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From the Desk of Mary Bennett, RN, CIC
Monitoring for infections throughout the ASC
CMS requires that a ASCs Infection Control Program must 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. Monitoring activities are to be done throughout the entire facility and must be documented.
By now, we should all be familiar with monitoring for infection, and the emphasis has most likely been on monitoring for post-operative or surgical site infections. Since CMS requires monitoring activities be done throughout the whole facility, we will focus on what may be an often overlooked area for monitoring. That is at the point of entrance to the facility, the reception and/or waiting area.
When assessing infection transmission risks, in the reception/ waiting area, there may be a group of people including the patients and their family members or companions that are in close proximity to one another. The close proximity increases the risk for transmission of infectious organisms particularly by airborne and droplet transmission routes. If proximity as a risk factor for infection transmission is compared between the areas of an ASC, there is usually a distance of at least several feet between beds in the pre-operative and post-operative areas and there may be further separation provided by cubicles or curtains. In contrast, in waiting rooms chairs are usually closely spaced. In this area of your facility, infection may not be limited to your patients and can be present in their family members or companions.
That brings the question about how to monitor the reception and waiting area for infections since these areas are not typically staffed with persons trained to identify infections. One important method is use of signage. Signs placed in readily visible locations at the entrance and adjacent to the sign in area can alert and instruct patients and their families or companions to report signs of illness. The sign you choose or create may include a concise list of symptoms or illness such as cold/cough, fever, rash, redness and draining of the eyes, nausea/vomiting and diarrhea, boils, draining wounds, and instructions about how to discreetly report such to an employee. A brief screening check list for patients to complete on arrival is another useful tool.
Follow-up for any report of illness from a patient or their family/companion or findings of illness in the patient screening checklist should be prompt. The nurse in charge should be notified immediately so that a confidential evaluation and triage can be performed and any infection control measures implemented to reduce transmission of infection. In the waiting area, tissues to cover coughing and sneezing, hand sanitizer or hand washing facilities, and trash receptacle should be readily available.
Although the admission/initial nursing assessment takes place after the patient has left the reception area, the assessment should screen for illness/infection. Any finding of infection should prompt transmission prevention measures appropriate for the infection.
Documentation of infections identified in the reception and waiting areas and the related follow up must be maintained. An infection present at admission is not considered a health care acquired infection nevertheless; these infections should be reported to stakeholders including the governing body. The reporting of these infections would be in a separate category from facility infection rates.
Mary's email
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2-day Infection Control Seminar
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Greetings ASC Administrator or Directors!
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| Hand Hygiene: Using Soap vs. Alcohol-Based Sanitizers |
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When is hand hygiene using soap and water instead of alcohol based hand sanitizer necessary?
Some groups of micro-organisms in certain environmental conditions develop endospores or spores. These spores enable to organism to survive and are very resistant to destruction by chemical and physical agents. Unfortunately, this means they are resistant to de-activation by alcohol based hand sanitizers. The most effective method to remove these organisms from the skin is by the mechanical removal that occurs with the friction and running water of soap and water hand washing. Organisms in the Clostridium and Bacillus groups are endospore formers. In the health care setting, Clostridium difficile is probably the most commonly encountered organism from these two groups. When caring for a patient with known or suspected C. difficile, the health care worker's hands should be cleaned using soap and water to reduce the risk of transmission. The CDC guidelines for hand hygiene specifically state that soap and water should be used for hand hygiene if exposure to Bacillus anthracis (anthrax) is suspected.
Remember, hand hygiene should always be done after removing gloves.
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| Engineered Sharps Injury Protection |
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The OSHA blood borne pathogen standard states:
1910.1030(d)(2)(i)
Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used.
And also states:
Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
Recently, I visited an ASC which had a large inventory of needles, syringe, and IV access devices but none of them had built in safety features. Some built in sharps injury protections include, but are not limited to, sheaths that shield the needle, various needle covering mechanisms that can be activated with one hand such as a flip down needle shield, needles that retract into the syringe or IV insertion device. Also available are scalpels with a sheath that can be activated with one hand to cover the blade, and blunt suture needles. Safety mechanisms that can be activated using one hand are preferred.
If your center doesn't use sharps with engineered sharps injury protections, they should be obtained. A variety of devices with engineered sharps injury protection are on the market so it is possible to find devices that will meet the needs of your facility and employees There is a requirement that the employees who will be using the devices must have input into their selection.
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| Influenza Vaccination |
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The weekly influenza surveillance report for the week of January 29, 2011 from the CDC states Influenza activity in the United States is increasing. You may have heard by now that many organizations including APIC are lobbying for mandatory immunization of healthcare workers. We will keep you posted.
Influenza vaccine can and should be administered as long as influenza is circulating in the community. The new recommendation from CDC for the 2010-2011influenza season is that all persons over 6 months of age receive influenza vaccine. It has long been recommended that those who provide care to people at high risk of influenza complications should receive the vaccine, this includes health care workers.
Persons at high risk for complications of influenza include:
- all children aged 6 months--4 years (59 months);
- all persons aged ≥50 years;
- adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus);
- persons who have immunosuppression (including immunosuppression caused by medications or by HIV);
- women who are or will be pregnant during the influenza season;
- children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;
- residents of nursing homes and other long-term--care facilities;
- American Indians/Alaska Natives;
- persons who are morbidly obese (BMI ≥40);
- HCP;
- household contacts and caregivers of children aged <5 years and adults aged ≥50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and
- Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza.
How many patients that receive services in your center are in these risk categories? Although the length of stay for patients in an ambulatory care setting is usually much shorter than for a patient admitted to a hospital, there is a risk for influenza transmission between patients and employees.
Influenza vaccination for employees in ambulatory care settings is appropriate to reduce these transmission risks. Since it is not likely that influenza activity has peaked and vaccination should be provided throughout the flu season, it is not too late for unvaccinated employees to receive influenza vaccination.
There are some people should not receive Influenza Vaccine such as:
- People who have a severe allergy to chicken eggs,
- People who have had a severe reaction to an influenza vaccination,
- People who have developed Guillian-Barré syndrome within 6 weeks of getting an influenza vaccine,
- Children less than 6 months of age (influenza vaccine is not approved for this age group), and
- People who have a moderate to severe illness with a fever (they should wait until they recover to get vaccinated).
For additional information about Influenza and influenza vaccination:
http://www.cdc.gov/flu/professionals/vaccination/index.htm
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf
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| Learning from Mistakes of Others |
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We have been presenting information on an on-going basis as to what we are hearing in the field relating to surgery center surveys and their citations.
Let's do a quick refresher and make sure that you are not in a similar situation...
Two facilities that we are currently assisting with their Plan of Corrections include the following citations:
- Review of the ambulatory surgical center log book listing the items sterilized showed no entries for surgery day 11/9/10
- Review of wall cabinet contained Pheneylephrine 2.5% ophthalmic drops opened, no staff initials, and undated.
- Bacteriostatic Sodium Chloride for injection with expiration date of 9/01/10.
- Review of nine personnel records for ambulatory surgery staff and physicians showed no infection control training.
- Based on interview and record review, the ASC failed to show evidence of a performance improvement program related to Infection Control.
- Based on observation and interview the facility failed to supply adequate number of instrument sets to avoid using flash sterilization.
- Based on observation nine ceiling tiles were soiled.
- Based on observation five items were found under sinks.
- Three of three patient recovery chairs were found to have tears in the vinyl covering.
If you feel that you need assistance with your survey or accreditation readiness, consider calling Excellentia. If you want to run something by me in your preparation for infection control survey, just give me a call.
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