How Low Can You Go?

How Low Can You Go?
Perioperative Perfection Assures ASCs’ Low Rates of Infection, Adverse Events

By John Roark

Historically, infection rates in ASCs and surgical hospitals are dramatically lower than in hospitals. What’s the secret?

The low incidence of infection and adverse events in ambulatory surgery centers (ASCs) and surgical hospitals can be attributed to a handful of factors. Patient selection, type and duration of procedures, and strict attention to aseptic best practices all contribute to healthy outcomes for patients and excellent track records for facilities.

“The lower infection rate at ASCs is primarily due to the admission criteria for the scheduling of patients,” says Susan R. Hollander, BSN, MBA, FACHE, vice president of Aspen Healthcare, Inc. “Anyone with an active infection, such as tuberculosis or methicillin-resistant Staphylococcus aureus (MRSA) is not an appropriate patient for most ambulatory facilities.” Additionally, Hollander points out, some states have restrictions on the American Society of Anesthesiologists (ASA) level of patients who are allowed to receive care at an ASC. “One example is the commonwealth of Pennsylvania,” she says. “The Pennsylvania Department of Health does not permit surgery at an ambulatory surgery facility on infants less than six months of age, nor patients who would fall into a Physical Status (PS) IV or PS V classifications. These patients have compromised immunity due to severe systemic diseases. If the patient requires a simple ambulatory procedure, it must be performed in a hospital setting.”

The staff’s focus on the perioperative experience (i.e., the actual surgical procedure), contributes to aseptic success, says Tom Meagher, RN, MSN, director of clinical operations for National Surgical Hospitals. “Everyone in the facility is focused on this process. The physicians, the pre-op area RNs, OR techs and RNs, the recovery room RNs, housekeepers, and administrative staff — all know the risks and issues associated with the prevention of infection, and coordinate their efforts to prevent infection. It is their primary focus to have the best surgical outcome, and that means to prevent infections.”

Before any discussion on comparing aseptic practices between hospitals and ASCs, it is important to understand that the patient population is generally healthier in the ambulatory setting. Additionally, some states follow Medicare conditions of participation, which restrict surgery to cases with an operating time of less than 90 minutes, do not invade a major body cavity, do not directly involve major blood vessels, and assure the patient will recover in four hours.¹ This eliminates cases with prolonged surgery and anesthesia times that could enhance the potential for a surgical site infection.

“The clientele that we get here are basically healthy,” says Diana Carr, RN, BSN, MHA, administrator at Creekwood Surgery Center in Kansas City, Mo. “They come in with better health histories; they’ve not been sick a long period of time. They don’t bring to the table the mixed bag that a hospital gets. Occasionally we do get someone who’s had an infectious process, which leads them to us for removal of something like, say, an implant. But those cases are few.”

“It’s a more defined patient population than what you’d see in a hospital,” agrees Michele Plumb, RN, BSN, PACU nurse manager at Creekwood Surgery Center. “We don’t have a lot of multi-system failure patients.”

Shorter procedure time and abbreviated length of stay decrease a patient’s exposure to nosocomial infections — and to the number of staff involved in the case. “With larger cases at a hospital, there is more staff participation by a lot of different entities that are actually in the room, bringing whatever is in their system into play into the patient’s infection not being present,” says Carr. “We don’t have that many in-play personnel that have to be in the room with the patient. Basically, it would be the circulator, the nurse that’s scrubbing, the doctor and anesthesia. This lessens the possibility for anything to come into that environment.”

An ASC’s smaller environment also lends itself to more efficient monitoring of clinicians’ behavior and observance of aseptic best practices, Carr says. “It’s easier to put policies, processes and procedures in place, easier to monitor and make sure those are adhered to,” she says. “There are few people here; we don’t have housekeeping, aides and orderlies and we don’t have people running in and out of the room, maybe washing their hands and maybe not. We see what everyone else is doing, and it’s all right there. If somebody doesn’t wash their hands here before they see a patient, someone is going to see.”

“For any patient care setting, an ongoing significant challenge is to accurately assess the competency of our caregivers, which includes employees, credentialed medical staff, allied health practitioners and any external personnel resources used to provide patient care,” says Cindy King, RN, CPHQ, director of quality services for Health Inventures. “Usually, overall staff turnover rates are low; the actual number of employees is much smaller compared to an entire hospital setting, and most of these persons are able to participate in quality committees and/or activities on a frequent basis where corresponding topics and policies might be discussed and input provided.”

The number and size of quality/infection control committees, and governance structure, is usually much smaller compared to hospital organizations, says King; “Issues can be addressed, feedback given and follow-up performed in a timelier manner. For these reasons and more, there appears to be greater consistency in direct communications, oversight and management of smaller teams. Involved personnel can be closely monitored for compliance to policy and procedure; medical staff members utilizing the facility on a frequent basis are usually actively involved in peer review that is performed on an ongoing periodic basis as part of the re-appointment process for credentialing. The number of external resource personnel who provide patient care are usually minimal and also reviewed by their peers. Most of these facilities are accredited by various national ambulatory associations and must also comply with stringent standards for the demonstration of staff competency, credentialing and privileging.”

The cornerstones of infection control are paramount in any healthcare setting, and having a healthy reverence for hand hygiene is where it all begins. “Hand hygiene protects the individual as well as the patient,” stresses Marcia Patrick, RN, MSN, CIC, director of infection control for MultiCare Health System in Tacoma, Wash. “It protects their families, because they’re not going to be taking things home.”

Patrick’s facility has instituted a procedure called ‘Gel In/Gel Out’ to maintain good hand hygiene. “Anyone who goes into a room has to gel their hands going in, and everyone coming out needs to gel coming out,” she explains. “That’s in addition to the usual preoperative hand preparation, which can either be a scrub or a gel. Our goal with Gel In/Gel Out is to keep whatever the patient has in that room, and not take it out into the hall. People would go from the room to get supplies or a piece of equipment. We want to make sure they aren’t taking anything from that room out into places where other people’s hands will be. That has a lot to do with multi-drug resistant organisms. We’re finding that a lot of patients who previously we never would have suspected are colonized with something like MRSA, are. We need to be very cautious with every patient. Every contact, whether it’s a pre-op, intraoperative or post-operative contact — hands need to be sanitized after touching every patient. It doesn’t matter what the touch is, even if it’s just putting a hand on the shoulder to say, ‘Good morning, Mr. Smith,’ taking blood pressure, or whatever. Hands need to be sanitized after touching every patient because the impact of these infections is so great.”

Patrick goes on to stress the importance of thorough environmental cleaning, “with special attention to the hand-touch areas, where someone in the room may have touched the patient or the patient’s environment and then picked up a telephone, used a keyboard or gone into a cabinet or drawer to get something.”

Control the environment, advises Meagher. “Assure that the facility is immaculately cleaned, that OR doors are kept closed to assure an effective air exchange within each OR, and damp-dust ORs on a daily basis.”

Creating and focusing on maintaining a sterile field is everyone’s responsibility. “Any practitioner involved in working within this type of environment must be aware of their own accountability and be extremely observant of others at all times so that the sterile field is not violated,” says King. “If there is ever a question from a practitioner as to the integrity of the sterile field, it must be considered not sterile and one would need to start over. It’s either sterile or it’s not; there is no in-between category, and that just might be one of the common misconceptions.”

Sterile processing (SP) is another area of great import, says Hollander, who recommends three primary areas for vigilance. “Initially, check for the organization of the sterile processing department with regard to work flow, setup, record-keeping and overall housekeeping tidiness. Secondly, check the storage area for sterilized instrument trays for overall housekeeping tidiness and accessibility from other areas of the building. Thirdly, walk the transportation route for the instruments from sterile to the user and the return trip back to the decontamination room with the soiled instruments. What types of containers are used for transportation — open or closed, appropriate size and the staff’s regard for their protection when handling the soiled instruments.”

Another area for potential breakdown is the adequacy of instrumentation and equipment, continues Hollander. “How often are the flash sterilizers used for instrument processing? Is there sufficient repetition to warrant the purchase of additional instruments?”

The proper way to sterilize a piece of equipment is to clean it first, says Cathy DiSabatino, RN for quality assurance/risk management at Northpoint Surgery and Laser Center in West Palm Beach, Fla. “You can’t have a piece of equipment with biological material on it and stick it in a sterilizer. First it has to have an enzymatic cleaning — it’s like washing the dishes before you put them in the dishwasher.”

A common fallacy surrounds the efficacy of sterilizers, says Patrick. “Some clinicians believe that sterilizers — whether gas, steam or other technologies — and other kinds of scope washers, have some kind of magic in them that render this item holy and pure,” she says. “In fact, it’s garbage in, garbage out. If you don’t scrub that item, if you don’t thoroughly clean it, it’s not going to be sterile or high-level disinfected.”

Another misconception concerns keeping patient-care areas clean, says Meagher. “Assuring that surgical site infections are prevented is a comprehensive process involving patient assessment by physicians and RNs, proper use of antibiotics at the right time for preventing surgical infections, sound professional practices and professional vigilance.”

Tracking monthly infection rates and reporting the information helps a facility pinpoint problem areas and track trends.

“We have quarterly meetings where we present infection control information to the medical executive committee,” says Carr. “I firmly believe that hospitals do that, but here it is more prevalent in the staff’s mind because we get feedback. We send out monthly tallies of the cases the surgeons have done, and they have to return it to us and let us know who had problems. The first inkling that we get is from the patients when we make their post-op phone call and there’s a problem. The patients have to actually respond to us, and we’re like dogs after a bone — we have to get that information back so we can pull up the data. So, it’s known to the surgeons and the people who work here what the infection rate is, and what has occurred over the last quarter.”

“We make a post-operative phone call on every patient,” says DiSabatino, who compiles infection rate information on a quarterly basis. “Additionally, I send a list of the patients that the doctor has done the previous month. They have to sign off on whether they’ve had any infections or complications. If anything comes back, I’ll trace it back, making sure that if an instrument was flashed, it was the within the right parameters. Was it sterilized appropriately?

“On our infection complication report there’s an area for me to track whether the parameters were met, what staff was in the room. We track everybody who takes care of the patient,” continues DiSabatino. “We track the rooms — if we always have an infection that comes back in Room 5, then I’m going to do environmental cultures.”

Education is not an option. Ensuring that all personnel are adequately trained in aseptic best practices ensures better outcomes and patient safety.

“Everybody has to be trained,” says Patrick. “A couple of years ago there was an outbreak of bloody diarrhea in a big GI center. It was during the summer, and the regular tech was on vacation for two weeks. The substitute tech wasn’t rinsing. The patients were basically getting glutaraldehyde enemas. We need to make sure that people are supervised and not just assume that they know what they’re doing, have competency checklists that are carefully developed and rigorously enforced to be sure that every single person knows what they are doing.”