INFECTIONS IN THE ASC

INFECTIONS IN THE ASC
Proper Protocol Supports Infection Prevention in ASCs

By Michelle Beaver

Ambulatory surgery centers (ASCs) are known for their overall low healthcare-acquired infection (HAI) rates, but until these statistics hover somewhere around zero, infection-prevention in the ASC industry will continue to require constant exploration.

It is difficult to document the most popular HAIs to come out of ASCs, but it is clear that post-surgical infections are much less common than in the acute care setting, says Debra Saxton Stinchcomb, RN, BSN, CASC, of Progressive Surgical Solutions based in Farmington, Ark.

Solutions differ depending on the specifics of individual facilities but certain infection prevention principles should be consistent regardless of size, specialty or speed of patient turnover, Saxton Stinchcomb says.

“A low-volume ASC will have fast turnover times if it is efficient in its processes,” she says. “Infections are not dependent on volume or speed unless infection control processes are not adhered to.”

While HAI statistics in the ASC industry are left open to interpretation, the effects of HAIs are not. Patient infections can lead to hospital admission, death, increased cost of care, or prolonged illness, according to the authors of a consensus panel report from the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA).

“Performing surgical procedures and invasive device insertions and managing and providing care for patients who are increasingly immunocompromised in these settings presents new infection control challenges,” the authors state. “Therefore, infection control practices must now encompass infections that patients may acquire as a result of their care or treatment.”

And while there is a great deal of published information on how to deal with infection control in the acute care setting, there is far less of such material for ASCs.¹

Success Brings Stress

While the ASC industry has seen huge growth over the years and its members have largely reaped the benefits, one downside is that as surgeries increase, infections can increase too. In fact, infection rates could rise substantially as ASCs continue to take on more complex surgeries, says Ginny Lipke, RN, BS, ACRN, CIC, of St. Luke Hospital in Ft. Thomas, Ky.

The most substantial increase will involve the acquisition of pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), community-acquired MRSA (CA-MRSA), vancomycin-resistant Enterococcus (VRE) and Clostridium difficile, Lipke says.

“Often patients forget to remind their healthcare worker or physician that they are a MRSA nasal carrier or that they were treated months ago for C. difficile,” Lipke says.

“This is important information that the worker needs to know so that they can take whatever extra precautions are needed to ensure that they or the facility environment are protected and that the patient is appropriately cared for,” she adds. “ASCs do need to directly ask each patient for this information if they are not doing active surveillance cultures.”

Members of the APIC and SHEA consensus panel agree that HAI rates could rise in the ASC industry. “Traditionally, infection control professionals have considered the risk for infection in the outpatient setting to be low,” the members state. “However, as more invasive procedures are performed in the ambulatory care setting, patients and healthcare workers alike are at risk for developing or transmitting infection.

“The growth in managed care, with its attendant pressure to reduce the duration of or eliminate the inpatient stay, has resulted in a shift of many services previously delivered only in hospitals to that of ambulatory care settings,” the authors continue. “However, the delivery of healthcare in the outpatient setting is very different from that in the acute care facility. The patient mix and interactions are more varied; patients’ clinical status may be well to acutely ill, requiring visits that may be brief or may last the entire day.”

The fact that complex surgeries are becoming more popular, combined with the fact that patients with greater surgical risk are looking toward ASCs, means that the implementation of effective infection control education programs is more important than ever, the consensus members conclude.

“Staff, patients, and caregivers must receive ongoing training regarding proper infection control procedures,” they add. “In addition, it is essential that healthcare workers receive at least a rudimentary knowledge of the epidemiology of healthcare associated infections specific to the setting in which they are employed. This knowledge will allow them to be better able to understand and comply with the practices and procedures necessary for the prevention and control of infections.”

Individual infection control plans should depend not just on the size, case mix, and turnover of a facility, but also on the risks posed to the population that the ASC serves. Every plan should comply with federal regulations, basic accreditations, and state and local licensing standards.¹

No Excuses

ASCs are certainly different than the average acute care facility, but infections occur in both arenas for the same reasons, Saxton Stinchcomb says.

Poor overall health of a patient can often lead to infection. Luckily for the ASC community, “Patients typically present to an ASC less risk factors than you may find in a hospital due to the selection criteria identified by a particular ASC,” Saxton Stinchcomb says. Other reasons, according to her, include:

• Ineffective cleaning, decontamination, and sterilization of instruments and equipment
• Inadequate monitoring of cleaning and sterilization processes 
• Inappropriate use of prophylactic antibiotics 
• Shoddy hand washing and/or scrubbing of peri-operative surgical staff 
• Improper skin preparation of the patient’s surgical site 
• Break in aseptic and/or sterile technique during the surgical procedure 
• Lack of environmental controls (pertaining to room cleaning, temperature/humidity, etc.) 

Proper cleaning and disinfecting requires due diligence regardless of how much business is done at a facility, and is always a challenge, Lipke says.

“Cleaning instruments and rooms is not a glamorous job, but it’s a critical one that demands attention to detail,” Lipke says. “The folks who clean our rooms and those in sterile processing are the unsung heroes of most hospitals and ASCs. As for high volume settings, the faster paced atmosphere can contribute to cutting corners with infection control practices.

“The key is to look at all the pieces of their process to see if you can build in the safeguards or tools that will ensure that the best practice for the patient is delivered,” Lipke says. “Adding extra steps or additional complicated forms to a busy nurse will not deliver the results you are looking for. If you can offer staff an efficient and faster way to accomplish a task and still deliver the germicidal action needed — everyone wins!”

Some cases such as large joint replacements could require additional equipment or processes (such as shielding) to assure that sterile technique is maintained, according to Saxton Stinchcomb, but generally, a vigilant staff is the bulk of what it takes to minimize infections.

Infection Reduction Advice

There are several ways for ASC staff members to cut down in HAIs, says Saxton Stinchcomb, and they all start with an active surveillance program. Related tips are to:

• Gather and track infection data 
• Encourage surgeons to culture postoperative infections to assist the ASC staff in identifying the source of the infection 
• Adhere to infection control procedures that are set in place 

The main infection prevention advice that Lipke promotes (proper handwashing and equipment cleaning) is simple, yet continues to be ignored far too frequently by some healthcare workers.

“Proper hand hygiene stressed to both employees and patients comes to mind first, then good cleaning practices for the environmental services workers, clinical staff and the patient too for when they get home,” Lipke says. “But for all this to become part of the culture of any facility, the facility’s administration must actively enforce it and supply the necessary tools for employees to get the job done.”

Proper skin antisepsis can also not be overestimated in the fight against MRSA and other biological foes.

“Recently published reports including the new Centers for Disease Control and Prevention (CDC) guidelines support the need for good pre-op skin cleansing,” Lipke says. “According to the CDC and the Institute for Healthcare Improvement (IHI), 38 percent of all nosocomial infections in surgery patients are surgical site infections (SSIs).”

Many of these SSIs start with organisms from the patient’s own flora, she adds.

Proper pre-op skin antisepsis with chlorhexidine gluconate (CHG) is a good way to start, Lipke contends.

“CHG has superior effectiveness against gram positive bacteria, good effectiveness against gram negatives and against viruses,” she says. “Its persistence lasts up to six hours and for antiseptics to work that are applied to the skin, they need to be left on the skin and not washed off. A 2 percent CHG product is available in patient-friendly packaging that does not require rinsing with water.”

The TASS Outbreak

One HAI, toxic anterior segment syndrome (TASS), has subsided significantly from its peak in April 2006, but did cause quite a stir and a lot of optical damage among the patient population. TASS is an acute, rapid onset, sterile anterior segment inflammation that can follow even uneventful cataract and anterior segment surgery. Most TASS victims develop symptoms within 12 to 24 hours after surgery.

From Jan. 17 to July 11, 2006, 113 centers reported TASS cases, according to members of the TASS Task Force which is sponsored by the American Society of Cataract and Refractive Surgery. Members of the task force have compiled data on the TASS outbreak (that began in early 2006), and strive to prevent the illness.²

The reported cases have declined to what is considered a baseline level, task force members claim, but the cause of the outbreak is still somewhat of a mystery.

“There were no conclusive epidemiologic data to suggest that any one product was responsible for the increase in TASS cases that were reported,” the task force conclusion states. “Careful analysis of the information provided did not reveal a single cause or point source related to this TASS outbreak.”

Most probable is that a combination of factors led to the outbreak and involved various woes in the cleaning and sterilization of instruments for cataract surgery, as well as high patient turnover that may not have left enough time for proper instrument cleaning.²

According to survey information that task force members gathered, the amount of cataract surgeries performed daily at centers that experienced TASS outbreaks varied from five to 50 (with a median of 15).

Researchers reviewed all products used from pre-operative through post-operative patient care, and shared the results with representatives of the Food and Drug Administration (FDA) and the CDC.

The task force researchers found that ultrasound (and other types of) hand pieces used for irrigation and aspiration could be a culprit if not flushed adequately between cases. “It is imperative that all reusable hand pieces and cannulas are flushed thoroughly (and immediately at the conclusion of the case),” the researchers say. They furthermore recommend use of disposable cannulas and stress that these products should not be reused.

Another potential problem is the use of ultrasound water baths to clean instruments, because the water baths can become contaminated with gram negative bacteria.²

“Growth of these bacteria with subsequent endotoxin production could cause contamination of the instruments,” the researchers state.

The endotoxin is extremely heat stable and can withstand autoclaving. Frighteningly enough, even if the bacteria is incapacitated by autoclaving, it may still lead to TASS.²

Nine centers in the survey, coincidentally, reported that they only clean their ultrasound baths once per week, whereas the task force recommends that each bath be emptied and cleaned thoroughly after each use, or at least at the end of every day.

The researchers also advise that, “additives to any of the solutions or medications going into the eye at any point of the surgery should be preservative free,” and no additives should be added to irrigating solutions.²

As for lenses, the researchers did not pinpoint any particular intraocular lens that was found to be exclusive to the TASS syndrome. In terms of injectors, no single factor was found to lead to TASS in that arena either.

“However, there was a potential issue involving the cleaning of reusable inserters used in conjunction with a disposable cartridge for the injection of the IOL (intraocular lens),” the researchers state. “There is a possibility that residual material (tissue, blood, etc.) in the reusable injector could be involved in TASS.”

Recommendations

The TASS task force has issued the following guidelines in its battle against the insidious illness — “The use of sterile, deionized/distilled water for flushing. The majority of manufacturers of phacoemulsification hand pieces similarly recommend flushing of both the irrigation and aspiration ports of phacoemulsification and I/A (irrigation and aspiration) hand pieces with specified volumes of sterile, deionized/distilled water at the conclusion of the case. Inadequate flushing may allow a buildup of residual cortex, ophthalmic viscoelastic device (OVD), and other materials on the inside of the phacoemulsification or I/A hand pieces that could conceivably cause TASS.”

• All traces of water baths, enzymes and detergents should be rinsed from instruments since residual matter can lead to TASS. Autoclaving will not deactivate any enzyme or detergent.²
• Autoclave units should be thoroughly cleaned according to manufacturers’ recommendations on a regular basis to defend against endotoxins from the sterilizer, as well as from materials in the steam sterilizer water supply.
• A written infection control protocol should be in use at all surgery centers, and should be monitored regularly. Several centers that reported TASS cases had no such protocol in place.

Doctors and nurses should keep up to date on all relevant recall information, says Dana J. Weinkle, MD, who owns two Florida eye surgery centers.

“Patients need to be aware of TASS as well as other potential risks associated with cataract surgery,” Weinkle says. “I do not discuss this condition specifically, but I do explain to each patient that a very remote risk of infection does exist.

“Since TASS is almost always preventable through careful ASC protocols, patients should feel confident that the ASC implements all known safeguards,” he adds. “Patients need not be fearful of this relatively rare complication. I can’t speak in general for all ASCs, but I can summarily state that the vast majority of ASCs are very safe places for outpatient surgery.”

One Captain of the Ship

It is the responsibility of every healthcare organization to implement fastidious infection control practices, even if this goal requires gathering evidence and protocols from differing facilities, says William Scheckler, MD, from the University of Wisconsin Medical School.

“The core of expertise in infection control is likely to reside within the acute care hospital infection control program,” Scheckler says. “Healthcare organizations should draw on this expertise. It is the duty and responsibility of healthcare organizations to implement these recommendations.”¹

While an infection control team is optimal, the average ASC does not have the resources for this. Fortunately, even one person who oversees infection control at an ASC can make a phenomenal difference. Putting a single person at the helm can aid in consistency, according to authors of the paper, “Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings.” In an ambulatory setting an infection control leader will likely have other responsibilities, but a predetermined amount of infection control hours should be honored per week, the authors state.

And while this infection control monitor is watching their co-workers’ actions, someone from ASC management should be watching this person as well, to ensure a healthy dose of checks and balances. This infection prevention leader should be in charge of tracking recent infection control regulatory changes and should have the authority (or access to the authority) to implement adjustments as they see fit. A close relationship with ASC management is imperative.

Infection control leaders ideally have the following resources:¹

• Consultative exposure to infection control professionals, epidemiologists and clerical support 
• Access to clinical publications, office supplies, office space, computers and Internet, microbiology laboratory time, reference laboratory testing, data management and statistical support, and a reasonable budget that supports exposure investigations 

Ideally, the lead person given infection control responsibilities will be specially trained, but if they are not, it is the onus of ASC owners and managers to ensure that this employee receives help from an experienced person or group that can provide oversight.

“Specific knowledge and training relevant to infection control and epidemiology makes this person more effective in overseeing an infection control program,” the APIC and SHEA authors state. “Thus persons with this responsibility who are not specifically trained in infection control should have the opportunity to take courses and avail themselves of other educational opportunities that will increase their capacities in the field of infection control.”

Such assistance is available through contract, or through less formal relationships with facilities and organizations outside of an ASC or ASC group.

“Given the increasing emphasis on cost containment and the need to justify expenditures, a trained and experienced infection control professional can be especially helpful in evaluating the cost of the program and balancing these expenses against the benefits and requirements of the infection control program,” the APIC and SHEA authors state.

Education

The average ASC employee knows that overall infection control and preoperative skin antisepsis is vital, but the extent of adherence varies, according to Lipke.

“It depends on the level of understanding that the employee has, and that’s where education comes in,” Lipke says. “It is also helpful to have managers and coordinators that embody the quest to implement best practices daily. Staffs model their behavior from what they observe around them, especially their leaders.”

It is extremely important that ASC workers across the country receive consistent and thorough training on infection control and more specifically, proper skin preparation, and there are several ways to promote such learning, Lipke says.

“Staffs need multiple opportunities to learn, but within the education, the message on infection control practices and good pre-operative care must be consistently reinforced,” Lipke adds. “Everyone learns differently and you need to ensure that you use different learning styles whether with video, written or verbal. But regardless, you have to keep the information presented practical. If the information cannot be practically applied, you’ve lost them.”

The consequences of this communication lapse of course, can be deadly, but hope avails. Even without the typically more behemoth resources of the acute care community, ASCs have been able to keep infection rates lower, and as ASC employees continue to learn more about infection prevention, the gap will likely widen. 

References

1. Friedman C, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. The Association for Professionals in Infection Control and Epidemiology, Inc., and the Society for Healthcare Epidemiology of America. 1998.

2. Mamalis N, et al. Toxic Anterior Segment Syndrome (TASS) Outbreak, final report, Sept., 2006.