By Karin Lillis
In 2009, the Centers for Medicare and Medicaid Services (CMS) launched an oversight and survey program for ambulatory surgery centers (ASCs) as a requirement to participate in Medicare – including a stringent set of infection control regulations. Experts in the field, however, say the CMS regulations sometimes create confusion among infection preventionists at ASCs.
“Ambulatory surgery centers want to do the right thing, but unfortunately the requirements aren’t always clear,” says Mary Post, RN, MS, CNS, CIC, infection prevention specialist with the Oregon Patient Safety Commission. Post developed the commission's model infection control program for ambulatory surgery centers.
“Safe injection practices are one of the biggest areas of confusion,” says Libby Chinnes, RN, BSN, CIC, an infection control consultant and owner of IC Solutions, LLC, in Mount Pleasant, S.C. “Do staff clean the tops of medication vials each time they insert a needle? Whether it’s a brand-new bottle or not – the top of the bottle should be wiped off with alcohol before the needle is injected into the vial.”
Post says she also receives a lot of questions about environmental cleaning – routine and terminal. It's also not unusual for her to hear about surveyors finding lapses in hand hygiene and scrubbing ports. “These are everyday practices where the might not have 100 percent compliance.”
But how does an ASC's infection control specialist ensure his or her facility doesn't run afoul of CMS regulations? Recently, Post and Chinnes shared tips to help ambulatory surgery centers prepare when CMS surveyors come to call.
- CMS regulations require an ambulatory surgical center to base its infection prevention program on nationally recognized guidelines – but it does not mandate a particular set, Chinnes says. Most facilities look to organizations like the Association of periOperative Registered Nurses (AORN) or agencies such as the Centers for Disease Control and Prevention (CDC). For example, an ASC might use AORN procedures for cleaning and processing instruments but rely on CDC guidelines for safe injection practices.
CMS will expect the ASC to ensure that it has reviewed those guidelines, document which sets they have selected and will use. “When the surveyors come, they will evaluate them to see if the facility is applying them consistently,” Post says.
- One person should manage an ASC’s infection prevention and control program and its unique plan. CMS regulations require that person to be a licensed professional, such as an RN or LPN, who has undergone specialized infection control training.
“Over the years, I’ve had different CEOs say to me, ‘A nurse is a nurse is a nurse. They all know aseptic technique.’ That’s not what we’re talking about. Just like a critical care nurse is a specialist, so is an infection preventionist,” Chinnes says. “We’re not just looking at hand hygiene or aseptic technique. We’re actually asking, ‘How can we give each ASC patient the best possible care based on the evidence in the literature – as if they were one of our family members?”
CMS, however, does not say how many hours of training an ASC’s infection preventionist must have – the federal guidelines “just say the person has to be licensed and trained in infection prevention and control." The ASC can look to professional organizations like the Association for Professionals in Infection Control and Epidemiology (APIC), Chinnes says, which offers a course specifically designed for the ASC setting as well as other courses and ongoing training like webinars.
- Don’t wait until the last minute. An ASC’s infection prevention program has to be dynamic – evolving and ongoing at all times, Post says. Make sure the infection preventionists have reviewed the CMS manual and guidance for surveyors. Use the CMS infection prevention worksheet. Different states, she says, may add on additional requirements to the federal agency’s guidelines. “Be prepared to show how the ASC will meet federal and state regulations,” Post says.
- Be well versed in the CMS standards. Chinnes advises infection preventionists to have a copy of the CMS standards and worksheet – a printed copy in hand that they can use with staff for interaction and education. “Know the guidelines from front to back. Make sure you read the whole document. There is great information you can use to read between the lines,” Chinnes says. “For example, the mention in the guidance for surveyors (prior to the worksheet) of poor infection control practices related to injections of medications, saline or other infusates in some ASCs which have resulted in the transmission of diseases, such as hepatitis C, to patients. The surveyor may ask the center staff the rational for practicing safe injection practices and want to know that staff understand this is part of standard precautions for all patients.”
Keep infection prevention and survey readiness materials easily accessible. “Put them in a binder and make sure more than one person knows where they’re located,” Post adds.
- Know the most common deficiencies for other organizations in your region or state.
- Be sure the infection prevention program is included in quality assurance programs.
- Make sure staff at all levels understand CMS infection control. “Sometimes even if we think something is clear in a policy, there may be questions about implementation.”
“Do some rounds and observe to see if people are doing what they’re supposed to do. Ask staff questions that pertain to the work they do, such as asking those who perform instrument reprocessing about instrument reprocessing. Take the CMS worksheet, print it out and fill it out together with staff,” Chinnes says. “When CMS surveyors come in, hopefully the fear and anxiety is decreased.” Use the CMS worksheets to assess the center’s strengths and deficiencies, Post adds, and perform mock surveys.
- Get to the front line. The infection preventionist needs to get to the bedside or observe how staff are cleaning instruments. “You can’t just sit in an office. You have to know what’s happening in your own organization. Use your eyes and ears,” Chinnes says. “Are we cleaning rooms and instruments according to the latest guidelines? You have to get out there and observe for shortcuts.”
- Train the trainer. The person heading the ASC’s infection prevention program might get several staff members and train them on the CMS worksheet. These staff members can work with different groups – one may work with anesthesia and another housekeeping.
But keep the training fun. One source, says Post: APIC holds an annual film festival where members submit training videos via YouTube. “Some are really fun and can be used in a lot of training situations,” Post says.
- Be sure to bring the surgeons on board. One of the gaps Chinnes says she sees: providing education to staff but not to surgeons. “You might have to work with surgeons differently, like a newsletter with a required post-test to fill out and return to facility. You might not be able to bring in the surgeons all at once for a formal in-service.”
Adds Post, “The surgeons are busy and you have to respect the time they have.” She recommends educating doctors as they come on board or before they perform their first procedure at the facility. “Communicate to them what the expectations are,” she says.
- Get the ASC's executives involved. “You must be sure that compliance with CMS standards goes all the way up the ladder of the organization to the board including the facility’s infection surveillance The board is ultimately responsible,” Chinnes says.
- Make unexpected visits. Sometimes the infection preventionists and leadership need to make unannounced visits to see what happens at the ASC after hours. A surgical tech or nurse might clean an operating room between surgeries, but how thorough is the terminal cleaning at the end of the day?
“Environmental services might come in at night. They’re contracted and the infection preventionist may never see them. You don’t have to go in every week, but sometimes the infection preventionist and leadership need to make surprise visits,” Chinnes says.
Chinnes understands the pressures clinicians and staff feel when they're expected to take on an increasing amount of responsibilities – but shortcuts, she warns, are dangerous.
“When a healthcare worker says he or she doesn’t have enough time,” Chinnes says, “My reply is 'You don’t have time not to do this.’”
Karin Lillis is a freelance writer.