Today's SurgiCenter - Keeping ASCs Infection-Free

Keeping ASCs Infection-Free

By Kelly M. Pyrek

Ambulatory surgery centers (ASCs) have long been safe harbors against infections and adverse events, making them a preferred mode of healthcare delivery for healthier patients undergoing routine, limited-duration, and elective procedures. However, with advanced technology, a greater number of invasive, complex procedures are being performed in ASCs on patients who may have undiagnosed or unrecognized infectious diseases, says Kathleen H. Petersen, MS, CIC, a staff specialist in infection control and epidemiology at the University of Michigan Hospitals and Health Centers in Ann Arbor, Mich. Her healthcare system includes two ASCs; one is almost exclusively ophthalmology and a little plastic surgery; the other performs about 400 to 500 procedures a month, including arthroscopies, etc.

“I think infections in ASCs are an overall low risk,” says Petersen, who is co-author of Infection Control in Ambulatory Care.1 “The patients who come to ambulatory care are generally healthier, with minor conditions and are not immuno-compromised. In general, the procedures being performed in ASCs are lowrisk procedures, and the patient is not in the OR for very long. The caveat is that as patients have more complex procedures or possibly stay overnight, they do become higher risk.

We see people who are undergoing chemotherapy who could have cataract surgery or undergo what we normally would consider low-risk procedures but because of their underlying condition, they might become a higher risk.”

Writes Petersen, “It is suggested that surgical site infections for ambulatory procedures are lower than those conducted in hospitals because:

1. Most procedures are either clean or clean-contaminated. These procedures have the lowest risk of infection.

2. Exposure to multi-drug resistant microorganisms is reduced. Patients are not exposed to microbes of other patients as in hospitals.

3. Patients undergoing contaminated or dirty procedures as outpatients are generally at lower risk. Patients who have more risk factors are generally hospitalized.”¹

Petersen emphasizes that no matter the setting — whether outpatient or inpatient — or the type of procedure, infection control principles remain the same.

“Everything, from the way the OR needs to be set up, with airflow and air handling, to the way the scrub needs to be done by the surgeon, would be the same, regardless of whether they are an inpatient or outpatient facility. This includes whether you are looking at how the sterilizer is being run or the instruments are being cleaned. For example, we do a lot of endoscopic procedures; the scopes are cleaned the same way they are cleaned in the hospital. Healthcare workers in both settings simply follow protocol. You don’t take shortcuts just because the patient is in an ASC; you are still cutting through skin and doing invasive procedures. So whether you are inserting an IV line, cleaning instruments, prepping the patient’s skin, or doing a surgical prep of your own hands, the basic aseptic principles are the same.”

Healthcare professionals acknowledge that outbreaks have been traced to physicians’ offices, urgent-care centers and ASCs, and include transmission of bacteria via contaminated instruments, contamination in eye and ear examinations, contaminated injectable agents and the transmission of airborne or droplet-borne diseases.² A study by the Epidemiology Program Office of the Centers for Disease Control and Prevention (CDC) identified clusters of infections associated with outpatient healthcare provided in medical offices, clinics, ophthalmologists’ offices and clinics, dental offices and alternative-care settings.³

“There are documented cases of outbreaks associated with bronchoscopies and cases of TB that were spread in outpatient facilities,” Petersen says, “and that’s quite alarming. All of the outbreaks that were associated with endoscopy were because some basic infection control principle was neglected. None of the outbreaks were related to the procedure itself; from the research that has been conducted, we know it’s because the follow-through is sometimes left undone and there are breaks in aseptic technique.”

Sometimes it comes down to something as simple as proper handwashing.

“It’s hard to watch clinicians in ambulatory care because they walk into a patient room, shut the door, and you can’t tell what they’re doing in there,” Petersen says, referring to her surveillance efforts at her healthcare system’s ASCs. “So I have to trust what people are telling me. When I do my surveys of the clinics, what I see as working successfully is the installment of easily-accessed alcohol hand sanitizers. Every time I go to the clinics I notice half empty bottles, and in this case, half-empty is good. So I know people are using the hand sanitizers. And when I talk to the nurses about how they think the doctors are doing in washing their hands, by and large they are pretty positive about physicians’ hand hygiene. But then again, it’s very subjective; we haven’t done any objective studies.”

Petersen says that personal protective equipment (PPE) is just as essential in the ambulatory environment as it is in other facilities. “PPE provides a barrier between a susceptible site (e.g., surgical wound, intravascular site, healthcare workers’ mucous membranes) and a potential source of microorganisms (e.g., healthcare workers’ hands or a patient’s infected wound) and reduces the likelihood that microbes will reach the site and cause an infection,” Petersen writes in Infection Control in Ambulatory Care. “Microorganisms may be present at all moist body sites and in moist body substances. Ambulatory care facilities need to evaluate the tasks performed by staff and then determine what types of PPE are needed to prevent exposures to patients and staff, and when PPE is to be used. The type, route and degree of exposure anticipated to blood and other potentially infectious materials will determine the selection of appropriate PPE.”

Rapid turnover of ORs in ASCs also can be a source of potential concern from an infection control standpoint.

“We always look at this when we do our facility surveys,” Petersen explains. “We ask how they’re cleaning the equipment between cases. Going by standards from the Association of periOperative Registered Nurses (AORN), if the OR environment wasn’t grossly soiled, for example, during short eye or plastic surgery procedures — some of the lumps and bumps removal — the environment is not going to be very contaminated with blood and body fluid. So, generally, the floors are not so much an issue as with the big procedures. When doing a survey, we tend to stay in the room to watch the procedure and how the cleaning is being done. Any surface that the patient touched or the instruments touched needs to be cleaned with a disinfectant.

If it’s dirty, clean it, and provide disinfectant solutions that are easy for healthcare workers to use. On the other hand, if you’re doing arthroscopies, where there’s a lot of bodily fluid around, you must diligently clean the environment.”

When it comes to proper cleaning of ORs and treatment rooms in the ASC environment, Petersen recommends putting one person in charge of the process for efficiency’s sake.

“Who this responsibility falls to in the ASC may depend on how big the center is; at one facility it might be the nurse because she already is in the OR getting things set up and in charge of it. Usually there’s a scrub tech assigned to take care of the instruments, so that person would take care of cleaning them and getting them into the sterilizer. The scrub nurse would be responsible for getting the instruments out of the sterilizer and taking them aseptically to the sterile table, if flash sterilization is being done. However, what works best for one facility may not work for another. People have to work together. What I have observed in smaller outpatient facilities is that healthcare workers very much take ownership of the patient, the environment and how they do things because they feel very invested in them; whereas if you are in a huge inpatient facility where they are doing 30,000 or 40,000 procedures a year, you get caught up in doing what you do and going home, period.”

One of the challenges of infection control in the ASC setting is establishing a line of demarcation between clean and dirty, especially in smaller, cramped facilities.

“Centers should look at their state’s rules for guidance,” Petersen says. “In Michigan, where we are, if your outpatient facility is connected to the hospital physically, you cannot have dirty and clean in the same room, and you can’t store clean things in a soiled area. In smaller physicians’ offices, crowding can become an issue. We don’t necessarily have people literally put a line down the middle of the floor because bacteria don’t know what that means. We do want the workflow to proceed from dirty to clean; moving from either high-level disinfection or sterilization work areas to the storage area. If people are allowed by their state regulations to keep soiled and dirty items in the same room, they really need to put the clean things in a covered environment — either in closed cabinets or drawers.”

Most ASCs don’t have a full-time infection control practitioner (ICP), so it’s up to facilities to designate one individual as being responsible for ensuring proper protocol is being followed. “The nature of infection prevention and control places responsibility for the activities of the infection prevention and control program among all departments and individuals within the organization,” write Margaret D. Bischekl, MD, FACP and Karen Ward, RN, ART, MHA, CPHQ, authors of Apollo Managed Care Consultants’ report, Infection Control in Ambulatory Care.4 “It is the combined efforts of everyone providing services, receiving services or visiting the organization that allows for the control of infections. Although responsibility for the infection prevention program does not rest with one single individual or department, responsibility for coordinating infection prevention activities must be designated to an individual qualified through appropriate training and experience. Even a small medical group requires an empowered, knowledgeable and enthusiastic staff member to ensure appropriate and consistent infection control and safety practices.”

“One person definitely needs to be responsible for infection control when setting up management and operations at an ASC,” Petersen says. “If the ASC is connected to a larger hospital, there will probably be a liaison at the ASC, someone that the ICP from the hospital works with to make sure things are going well in the outpatient facility. The liaison is a staff position, and the individual gives recommendations to management for implementation; the managers have the line responsibility. If the setting is independent of the hospital, then maybe it will be the individual who does employee health, quality assurance or utilization review. There’s no doubt this person will wear many hats.”

Petersen continues, “In our healthcare system’s model, we have infection control liaisons in each of our clinics and in our ASCs. That person might be a nurse, a medical assistant, or an administrator; they are our point persons for exchange of important information concerning infection-control issues.”