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Infection Control Program. Infection Control Program. § 416.51 The ASC Infection Control Program must: Provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases;

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infection control program2
Infection Control Program
  • §416.51
  • The ASC Infection Control Program must:
    • Provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases;
    • Be based on nationally recognized infection control guidelines;
infection control program cont
Infection Control Program (cont)
  • Be directed by a designated healthcare professional
  • Be integrated into ASC’s QAPI program;
  • Be ongoing
  • Include actions to prevent, identify and manage infections and communicable diseases, and
  • Include mechanism to immediately implement corrective actions and preventive measures to improve the control of infection within the ASC.
infection control program4
Infection Control Program
  • § 416.51
  • The ASC must maintain an explicit infection control program
  • The program is responsible for providing a plan of action for preventing, identifying, and managing infections and communicable diseases.
    • The plan of action must include mechanisms that result in immediate action to take preventive or corrective measures that improve the ASC infection control program.
activities of infection control program
Activities of Infection Control Program
  • Development and implementation of infection control measures related to personnel
  • Identifying infections
  • Monitoring infection control program compliance and plan evaluation
  • Active surveillance
  • Compliance with reportable disease requirements of local health authorities
minnesota department of health infectious disease epidemiology prevention and control
Minnesota Department of HealthInfectious Disease Epidemiology, Prevention and Control
  • 651-201-5414 or 1-877-676-5414
  • http://www.health.state.mn.us/divs/idepc/dtopics/reportable
infection control guidelines
Infection Control Guidelines
  • 42 CFR 416.51
  • The infection control program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines
  • Follow nationally recognized infection control guidelines
  • Documentation that the ASC considered and selected national-recognized infection control guidelines for its program
condition of coverage infection control program
Condition of Coverage-Infection Control Program
  • Examples of national recognized organizations include:
  • Centers for Disease Control and Prevention(CDC)
  • Associations for Professional in Infection Control and Epidemermiology (APIC)
  • Society for Healthcare Epidemiology of America (SHEA)
  • Association of Peri-Operative Registered Nurses
infection control program designee
Infection Control Program Designee
  • §42 CFR 416.51 (b) (1)
  • The ASC must designate in writing, a qualified licensed health professional with training, who will lead the facility’s infection control program
  • Leadership must be on-site

−Consultant may be used

− On-site time not specified: must be sufficient to ASC’s program size

system to identify infections
System to Identify Infections
  • § 416.51 (b) (3)§ 416.44 (a) (3)
  • System to identify infections that may be related to procedures performed at the ASC
    • Follow up with primary care providers
    • Physician performing the procedure obtains information and reports to ASC
    • Contact with patient following discharge
      • Emails
      • Phone call
asc personnel
ASC Personnel
  • § 416.51 (b)
  • Infection Control training for staff
    • Frequency
    • Same categories
    • Documentation of training
  • Evaluating ASC staff immunization status
  • Policies articulating when infected ASC staff are restricted from direct patient care
infection control and related practices
Infection Control and Related Practices
  • Hand Hygiene
  • Injection Practices
  • Single Use Devices
  • Point of Care Devices (e.g. blood glucose monitors)
  • Sterilization
  • High–Level Disinfection
hand hygiene
Hand Hygiene
  • §416.51 (a)
  • Staff perform hand hygiene:
    • After removing gloves
    • After direct patient care
    • After contact with blood, body fluids or contaminated surfaces (even if gloves are worn).
injection practices
Injection Practices
  • §416.48(a)
  • Needles are used for only one patient
  • Syringes are used for only one patient
  • Medication vials are always entered with a new needle
  • Manufactured prefilled syringes are used for only one patient
  • Multi-dose medications, used for more than one patient, are not stored or accessed in the immediate areas where direct patient care occurs
injection practices cont
Injection Practices (cont)
  • Multi-dose medications used for more than one patient are dated when opened and discarded within 28 days or according to manufactures recommendations, whichever comes first
single use devices
Single Use Devices
  • §416.44(a)
  • Single use devices are reprocessed
    • Approved by FDA for reprocessing
    • Reprocessed by an FDA-approved preprocessor.
point of care devices
Point of Care Devices
  • Manufacturer’s instructions indicate more than one patient use
  • Device is cleaned and disinfected before each use
flash sterilization
Flash Sterilization
  • §416.51(a)
  • S&C Program Memo-09-55
  • Sterilization of unwrapped/uncontained loads should not be routine practice in ASCs but should be used for an urgent and unpredicted need for a specific device
high level disinfection
High –Level Disinfection
  • High-level disinfection equipment should be maintained according to manufacturer instructions
  • Chemicals for high-level disinfection must
    • Be prepared appropriately
    • Be tested for appropriate concentration
    • Be replaced appropriately
    • Have documentation of preparation and replacement
high level disinfection cont
High-level Disinfection (cont)
  • Equipment subject to high-level disinfection is:
    • Disinfected for appropriate amount of time
    • Disinfected at the correct temperature
    • Allowed to air dry before use
    • Stored in a designated clean area
patient admission assessment and discharge
Patient Admission Assessment and Discharge
  • §416.52
  • The ASC must ensure each patient has the appropriate pre-surgical and post-surgical assessments complete and that all elements of the discharge requirements are complete
ad