Infection Control Plans in Ambulatory Surgery Centers: Plan to Succeed!

Author: Jennifer Bender MPH, BSN, RN, CIC,

Undeniably, ambulatory surgery centers (ASCs) are playing an increasingly important role in the US healthcare system, with almost 70% of surgical procedures being performed in an ambulatory setting—many of which are performed in a same-day surgery center, or ASC.¹ Given the rapidly increasing number of procedures performed in this setting, national programs to measure and improve the quality of care provided in ASCs are essential.

A Centers for Disease Control and Prevention (CDC) report published in 2010 found that ASC lapses in infection control were common. Of 68 ASCs, most (67.6%) had at least one infection control finding. Common findings included using single-dose vials for more than one patient (28.1%), equipment reprocessing failures (28.4%), and blood glucose monitoring equipment failures (46.3%).²

In June of 2015, the Center for Medicare and Medicaid Services (CMS) released an update to the Ambulatory Surgical Center Infection Control Surveyor Worksheet (ICSW), which is used by federal and sometimes state surveyors to determine infection control program compliance as pertains to the Conditions for Coverage (CfC) requirements.³ As part of the survey requirements, ASCs must have both an explicit infection control program and documentation that the program follows nationally recognized infection control guidelines. Most, if not all, facilities refer to this document as their “infection control plan.” The aim of this document is to walk through some of the essential pieces of an ASC infection control plan and thus help the facility to plan to succeed both in any potential infection control survey and at preventing infections related to procedures performed within their walls.

Risk Assessment

A risk assessment is a companion document to the infection control plan. It should identify risks specific to the facility to allocate infection prevention resources appropriately and to inform planned activities under the infection control program. A facility should perform a risk assessment at least annually and consider:

• Community (rural/urban, potential natural disasters),
• Population (age demographics, characteristics, available health statistics),
• Facility/utility (age of building, HVAC considerations, connections with other buildings, any potential construction projects),
• Staff competencies,
• Services and procedures offered (treatments, procedure types, pharmaceutical/compounding considerations, infections likely to occur, low-vs.-high volume procedures),
• Patient care/Infection Control Practices (Personal Protective Equipment (PPE), Isolation, Hand Hygiene, Injection Safety)
• Staff Immunity (New hire health screening and annual vaccination program)
• Medical Devices (Selection, cleaning/disinfection/sterilization, water reservoirs, handling and storage)
• Facility Type (orthopedic, dental, etc.)
• Patient Safety (Healthcare-associated infection surveillance and trending, requirement for day-of-procedure screening, other quality outcomes trending)⁴

A risk assessment may also be considered any time a facility makes a major change – things that may prompt additional risks (and therefore an additional risk assessment) include but are not limited to adding a building, service line, or procedure type.

Occupational Health

Staff training is key to a successful infection control program – everything can be perfect on paper, but if employees are not aware of policies and procedures, lapses are all but guaranteed. According to the CMS ICSW, facilities can be cited at the condition-level if infection control training is completely absent. Ideally, all staff should be trained on hire and annually on the IC program.

Vaccinations are essential to prevent healthcare workers in all settings. Vaccinations recommended by the CDC for healthcare works include COVID-19, chickenpox (varicella), influenza, Hepatitis B, meningococcal, measles, mumps, and rubella (MMR), and tetanus, diptheria, and pertussis (Tdap).  Healthcare workers may also be recommended to be up to date on human papillomavirus(HPV) or shingles (varicella) vaccines depending on their age or other factors.⁵

All newly hired healthcare personnel should be screened for tuberculosis (TB), and the local health department should be notified if TB disease is suspected. Annual TB testing for healthcare staff is not recommended unless there is a known exposure or a significant likelihood of exposure – something that can be addressed in a facility’s annual risk assessment. TB screening and testing includes a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (this is more commonly a blood draw but may also be a two-step TB skin test.) Although annual screening for TB is not required, annual TB education is – TB infection control and education materials can be found on the CDC website.⁶

Standard Precautions are a set of principles that prevent infections anywhere healthcare is provided, and includes a facility’s hand hygiene program, PPE use whenever there is a potential for exposure to infectious material, respiratory hygiene and cough etiquette, patient placement/cohorting, environmental infection prevention (cleaning, disinfection, and sterilization), laundry handling, safe injection practices, and sharp safety. Current guidelines for all these topics can also be obtained directly from the CDC.

The bloodborne pathogens (BBP) exposure control plan and needlestick prevention efforts should also be part of the infection control plan. Employers are required by OSHA to update this plan annually and it should be included or referenced by the infection control plan. The BBP exposure control standard set forth by OSHA requires the use of standard precautions, engineering controls like sharps disposal containers and safer medical devices, work practice controls, adequate PPE availability, provision of both hepatitis B vaccines and post-exposure evaluations and follow up after any potential BBP exposure incident, labels and signs to communicate hazards, regular training on the plan, and record maintenance to include medical and training records as well as a sharps injury log.⁷

Environmental Cleaning

A facility should have a cleaning schedule that includes detailed written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel, frequency, and chemicals to be used. Every employee who cleans and disinfects patient care areas should be trained on cleaning procedures on hire (prior to performing environmental cleaning and disinfection), annually, and whenever there is a change in policy or procedure. The facility should routinely audit adherence to these policies and procedures, including compliance with manufacturer instructions for use (IFU) regarding contact/wet/kill time for any chemicals used and compatibility with any medical devices or surfaces these chemicals are used on. Something to consider when choosing disinfectants is ease-of-use—is it ready to use, like a pre-saturated wipe, or will staff have to mix it carefully and discard solution daily?

A note regarding environmental cleaning in ASCs specifically: the clinical administration of the facility may contract out environmental services, especially if the center is not a part of a larger health system. This can sometimes lead to a disconnect between clinical and environmental services (EVS) staff – even if an EVS staff is contracted, the facility will still be responsible for approving procedures such as cleaning schedules and products used and should have oversight of the EVS process regardless of whether staff is employed directly by the facility or contracted to clean after hours.

Cleaning, Disinfection, and Sterilization

Another major consideration anywhere that surgical procedures are performed is the cleaning, disinfection, or sterilization of surgical instruments and other medical devices. The facility should be well-versed in the Spaulding classification, manufacturer IFUs for any instruments and reprocessing equipment, and be able to identify which instruments are cleaned and reprocessed, and which are single use. The facility should not be reprocessing any single use devices – something that in 2022, The Joint Commission noted that it was seeing with more frequency.⁸

The facility should be able to speak to whether reprocessing occurs on-site or off-site. If instruments are transported off-site to be reprocessed, the facility should still have detailed procedures for instrument cleaning and packing for transport.

All instruments should be cleaned and inspected for visual debris before being packaged for sterilization – if an instrument is not clean, it can’t be sterilized. The facility should also have chemical or biological indicators to verify that sterilization is being performed adequately as well as a tracking system to recall instruments that have been reprocessed inadequately – that may be due to a failed indicator, but instruments may also be recalled due to improper storage or compromised packaging.

Immediate-use steam sterilization (IUSS), if performed, should not be relied upon – and implants, post-procedure decontamination of potential prion disease (e.g. Creutzfeldt-Jakob disease) cases, devices that have not been validated for specific cycle employed, or single-use devices should never be processed using IUSS. Using IUSS on a routine basis can result in a citation for deficient practice.³

High-level disinfection (HLD) performed in the facility must also be pre-cleaned according to manufacturer instructions or, if they are not provided, evidence-based guidelines prior to high-level disinfection. Much like sterilization, if an item is not clean, it cannot be disinfected.

Chemicals used for HLD should be prepared, tested, and replaced according to manufacturer IFUs and proper documentation of this process should be kept in a log. Once disinfected, the items should be allowed to dry and stored in a designated clean area to prevent contamination.

Conclusions

This is a ton of information, and it’s only the tip of the iceberg. Why does it matter? A recent report in the Journal of Infection Control and Hospital Epidemiology (ICHE) looked at 4,045 ambulatory surgery centers and found that their SSI rates ranged from 0.0%-3.2% for common procedures, mirroring hospital SSI rates.⁹ The same report came to the conclusion that these rates may be underestimated as often, they are calculated using traditional hospital-based surveillance (and some patients may develop an infection but never return to the hospital.)

Developing a comprehensive infection control program, risk assessment, and plan in an ambulatory surgery setting is no small undertaking. Fortunately, there are many resources available from organizations like the Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), and the Association for Professionals in Infection Control and Epidemiology (APIC). Even with these resources, as more care shifts to the outpatient setting, infection prevention becomes more complicated and more important. Facilities should have an infectious disease-trained medical director or infection preventionist to assist in developing and employing their program. There are consultants available to help with this kind of work, but it is also worth the investment to train an employ a staff person to be in the ASC and responsible for the infection control program as well.

Infections can happen anywhere, and planning for an adequate infection control program helps to prevent them – and to save lives.