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) • 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 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 • 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 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 • 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 • 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 • §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 • § 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 • § 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 • Hand Hygiene • Injection Practices • Single Use Devices • Point of Care Devices (e.g. blood glucose monitors) • Sterilization • High–Level Disinfection
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 • §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) • 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 • §416.44(a) • Single use devices are reprocessed • Approved by FDA for reprocessing • Reprocessed by an FDA-approved preprocessor.
Point of Care Devices • Manufacturer’s instructions indicate more than one patient use • Device is cleaned and disinfected before each use
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 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) • 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 • §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