Ambulatory surgery centers have made significant strides over the past several years in improving their infection prevention efforts, says Phenelle Segal, RN CIC, president of Infection Control Consulting Services based in Blue Bell, Pa. This is critical because how much they have improved is now tested on a more frequent basis than ever before.
ASCs can continue to expect their usual surveys — from accrediting agencies, Medicare, OSHA, the State Department of Health, etc. — and now the U.S. Department of Health and Human Services (HHS) also has ASCs in its sight as it has included ambulatory surgery in its five-year action plan to prevent healthcare-associated infections. Their report for mandatory ASC requirements is about to be released and will spell out requirements ASCs will need to meet intended to help further improve and expand on their process and outcome measures. "The key point here is for ASCs to understand that not only is CMS requiring them to beef up their operations (through the Conditions for Coverage) but HHS is going to mandate they take on additional processes to improve the outcomes for patients in ambulatory surgery," says Ms. Segal.
In a 2008 pilot study, CMS inspectors visited ASCs in three states — Maryland, North Carolina and Oklahoma — and using an audit tool based on Centers for Disease and Control guidelines for prevention of infections, the surveyors found two-third of surveyed ASCs had lapses in infection control and half of the facilities had not undergone full inspection in more than five years, says Ms. Segal. In addition, details from various states are being released on an ongoing basis to the public. For example, in March, a report came out of New Jersey which said of 91 facilities that were surveyed, many of them were in jeopardy due to lack of infection prevention/control best practices.
One of the critical areas where she has seen ambulatory surgery facilities falling short is on safe injection practices, she says. ASCs must recognize that HHS is stepping up protection for patients in the ambulatory surgery setting and they need to make sure all staff members, including physicians, understand the importance of adhering to policies and procedures in place. "You need to look very carefully at all of those safe injection practices," says Ms. Segal. "When surveyed, if there's inconsistency between policies, procedures and practice, they will be cited. We cannot be cavalier. The days of 'it hasn't happened to me, it hasn't happened here in this facility and it won't' are long gone."
Here is a checklist of 12 rules provided by Ms. Segal which ASCs should follow to better ensure compliance with safe injection requirements.
1. Pre-drawn medications must be labeled properly. Medications pre-drawn at the beginning of the day need to be labeled specifically with the time of the draw, initials of the person drawing up the medication, name of the medication, strength of the medication and the expiration date, if the manufacturer has not printed it on the vial, Ms. Segal says. While pre-drawing medications is standard practice, to err on the side of caution, it remains a safer practice to prepare syringes and spike IV bags as close to administration as possible.
2. Single needle and single syringe are used for a single patient.
3. Medication vials are always entered into with a new needle and new syringe regardless of whether that medication vial is dedicated for that patient only. This is very important and a common area of confusion, says Ms. Segal. If an ASC has a procedure taking place and is using one vial of medication, the ASC must always use a new needle and syringe each time a staff member goes into that same vial to draw additional medication even if it's for the same patient and for the same procedure.
"The reason for that is CMS is attempting to get people to have repeated practices that will leave no room for error should there be an incident where there is a possibility for error," she says. "It's like your seatbelt. We had to get to a point where you would be fined if you didn't have your seatbelt on. So now every time you get in the car, you automatically put on your seatbelt. [CMS is] trying to install good practices where every single time you enter a vial, you don't even think about if it's same patient, different patient, same medication or different medication; every time you enter a vial, whether it is a single-use or multi-dose, it is a new needle and a new syringe."
4. Single-use medication vials are used for only one patient and discarded when the vial is empty or at the end of the procedure. "It shouldn't be left lying around so there isn't that room for error where a single-dose medication could be used for someone else," says Ms. Segal. "That's where you can run into trouble."
5. Manufactured pre-filled syringes that may have enough medication for more than one patient must still only be used for one patient and discarded at the end of the procedure.
6. Bags of IV solutions are used for only one patient and discarded at the end of the procedure.
7. Medication administration tubing and connectors are only used for one patient.
8. Multi-dose injectable medications are only used for one patient. ASCs seem to run into problems with this issue, Ms. Segal says. Since it's a multi-dose medication and there's the cost factor to consider, ASCs may not want to discard the medication until all doses are used. While CMS strongly endorses and prefers this practice, "if an ASC chooses to use a multi-dose medication for more than one patient — and only in instances where they must do so because they don't have enough of the medication — the medication must be dated when it is first opened and it must be discarded after 28 days of opening or according to manufacturer's expiration date or lastly, if the package insert states otherwise, whichever comes first," she says.
9. Rubber septum on a multi-dose vial that is used for more than one patient is disinfected with alcohol prior to each vial entry. "Once again, a clean needle and syringe should be used each time the multi-dose medication vial is entered," says Ms. Segal.
10. Multi-dose medications used for more than one patient are not to be stored or accessed in the immediate area where direct patient contact occurs. "That's because they don't want to risk contamination of that vial," she says.
11. All sharps are disposed of in a puncture resistant sharps container. Sharps containers should be replaced when the fill-line is reached.
12. Point-of-care devices — e.g., blood glucose monitoring devices or machines — need to be cleaned with an EPA-registered disinfectant/germicidal wipe. They used to be cleaned with an alcohol swab but that is no longer acceptable, says Ms. Segal. "The most effective germicide for elimination of bloodborne pathogens is bleach," she says. "Therefore, bleach wipes can be used to clean the machine as well. The disinfectant wipes used in the facility are also acceptable."
Before you use either the bleach or disinfectant wipe, make sure to check the manufacturer's instructions for cleaning to ensure these specific products are not harmful to the device or machine.
In summary, Ms Segal says that "it is imperative that ASCs look at developing and maintaining safe practices for patients before they are inspected. Being proactive in today's environment will serve the facilities well and with stellar practices in place, they reduce the risk of being cited."
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