By Marcia Patrick, RN, MSN, CIC
The study, "Infection Control Assessment of Ambulatory Surgical Centers," in the June 9, 2010 issue of JAMA, noted that two-thirds of 68 ambulatory surgery centers (ASCs) surveyed had one or more deficiencies in infection control practice. The survey was done to test an assessment tool to be used by surveyors conducting Medicare surveys of ASCs. Assessments covered five important areas of infection control:
-- Hand hygiene
-- Injection safety and medication handling
-- Equipment reprocessing
-- Environmental cleaning
-- Handling of blood glucose monitoring equipment
Deficiencies in any of these five areas are associated with a risk of infection transmission to patients -- from unclean hands; improper injection techniques such as reusing needles and/or syringes or contaminating multi-dose vials and using them on another patient; using single-use medication vials on more than one patient; using contaminated medical equipment such as instruments used in operations or endoscopes used to examine or treat various body areas; contaminated environmental surfaces such as unclean gurneys, OR tables and the like; and transmission of bloodborne pathogens such as hepatitis or HIV from contaminated blood glucose monitoring equipment.
Most hospitals have experienced infection preventionists on staff that monitor practices for safety. They have experienced operating room personnel who are familiar with proper OR practices. People working in instrument and scope reprocessing are well-trained and do their work well. There are dedicated environmental services or other support personnel who perform environmental cleaning to assure the environment wont contribute to infections. Blood glucose monitoring equipment is designed to be used on more than one patient and to minimize the risk of exposure. The equipment is disinfected between patients. There are systems in place to assure all of this is being done correctly all of the time.
Over the years, procedures that were once the province of hospitals have moved to the outpatient arena. Procedures that used to require a large incision now can be done through small "keyholes" resulting in much less patient discomfort after the procedure and a much faster recuperation time. Procedures such as total knee replacements and laminectomies can be done on an outpatient basis for some patients.
The downside of this is that more and more complex, difficult-to-clean and disinfect equipment has come on the scene. Manufacturers dont always consider the cleaning requirements before they bring a product to market. Endoscopes that enter the body are narrow and have tiny, narrow channels that must be completely cleaned with a brush to ensure all debris has been removed in order for the disinfectant to be effective. There are small ports and connectors that also must be thoroughly scrubbed before disinfection. Instruments used in "keyhole" procedures also often have small channels, instruments that are used for cutting or grasping a bit of tissue for a biopsy or other test. Some of the units used for disinfection and sterilization after cleaning have specific connectors that must be used and hooked up correctly in order for the disinfectant to reach all the areas that are contaminated. This does not always happen.
Outpatient facilities are often not built for healthcare, but for office occupancy. Yet, operating and procedure rooms are built and may not have adequate ventilation; the space for cleaning, disinfection and sterilization of instruments may be too small to safely accomplish these tasks; and adequate sinks for handwashing may not be available in all exam and treatment rooms.
Staff may not always have the level of expertise to understand all the major and subtle barriers to good infection prevention. In Nevada, the physician owner of an endoscopy center and two nurse anesthetists who worked there were charged with 26 counts related to improper practices around medication administration. Allegedly, a single-use anesthetic drug called Propofol was used on more than one patient; syringes used to access the vial were also used on more than one patient, contaminating the contents of the vial and because it is a very expensive medication, at the end of the day all the partially filled (and contaminated) vials were collected and contents pooled for use the next day. This was done to save money. I doubt any of these individuals started out their day thinking, "How can I harm patients today?" It was a lack of knowledge, certainly, but also a lack of adequate oversight. The endoscopy center apparently had been checked by state surveyors, but they did not uncover the aforementioned lapses.
Hospitals have a great deal of oversight by various regulators and the state and national level, and sometimes even regional or local oversight in addition. ASCs in many states do not have any oversight or the surveyors do not know what to look for to identify some of these hard to detect lapses. In some cases, the ASC may "clean up their act" when surveyors show up. These are likely rare, but it may occur.
Obviously, there are many, many excellent ASCs that understand and follow good practices to keep their patients safe. The problem is, as a consumer, how can you know?
The Centers for Medicare and Medicaid Services (CMS) will be using the inspection tool that was trialed in three states in the 68 different clinics and updated based on actual use. It specifically gets at the five critical areas noted above, to ensure patient safety. CMS requires a licensed person be designated as the individual responsible to oversee the infection control program and requires that they receive adequate training and time to do the job. It will take time for all the ASCs that accept federal dollars to be inspected. And then there are those who are not under any scrutiny, as they dont accept federal dollars.
Until adequate oversight of all ambulatory facilities is in place, we will continue to read of bad practices cause patient harm -- whether from poor hand hygiene, improper use of medications and injection equipment, incorrect practices around cleaning, disinfection and sterilization, environmental cleaning and misuse of glucometers. Its a scary world out there and more oversight is critical to protect patient safety. We must recognize the facilities that are doing a great job, but get the others on board as soon as possible.
Marcia Patrick, RN, MSN, CIC, is director of infection prevention and control a t the MultiCare Health System in Tacoma, Wash., and is a member of the board of directors of the Association for Professionals in Infection Control and Epidemiology (APIC).