4 Commonly Cited ASC Infection Prevention Survey Deficiencies
Commonly cited survey deficiencies
1. Written materials are needed, yet are absent, incomplete or insufficient to meet standards. Ambulatory surgery centers need written documentation of the following as it relates to infection prevention, according to Ms. Wallander:
• Governing body formal meeting minutes demonstrating consideration, selection, approval and implementation of the infection prevention program
• Policies and procedures
• Required recordkeeping, such as surveillance and equipment processing logs
• Evidence of delegation of responsibilities to a trained and qualified healthcare professional
Ms. Wallander suggests keeping a master set of policies and procedures in an electronic format for easy access and update. "If you're housing multiple copies of paper policies and procedures, you need to be particularly diligent in making sure every copy is updated," she says.
2. Inadequate cleaning, disinfection and sterilization of instruments, equipment and supplies. Professional organizations, such as the Association for the Advancement of Medical Instrumentation, the Centers for Disease Control and Prevention and the Association of periOperative Registered Nurses have standards for cleaning, disinfection and sterilization that healthcare providers should follow. Here are some other tips to avoid pitfalls in cleaning, disinfection and sterilization, according to Ms. Patrick:
• Follow written manufacturers' instructions or nationally recognized guidelines, whichever is more stringent, for processing.
• Have adequate supplies, such as brushes, indicators, peel packs, pans, etc.
• Wear proper personal protective equipment.
• Ensure staff are well-trained and understand the process.
• Allow adequate time for processing.
• Establish unidirectional flow from dirty to clean.
• Autoclaves must have a printout of each cycle so load parameters can be validated for each cycle.
Immediate use sterilization
Immediate use sterilization is an area of sterilization that can present additional patient safety risks if it is not done properly. Here are some tips from Ms. Patrick and Ms. Wallander:
• Do not substitute immediate use for adequate numbers of instruments.
• Monitor what is being sterilized via immediate use.
• Use proper wrappers or caskets for immediate use sterilization.
3. Not adhering to safe injection practices. There are nationally recognized guidelines for safe injection practices that ASCs need to formally adopt and document in formal meeting minutes. The CDC's One and Only Campaign is a useful resource for guiding safe practices, according to Ms. Patrick. Here are some other tips:
• Use the most current version of safe injection practices.
• Educate staff.
• Conduct surveillance to ensure adherence.
• Draw medication away from direct patient care areas, not the operating room or treatment room, at time of use. A dedicated space is best.
• Spike IV bags when ready to use, not before. Do not exceed one hour between spiking and administration.
• Ensure hand hygiene before prepping and giving medication and accessing IV ports.
• Label multi-dose vials when opened with a discard date in 28 days. Give drawn medication within one hour.
4. Insufficient surveillance of infection prevention practices. Healthcare organizations should use surveillance to identify deficiencies in processes and outcomes for high-volume and high-risk procedures. The CDC's National Healthcare Safety Network is a helpful resource for learning about surveillance definitions and benchmarking data, according to Ms. Patrick and Ms. Wallander.
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