Preventing Infections in the Ambulatory Surgery Setting
By Kelly M. Pyrek
Withas many as 6 million surgeries performed annually in the nation's estimated2,700 ambulatory surgery centers (ASCs), infection control measures are becomingan imperative within these freestanding outpatient surgicenters, physicians'offices and postsurgical recovery facilities.
Although the potential for exposure to infectious agents may not be as greatas in a hospital operating room, documented cases of infection have occurred inmedical offices, surgicenters, urgent-care clinics and alternative-caresettings, and include transmission of bacteria via contaminated instruments,contamination in eye and ear examinations, contaminated injectable agents andthe transmission of airborne or droplet-borne diseases.1 A study bythe Epidemiology Program Office of the Centers for Disease Control andPrevention (CDC) identified clusters of infections associated with outpatienthealthcare provided in medical offices, clinics, ophthalmologists' offices andclinics, 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 rigorousinfection control practices shouldn't vary from one clinical environment to thenext. However, it is prudent to understand the ways in which ASCs differ fromhospital ORs, according to Shauna Smith, RN, CAPA, interim director of nurses atMountain View Surgical Hospital in Idaho Falls, Idaho.
"The ambulatory surgery environment is unique for infectioncontrol," Smith says. "By nature, surgical center patients arehealthy, there are no medical patients to contribute organisms to theenvironment of the facility, and because patients spend less time in a surgicalcenter, the risk of acquiring a nosocomial infection is less."
Guidelines from the Association for Professionals in Infection Control andEpidemiology (APIC) state: "In all areas of ambulatory care, patients atdifferent levels of wellness are clustered in common waiting areas. The range ofpotentially transmissable infections depends on the population served and typeof services offered. Healthcare workers (HCWs) in these settings are exposed tolarger numbers of patients than their hospital colleagues. A high proportion ofpeople may be at risk for droplet-borne or airborne disease transmission that isenhanced by close quarters, communal objects and movement between examinationrooms and procedure rooms."3
In their book "Infection Prevention in Surgical Settings," BarbaraJ. Gruendemann, RN, MS, FAAN, CNOR and Sandra Stonehocker Mangum, RN, MN, CNORwrite, "The risk of nosocomial infection has been thought to be minimal inambulatory surgical settings because of the short stay in the facility, theshort duration of anesthesia, the 'minor' nature of the surgical procedures andthe general good health of the patient. However, surgical site infections (SSIs)remain an important cause of morbidity, mortality and excess hospital costsduring the post-operative period when patients must be admitted to an acute carefacility for treatment of SSIs. As the shift toward more ambulatory surgerycontinues and more procedures are performed on an outpatient basis, verificationwill be needed that high-quality services are being provided in same-day surgerycenters."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 tosupport the needs of today's more complicated procedures. According to the APICguidelines, "One may find few or no sinks, combined clean and dirty workareas or specimen-testing areas combined with HCWs' break areas. Many times,there are no separate areas for decontamination, preparation, assembly andsterilization 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 surgerycenter draw a line with red tape down the center of a room and say, 'This sideis clean and this side is dirty and that's the way we're going to handle thesituation.' Sometimes that's truly all the space they have to work with in asmall facility. The principles are the same in an ASC as they are in a hospitalOR: clean and dirty must be kept separate, whether it is supplies, instrumentsor equipment. Due to a lack of time and staff, you may still see dirty linenstashed beside the sterile goods. Small surgery centers must often be creativein the way they separate clean and dirty, using every available space."
Smith agrees the separation of clean and dirty is one of the greatestobstacles ASCs face. "The challenge then becomes to gain employee buy-in tothe issue of separating the two as best as possible," she says. "Theother challenge is gaining administrative support for remodeling or newconstruction to meet the need for more space. When a facility is seekingaccreditation, the issue generally has better administrative support. When theinfection control professional (ICP) spends time in these critical areas, bettercompliance is obtained. Regular rounds into the central processing area, ORs andall around the facility will be enlightening for the ICP and encouragescompliance with procedures. Oftentimes the staff working in these areas has thebest solutions for the space problems and other infection control-relatedissues."
Smith continues, "Every surgical center in the country should carry outstandard precautions every day. The challenge seems to still be one of those oldsacred cows of "dirty" cases and patients with known conditions suchas HIV. With standard precautions we treat all cases the same, and the way we dothat should protect the patient, the staff and all future patients fromacquiring any nosocomial infections."
Establishing a proper work flow is essential to good infection control. A"dirty-to-clean" work flow control instrumentation, specimens andtraffic, according to APIC guidelines.7 The ideal work flow includesdesignated areas for receiving and reprocessing contaminated equipment andspecimens. The work should flow from soiled receiving areas to decontaminationareas to sterile processing areas to storage areas. Physical barriers should beerected to indicate contaminated areas, and there should be a protocol toexclude "nonprocessing" HCWs, non-OR HCWs and patients from"dirty" areas of the surgicenter. APIC guidelines state: "HCWsshould move from clean areas to dirty areas with appropriate measures taken whenthey reenter clean areas, especially in ambulatory surgery centers, centralservice and laboratories."
Varied case mixes
A wide variety of patients tend to congregate in an ASC's waiting or recoveryareas, 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 orincubating communicable or infectious diseases, and family members or friendsaccompanying these patients. "The delivery of healthcare in the outpatientsetting is very different from that in the acute care facility," writeGruendemann and Mangum.8 "The patient mix and interactions aremore varied, patient clinical statuses can range from healthy to acutely ill,and visits can range from brief to all day. Infection control professionals haveusually considered the risk for infection in the outpatient setting to be low.However, as more invasive procedures are performed in the ambulatory caresetting, patients and HCWs alike are at risk for developing or transmittingdisease."
"When we first started seeing surgery centers spring up we were thinkingabout low-risk patients going there for their hernias or breast biopsies, but weweren't thinking about people who were sick having complicated proceduresthere," acknowledges Chinnes. "The complexity of cases has evolvedthrough the years, and we see people discharged quicker even after undergoingcomplex, invasive procedures. And with a more diverse patient mix, more peopleare susceptible to infections."
Gaps in staff knowledge
In the fast-paced, small-staffed environment of an ASC, there may not be apredetermined person responsible for cleaning, disinfecting and sterilizingreusable instruments. If it is a shared responsibility among a team of HCWs,there could be gaps in knowledge and technical ability. "Different types ofinvasive procedures are performed with a wide variety of instrumentation inexamination rooms, procedure rooms and in operating room suites," accordingto APIC guidelines.9 "The difficulty lies in knowing exactlywhat procedures are performed, how to support them with properly reprocessedinstrumentation and what protective barriers are needed to protect HCWs andpatients."
The lack of knowledge can sometimes be eye-opening. "One of the worsthorror stories I have heard was several years ago," Smith recalls. "Asmall, rural center was using a toaster oven to sterilize instruments. There wasno licensed nurse or designated ICP on staff there, but it seems the physicianwould have known better."
ASC staff, like their hospital colleagues, also must avoid breaks in aseptictechnique. "Aseptic practices such as opening and setting up rooms andsterile fields, scrubbing, gowning, gloving, prepping the patient's skin,wearing proper attire and following standard precautions should be followedfaithfully and role modeled throughout the facility," Gruendemann andMangum write.10
Lack of surveillance
Infections transmitted in outpatient surgery settings are normally notmonitored systematically nor likely to be detected by routine surveillance. Thechallenge is that many ASCs do not have a dedicated infection controlpractitioner, a concern to many experts. "Access to infection control andepidemiologic expertise and resources is a necessity for any alternativesurgical setting, regardless of its size, type of organization or distance froma hospital or other resource center," writes Gruendemann and Mangum.11"A qualified, designated individual must oversee and manage all infectionprevention and control efforts; this person may have other responsibilities,too, if the facility is small. Regulations, standards and professionalguidelines must be up to date and made relevant to the setting. Education mustbe ongoing and appropriate, ensuring that employees are knowledgeable abouttrends and practices."
"The requirement for a designated infection control person varies basedon location (state law), accreditation and licensure of the individualfacility," Smith explains. "The one federal consistency is theOccupational Safety and Health Administration (OSHA) Bloodborne PathogenStandard 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, homehealthcare -- as resistant strains [such as methicillin-resistant Staphaureus (MRSA)] increase in the community, people with those resistantorganisms are going to have surgery at outpatient surgicenters," saysChinnes. "There are two schools of thought about how to handle patientscolonized with resistant organisms. If we knew a patient with MRSA was havingsurgery, we'd put them on contact isolation; some people would say we just needto use standard precautions. We would isolate the patient, not so much fromother patients, but to make sure staff members are careful when moving from oneperson to the next when delivering care. MRSA is everywhere now; surgicalpatients with open wounds are very much at risk and we have to protect them. Wemight put the known MRSA carrier on contact isolation in a private room, or putthem in a curtained-off area at the end of an open recovery room. We don't dothis to stigmatize them, but to remind the staff not to rush over to the nextpatient 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 allhealthcare facilities in that community. Surgery centers should be evaluatingtheir prophylactic antibiotic procedures and step up communication with thephysician offices to identify potential problem cases. Adding a question to thepre-op evaluation about these pathogens might be a consideration. Helpingprevent resistant strains is the responsibility of all healthcare providers, andeducational sessions about these resistant strains provided to physician officepersonnel will aid in communication between office and center and helpcommunity-wide understanding of the issues."
According to APIC guidelines, the first step in identifying the infectioncontrol needs of an ASC is to determine the following:12
According to the Joint Commission on the Accreditation of HealthcareOrganizations (JCAHO), successful infection control program identifies thefollowing:13
Regardless of the setting, infection control procedures must address thefollowing:
It's no surprise that APIC considers the ICP to be the first line of defenseagainst the transmission of infectious diseases in the ambulatory care setting.It states: "As the trend toward ambulatory care and preventive healthcareincreases, expansion of the ICP's sphere of influence can be expected. The roleof an ICP has a profound impact on facility-wide and community-wide delivery ofhealthcare. The scope of the ICP in ambulatory care is interdepartmental andmultidisciplinary. Using a preventive health perspective, the ICP ensures therights of patients and HCWs to a healthy environment. The ICP helps thefacility's administration recognize potential risk management issues and fulfillits legal responsibility to safeguard public health as well as that of HCWs."14
Infection control practitioners can turn to numerous sources for informationabout infection control practices in the ambulatory care setting. Chief amongthem are APIC's guidelines as well as those of the Association of periOperativeRegistered Nurses (AORN) as outlined in its Ambulatory Surgery Principles andPractices manual. Other sources of information are the Accreditation Associationfor Ambulatory Health Care, Inc. (AAAHC) and the American Association forAccreditation of Ambulatory Surgery Facilities (AAAASF).
"Each facility must evaluate its own needs for licensure andaccreditation and choose which guidelines suit them best," Smith says."I believe that knowing all of the guidelines makes the ICP stronger andmore able to manage their program. They provide a basis from which to choose thebest of the best in policy and procedure development."