Infection Prevention Violations in Ambulatory Surgery Centers
Despite increasing regulations and ongoing reminders of "best practice" in the ambulatory surgery center (ASC) setting, Infection Control Consulting Services (ICCS) continues to observe suboptimal infection prevention and patient safety practices. These practices not only threaten the wellbeing of patients, but may also put an ASC's licensure and accreditation at risk.
Phenelle Segal, President of ICCS, recently visited several ASCs and noted practices that would be in direct violation of Centers for Medicare & Medicaid Services (CMS), The Joint Commission, AAAHC and AAAASF requirements and standards.
These violations can be broken down into three categories.
1. Safe Injection Practices/Multi-Dose Vial Use
Beginning in 2009, ASCs came under close scrutiny by the government and accreditation agencies after thousands of patients undergoing care at a Las Vegas endoscopy center from 2004 and 2008 were potentially exposed to hepatitis C and other bloodborne pathogens due to unsafe injection practices.
Issues surrounding safe injection practices and the use of multi-dose vials, in particular, continue to be an area of concern. Phenelle observed the following deficiencies at the ASCs she visited:
- Multi-dose vials used for more than one patient are stored in the immediate area where procedures are taking place until they are returned to the pharmacy at the end of the day.
- Most multi-dose vials used for more than one patient are not labeled.
- Multi-dose vials are left in the drawer or on top of the medication cart open and unlabeled.
- Syringes filled with local anesthetic on the prep tray that were used for arthroscopic procedures are not labeled.
- Multi-dose vial of local anesthetic was unmarked.
- Rubber diaphragm of vials were not wiped with alcohol, despite the addition of this practice to the CMS ASC Infection Control Surveyor Worksheet in 2015.
Note: These practices are particularly alarming as not only are they a significant threat to patient safety, but a facility with these practices could find themselves subject to immediate jeopardy status with CMS.
2. Surgical Attire
Surgical attire continues to be an area of confusion or misunderstanding for staff despite the availability of guidelines, such as those from AORN. Phenelle observed the following deficiencies:
- Surgeon entered the restricted area wearing scrubs from another outpatient facility, despite being reminded that only scrubs approved by the ASC are acceptable.
- Equipment vendor entered the restricted area wearing scrubs from the outside and did not change into ASC acceptable attire.
- Staff wore masks that were loosely tied at the neck. This practice of "allowing venting" goes against AORN guidelines.
- Equipment vendor wore long-sleeved undershirt with at least 6 inches of shirt visible beyond the scrub top sleeve.
- Head coverings were inconsistent. Several staff members placed bouffant caps behind the ears (exposing them) when the correct way to don the caps is over the ears. Surgeon caps were worn by several staff members but were not covered with a bouffant cap. Hair and scalp was exposed.
3. Hand Hygiene
Hand hygiene is an issue that has been under the spotlight for years, but still challenges ASCs throughout the country. The following deficiencies were noted:
- Inconsistent use of alcohol sanitizer, often absent when staff entered the operating room during a procedure as well as before and after glove use.
- Rings, watches and necklaces that were not contained within the surgical attire were worn in the OR by various staff members, including OR nurses and CRNAs.
- Nurse and surgeon wore nail polish. While standards and guidelines do not prohibit nail polish unless it is chipped, ICCS prefers to see unpolished nails in the surgical setting. The introduction of several types of nail polish products over the past several years, including gel overlays, has caused concern about the risk of harboring organisms. This issue remains mostly unresolved. ICCS has observed that unresolved issues create double standards which we believe further jeopardize patient safety.
These violations and deficiencies are subject to citations. This can include, as noted above, possible immediate jeopardy, particularly with respect to multi-dose vials. They were serious enough in Phenelle's opinion to warrant a special report of this nature.
The violations of safe practice indicate the need for ASC administrators and leadership to review the allocation of time and resources to infection prevention. As Phenelle has observed, CMS and the accreditation organizations are particular about how much time is devoted to infection prevention. ICCS consultants visit many ASCs (and other providers) that are not allocating what will likely be deemed an appropriate amount of time, and this is likely contributing to infection prevention and control shortfalls.
To learn about the many services ICCS provides to ASCs, including on-site visits, mock surveys and survey preparation, preparation of and assistance with corrective plans of action, and development of infection prevention risk assessment, contact ICCS today.