fingerstick device for more than one individual, even if the lancet is changed.
  • Using the same needle for more than one individual.

The ASC must ensure that its infection preventionist has infection control training. The ASC must have a system to identify infections related to procedures performed; surveyors will look for it. If staph infection-control training is absent, the worksheet instructs surveyors to give the ASC a condition level deficiency. Training should be provided in orientation for new staff and practitioners and periodically afterward.

Other new categories require soap and water or hand sanitizer to be readily accessible. Staff providing direct care cannot wear artificial fingernails or extenders, which is also a CDC hand-hygiene guideline.

There are many additions related to processing and sterilizing equipment. Items should be pre-cleaned according to the manufacturer or, if is none provided, then according to evidenced-based standards. It also covers the use of chemical and biological indicators.

ASCs should carefully review this section to ensure compliance. Staff should be trained and be familiar with all of the sections contained in the ASC revised infection control worksheet.

The ASC revised infection control surveyor worksheet, Exhibit 351, dated June 17, can be found here.

The upcoming webinar covering this topic can be found here:
[Live Webinar] Ambulatory Surgery Centers: Infection Control Standards & Safe Injection Practices from CMS
or contact us at [email protected] or 800.688.2421 for additional information.

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