Preventing Infections in the Ambulatory Surgery Setting
By Kelly M. Pyrek
With as many as 6 million surgeries performed annually in the nation's estimated 2,700 ambulatory surgery centers (ASCs), infection control measures are becoming an imperative within these freestanding outpatient surgicenters, physicians' offices and postsurgical recovery facilities.
Although the potential for exposure to infectious agents may not be as great as in a hospital operating room, documented cases of infection have occurred in medical offices, surgicenters, urgent-care clinics and alternative-care settings, and include transmission of bacteria via contaminated instruments, contamination in eye and ear examinations, contaminated injectable agents and the transmission of airborne or droplet-borne diseases.1 A study by the Epidemiology Program Office of the Centers for Disease Control and Prevention (CDC) identified clusters of infections associated with outpatient healthcare provided in medical offices, clinics, ophthalmologists' offices and clinics, dental offices and alternative-care settings.2
While many healthcare professionals still consider ambulatory care to be the "Wild West" of healthcare delivery systems, experts say rigorous infection control practices shouldn't vary from one clinical environment to the next. However, it is prudent to understand the ways in which ASCs differ from hospital ORs, according to Shauna Smith, RN, CAPA, interim director of nurses at Mountain View Surgical Hospital in Idaho Falls, Idaho.
"The ambulatory surgery environment is unique for infection control," Smith says. "By nature, surgical center patients are healthy, there are no medical patients to contribute organisms to the environment of the facility, and because patients spend less time in a surgical center, the risk of acquiring a nosocomial infection is less."
Guidelines from the Association for Professionals in Infection Control and Epidemiology (APIC) state: "In all areas of ambulatory care, patients at different levels of wellness are clustered in common waiting areas. The range of potentially transmissable infections depends on the population served and type of services offered. Healthcare workers (HCWs) in these settings are exposed to larger numbers of patients than their hospital colleagues. A high proportion of people may be at risk for droplet-borne or airborne disease transmission that is enhanced by close quarters, communal objects and movement between examination rooms and procedure rooms."3
In their book "Infection Prevention in Surgical Settings," Barbara J. Gruendemann, RN, MS, FAAN, CNOR and Sandra Stonehocker Mangum, RN, MN, CNOR write, "The risk of nosocomial infection has been thought to be minimal in ambulatory surgical settings because of the short stay in the facility, the short duration of anesthesia, the 'minor' nature of the surgical procedures and the general good health of the patient. However, surgical site infections (SSIs) remain an important cause of morbidity, mortality and excess hospital costs during the post-operative period when patients must be admitted to an acute care facility for treatment of SSIs. As the shift toward more ambulatory surgery continues and more procedures are performed on an outpatient basis, verification will be needed that high-quality services are being provided in same-day surgery centers."4
According to APIC guidelines, the challenges for infection control include:5
An ASC built in the 1970s or 1980s may not have been originally designed to support the needs of today's more complicated procedures. According to the APIC guidelines, "One may find few or no sinks, combined clean and dirty work areas or specimen-testing areas combined with HCWs' break areas. Many times, there are no separate areas for decontamination, preparation, assembly and sterilization of reusable goods."6
Independent infection control consultant Elizabeth Chinnes, RN, BSN, CIC, president of consulting firm IC Solutions in Mount Pleasant, S.C., says she has "seen everything" in her more than 25 years of work in the field. "Nothing surprises me anymore; I've seen HCWs at an ambulatory surgery center draw a line with red tape down the center of a room and say, 'This side is clean and this side is dirty and that's the way we're going to handle the situation.' Sometimes that's truly all the space they have to work with in a small facility. The principles are the same in an ASC as they are in a hospital OR: clean and dirty must be kept separate, whether it is supplies, instruments or equipment. Due to a lack of time and staff, you may still see dirty linen stashed beside the sterile goods. Small surgery centers must often be creative in the way they separate clean and dirty, using every available space."
Smith agrees the separation of clean and dirty is one of the greatest obstacles ASCs face. "The challenge then becomes to gain employee buy-in to the issue of separating the two as best as possible," she says. "The other challenge is gaining administrative support for remodeling or new construction to meet the need for more space. When a facility is seeking accreditation, the issue generally has better administrative support. When the infection control professional (ICP) spends time in these critical areas, better compliance is obtained. Regular rounds into the central processing area, ORs and all around the facility will be enlightening for the ICP and encourages compliance with procedures. Oftentimes the staff working in these areas has the best solutions for the space problems and other infection control-related issues."
Smith continues, "Every surgical center in the country should carry out standard precautions every day. The challenge seems to still be one of those old sacred cows of "dirty" cases and patients with known conditions such as HIV. With standard precautions we treat all cases the same, and the way we do that should protect the patient, the staff and all future patients from acquiring any nosocomial infections."
Establishing a proper work flow is essential to good infection control. A "dirty-to-clean" work flow control instrumentation, specimens and traffic, according to APIC guidelines.7 The ideal work flow includes designated areas for receiving and reprocessing contaminated equipment and specimens. The work should flow from soiled receiving areas to decontamination areas to sterile processing areas to storage areas. Physical barriers should be erected to indicate contaminated areas, and there should be a protocol to exclude "nonprocessing" HCWs, non-OR HCWs and patients from "dirty" areas of the surgicenter. APIC guidelines state: "HCWs should move from clean areas to dirty areas with appropriate measures taken when they reenter clean areas, especially in ambulatory surgery centers, central service and laboratories."
Varied case mixes
A wide variety of patients tend to congregate in an ASC's waiting or recovery areas, including children, the elderly, pregnant or antepartum women, immunocompromised individuals, those with chronic or debilitating diseases, patients in a post-trauma or post-operative condition, those with active or incubating communicable or infectious diseases, and family members or friends accompanying these patients. "The delivery of healthcare in the outpatient setting is very different from that in the acute care facility," write Gruendemann and Mangum.8 "The patient mix and interactions are more varied, patient clinical statuses can range from healthy to acutely ill, and visits can range from brief to all day. Infection control professionals have usually considered the risk for infection in the outpatient setting to be low. However, as more invasive procedures are performed in the ambulatory care setting, patients and HCWs alike are at risk for developing or transmitting disease."
"When we first started seeing surgery centers spring up we were thinking about low-risk patients going there for their hernias or breast biopsies, but we weren't thinking about people who were sick having complicated procedures there," acknowledges Chinnes. "The complexity of cases has evolved through the years, and we see people discharged quicker even after undergoing complex, invasive procedures. And with a more diverse patient mix, more people are susceptible to infections."
Gaps in staff knowledge
In the fast-paced, small-staffed environment of an ASC, there may not be a predetermined person responsible for cleaning, disinfecting and sterilizing reusable instruments. If it is a shared responsibility among a team of HCWs, there could be gaps in knowledge and technical ability. "Different types of invasive procedures are performed with a wide variety of instrumentation in examination rooms, procedure rooms and in operating room suites," according to APIC guidelines.9 "The difficulty lies in knowing exactly what procedures are performed, how to support them with properly reprocessed instrumentation and what protective barriers are needed to protect HCWs and patients."
The lack of knowledge can sometimes be eye-opening. "One of the worst horror stories I have heard was several years ago," Smith recalls. "A small, rural center was using a toaster oven to sterilize instruments. There was no licensed nurse or designated ICP on staff there, but it seems the physician would have known better."
ASC staff, like their hospital colleagues, also must avoid breaks in aseptic technique. "Aseptic practices such as opening and setting up rooms and sterile fields, scrubbing, gowning, gloving, prepping the patient's skin, wearing proper attire and following standard precautions should be followed faithfully and role modeled throughout the facility," Gruendemann and Mangum write.10
Lack of surveillance
Infections transmitted in outpatient surgery settings are normally not monitored systematically nor likely to be detected by routine surveillance. The challenge is that many ASCs do not have a dedicated infection control practitioner, a concern to many experts. "Access to infection control and epidemiologic expertise and resources is a necessity for any alternative surgical setting, regardless of its size, type of organization or distance from a hospital or other resource center," writes Gruendemann and Mangum.11 "A qualified, designated individual must oversee and manage all infection prevention and control efforts; this person may have other responsibilities, too, if the facility is small. Regulations, standards and professional guidelines must be up to date and made relevant to the setting. Education must be ongoing and appropriate, ensuring that employees are knowledgeable about trends and practices."
"The requirement for a designated infection control person varies based on location (state law), accreditation and licensure of the individual facility," Smith explains. "The one federal consistency is the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard which requires a designated person to oversee the program."
The Threat of Community-Acquired Resistance
"Just like in any other setting -- hospitals, long-term care, home healthcare -- as resistant strains [such as methicillin-resistant Staph aureus (MRSA)] increase in the community, people with those resistant organisms are going to have surgery at outpatient surgicenters," says Chinnes. "There are two schools of thought about how to handle patients colonized with resistant organisms. If we knew a patient with MRSA was having surgery, we'd put them on contact isolation; some people would say we just need to use standard precautions. We would isolate the patient, not so much from other patients, but to make sure staff members are careful when moving from one person to the next when delivering care. MRSA is everywhere now; surgical patients with open wounds are very much at risk and we have to protect them. We might put the known MRSA carrier on contact isolation in a private room, or put them in a curtained-off area at the end of an open recovery room. We don't do this to stigmatize them, but to remind the staff not to rush over to the next patient without taking off their gloves and washing their hands."
Smith says community-acquired infections shouldn't be taken lightly. "When there is an increase of any community infection, it impacts all healthcare facilities in that community. Surgery centers should be evaluating their prophylactic antibiotic procedures and step up communication with the physician offices to identify potential problem cases. Adding a question to the pre-op evaluation about these pathogens might be a consideration. Helping prevent resistant strains is the responsibility of all healthcare providers, and educational sessions about these resistant strains provided to physician office personnel will aid in communication between office and center and help community-wide understanding of the issues."
According to APIC guidelines, the first step in identifying the infection control needs of an ASC is to determine the following:12
- The type of practice and all surgical specialties involved
- The patient case mix
- The patient case load
- HCW level of training and education
- Level of nursing support for the practice
- Types of invasive procedures performed and where they are usually performed
- Specific instruments and equipment used
- Facility design
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), successful infection control program identifies the following:13
- At-risk patient populations
- At-risk procedures, such as those requiring invasive devices
- Causes, risks and patterns of infections that arise in a particular healthcare setting
Regardless of the setting, infection control procedures must address the following:
- Control of bloodborne pathogen exposure
- Standard precautions and hand hygiene
- An occupational health program
- Medical waste and specimen handling and disposal
- Surveillance and reporting activities for patients and staff
It's no surprise that APIC considers the ICP to be the first line of defense against the transmission of infectious diseases in the ambulatory care setting. It states: "As the trend toward ambulatory care and preventive healthcare increases, expansion of the ICP's sphere of influence can be expected. The role of an ICP has a profound impact on facility-wide and community-wide delivery of healthcare. The scope of the ICP in ambulatory care is interdepartmental and multidisciplinary. Using a preventive health perspective, the ICP ensures the rights of patients and HCWs to a healthy environment. The ICP helps the facility's administration recognize potential risk management issues and fulfill its legal responsibility to safeguard public health as well as that of HCWs."14
Infection control practitioners can turn to numerous sources for information about infection control practices in the ambulatory care setting. Chief among them are APIC's guidelines as well as those of the Association of periOperative Registered Nurses (AORN) as outlined in its Ambulatory Surgery Principles and Practices manual. Other sources of information are the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
"Each facility must evaluate its own needs for licensure and accreditation and choose which guidelines suit them best," Smith says. "I believe that knowing all of the guidelines makes the ICP stronger and more able to manage their program. They provide a basis from which to choose the best of the best in policy and procedure development."