By Kelly M. Pyrek
As healthcare delivery evolves, institutions and systems are expanding their campuses to include ambulatory and long-term care facilities. And for infection preventionists working in stand-alone facilities, they must stay up to date on infection prevention imperatives.
Ambulatory Care
High-profile outbreaks in ambulatory surgery centers in recent years have given the industry a black eye and prompted agencies such as the Centers for Medicare and Medicaid Services (CMS) to issue new conditions for coverage that are designed to bolster infection prevention and control knowledge and implementation in outpatient care. Specifically, the ASC must maintain an infection control program that seeks to minimize infections and communicable diseases, provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases, and to and achieve the following: be based on nationally recognized infection control guidelines; be directed by a designated healthcare professional with training in infection control; be integrated into the ASC’s QAPI program; be ongoing; include actions to prevent, identify and manage infections and communicable diseases, and include a mechanism to immediately implement corrective actions and preventive measures that improve the control of infection within the ASC.
Peggy SaBell, RN, MS, CIC, director of a regional infection control program for Kaiser Permanente in Colorado, emphasizes the importance of conducting risk assessments. "My perception, after working in ambulatory care for many years, is that we must be very clear about where our risks are and conduct a thorough risk assessment," SaBell says. "Our hospital peers are conducting risk assessments for their setting, and we need to do the same for ours, drilling down to where our risks are in order to plan our programs and our interventions around them."
SaBell provides an example of the inherent challenges of identifying the risks encountered in ambulatory care: "Let's say someone shows up for surgery and has a draining wound. You may culture it or the patient may go to the hospital and have it cultured, but you are still taking care of a patient for whom you are awaiting results. Or a patient has diarrhea and no cultures have been performed and we don't know if it's C. difficile. The point is that in ambulatory care, many times we isolate and perform our actions around general rather than specific information -- we are simply trying to provide care around the draining wound or the diarrhea, instead of being able to respond to the identified risk. So this is why it's so important to pinpoint where the risks are. Anytime you have a procedural setting, there are risks everywhere and one of those is safe injection practices. That's something we have to look at in all healthcare settings."
The new Guide to Infection Prevention in Healthcare Settings, produced by the Centers for Disease Control and Prevention (CDC), outlines the minimum expectations for safe patient care and serves as a summary guide of infection prevention recommendations for ambulatory care settings. It acknowledges the strides that still need to be made in infection control in outpatient care: "Compared to inpatient acute care settings, ambulatory care settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. While data describing risks for HAI are lacking for most ambulatory settings, numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures (e.g., reuse of syringes leading to transmission of bloodborne viruses)."
Two trends are melding to create a perfect storm: over the past several decades there has been a significant shift in healthcare delivery from the acute, inpatient hospital setting to a variety of ambulatory and community-based settings, and the acuity levels are rising quickly as healthcare workers must content with patients who are sicker and have numerous co-morbidities.
"We are seeing patient acuity levels climbing higher every year and we're doing more procedures in the outpatient arena annually," SaBell confirms, adding that as the sophistication of the care required grows, so do the infection prevention strategies. "Any time you are doing invasive procedures, strict infection control measures must be in place, and it's the same standards we must uphold like our hospital peers do. Strategies like good hand hygiene crosses through all of the different healthcare settings, of course. So do proper disinfection and sterilization of surgical instruments and devices, as well as environmental hygiene -- it's the same whether you are in acute care, ambulatory care or long-term care. These are principles that must be adhered to across the board."
SaBell continues, "Good training in aseptic technique will see a nurse through everything. I suspect that some individuals in ambulatory care have been lulled into thinking that infection control isn't as important as it is in acute care, and perhaps they didn't stay current on infection control as well as they should have. The basics of good aseptic technique or good hand hygiene apply to everyone."
And as the aforementioned CDC guide emphasizes, "All healthcare settings, regardless of the level of care provided, must make infection prevention a priority and must be equipped to observe Standard Precautions." Standard Precautions are defined as the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect healthcare workers and prevent these personnel from spreading infections among patients. Standard Precautions include: hand hygiene; use of personal protective equipment (e.g., gloves, gowns, masks); safe injection practices; safe handling of potentially contaminated equipment or surfaces in the patient environment; and respiratory hygiene/cough etiquette. As the guide notes further, "Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence."
Carol Imes, RN, MPA, CNOR, director of the Mentor Surgery Center in Mentor, Ohio, says she believes in the power of education to help ambulatory care professionals stay current with best practices. "Ambulatory surgery managers continue to work hard to meet the CMS regulations," she says. "Continue to read every thing you can on infection control practices. Read professional magazines and articles. Attend webinars and seminars. The infection control nurses received their initial training in infection control, but it is best practice to get annual training. Take another look at the regulations since we have had time to work on the most pressing issues and now can look for things we may have missed when the standards were first released. And have at least one staff member be a member of AORN and APIC so you can keep with the latest information on infection control."
Imes continues, "All of the ambulatory managers I know have taken the CMS mandates very seriously and continue to make improvements in infection control. Personally I have thought that ambulatory centers have been always been aggressive in their infection control and historically have very low infection rates. However, I am increasing the handwashing audits and making more observations. I am trialing disinfectants with a 2- to 3-minute kill time since our turnover time is short. We have always investigated infections that occur in our center, and the surgeons are reporting them more quickly than before. All my staff is much more cognizant of infection control practices."
Many ASCs have now experienced a CMS survey to which the infection control conditions for coverage have been applied, and SaBell emphasizes that "it's critical for us to examine the areas that CMS will be looking at because doing so gives us a good idea of what the risks are in our setting." SaBell adds, "I think the dust is starting to settle, and while there are still some struggles, more CMS survey-related education and networking opportunities are available from APIC and others than ever before. I went to a seminar recently where the target audience member was a new infection preventionist or the person in the ASC who is now handling infection prevention; one of the speakers was a CMS auditor and safe injection practices was the main subject of the presentation -- that tells me CMS is getting serious about this topic. I think we have a better idea of what CMS is looking for -- they want an integrated infection control program and they want to see that we are actually keeping track of things like hand hygiene done pre-operatively, perioperatively and post-operatively. As more ASCs get surveyed, more information is being shared; for example, I have talked to a lot of people about our survey, what CMS surveyors were looking at and how to prepare. It's still a work in progress because we still need to identify within our organizations the practices that must be changed. I think we now know where we are going with our programs and it's a matter of getting additional administrative support in our centers, and changing some long-held practices."
Instigating a culture change is one of the most daunting tasks an infection preventionist faces, and SaBell agrees it's not an overnight fix. "It's more difficult to bring about a culture change because many ambulatory care providers think that we just get healthy people as patients and that's rapidly changing," she says. "Plus, the infection control message may not be as in your face as it is in the hospital setting -- for example, people may do a better job of washing their hands in the hospital because that message is being driven home a lot harder. Certain habits or practices are more difficult to improve because they more ingrained. In hospitals there is more education whereas in outpatient centers there is an over-riding focus on getting patients in and out quickly and infection control may be taking a back seat. Providing the best care and never letting things slide is absolutely imperative -- we must never say to ourselves, 'Well, we have a low infection rate, so we don't really need to focus on infection control.' We don't ever want to become complacent."
SaBell continues, "We must continually look at our processes and our outcomes to identify areas needing improvement, whether it's by doing more education or intervening when something is not being done in the right way. We moved our hand sanitizer dispensers to where the patients are, right there in pre-op or in recovery, so they see the nurses performing hand hygiene. We must make it very clear to our patients what we are doing to prevent infections. Much of our post-op patient instruction focuses on preventing infections. We want patients to be able to attest that they received really good care and that they saw staff washing their hands or scrubbing the hub of their IV."
Implicated in many outbreaks in ambulatory surgery centers are contaminated surgical instruments and scopes that have not been cleaned, disinfected and sterilized properly, so it is essential that outpatient facilities establish and follow policies and procedures for containing, transporting, and handling equipment that may be contaminated with blood, body fluids and other potentially infectious material.
"I think there is still confusion about immediate-use sterilization and what is acceptable and what is not," says Imes. "As a nurse, I have had to learn about sterile processing, sterilizers, settings, special requirements for power equipment. I rely a lot on my central processing personnel. We have purchased many instruments trays so we do not have to worry about having sterile instruments when we have quick turnover times. Look at your instrument sets and duplicate ones that you use frequently. Educate staff to be vigilant in checking autoclave tapes and indicators to make sure all parameters are met. Encourage staff to challenge each other if there is a break in sterile technique."
The aforementioned CDC guide makes the following recommendations for cleaning, disinfection and/or sterilization of medical equipment in ambulatory care settings:
1. Facilities should ensure that reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately prior to use on another patient
2. Reusable medical equipment must be cleaned and reprocessed (disinfection or sterilization) and maintained according to the manufacturer’s instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use
3. Assign responsibilities for reprocessing of medical equipment to healthcare workers with appropriate training
a. Maintain copies of the manufacturer’s instructions for reprocessing of equipment in use at the facility; post instructions at locations where reprocessing is performed
b. Observe procedures to document competencies of healthcare workers responsible for equipment reprocessing upon assignment of those duties, whenever new equipment is introduced, and on an ongoing periodic basis (e.g., quarterly)
4. Assure that healthcare workers have access to and wear appropriate personal protective equipment (PPE) when handling and reprocessing contaminated patient equipment
