Ambulatory Surgical Site Infections: Following the Roadmap to Elimination

By Kay Temple

Government agencies and professional organizations are helping ambulatory surgical centers (ASCs) integrate infection control practices to help move the dial on surgical site infections (SSIs).

SSIs are a recognized area for risk mitigation in any infection prevention and control program (ICP). Despite improved interventions, they are still a formidable foe in the hospital setting. The Centers for Disease Control (CDC) says that 75 percent of hospital-acquired SSI-associated deaths are directly attributable to the site infection. Overall mortality rate nears 3 percent. Costs associated with SSIs are also significant. According to information included in a 2011 Annals of Surgery review, "Updated Recommendations For Control Of Surgical Site Infections," an SSI incidence of only 1 percent projected inpatient costs of nearly $900 million per year. Overall costs were estimated to be close to  $1.6 billion. Yet those figures were considered conservative since the review indicated they might only reflect 10 percent of total costs. Not factored were indirect costs of lost work time, job loss and caregiver costs.

Ambulatory Surgical Centers, Federal Oversight and SSIs
The sobering hospital SSI numbers raise mirror questions for ASCs. What is the SSI rate in ambulatory settings? What are the treatment costs of ASC-related SSIs? With six million procedures at a cost of almost $3 billion to Medicare in 2007, the Centers for Medicare and Medicaid Services (CMS) wants to keep an eye on infection prevention and control efforts within the nearly 5,300 Medicare-certified ASC facilities. Answers to SSI questions will be coming from new directives and programs being implemented.

Defined by CMS as "distinct entities that operate exclusively to provide surgical services to patients who do not require hospitalization and are not expected to need to stay in a surgical facility longer than 24 hours," it is easy to see why tracking ASC patients after surgery is no easy task.
Despite these challenges, the U.S. Government Accountability Office (GAO), suggested that ASCs could be held to standards used for acute care settings. The GAO recommended that "data on the implementation of CDC-recommended infection control practices...can be collected more easily and can provide critical information on why healthcare-associated infections (HAIs) are occurring and what can be done to help prevent them." Translation: start monitoring ASCs  infection prevention and control policies and procedures.

From the GAO advisory emerged 2009 CMS modifications to several areas of its outpatient payment system's conditions for coverage (CfCs). One change specifically addressed standards for infection control and currently CMS requires ACSs to have in place:
• An infection prevention and control program based on nationally recognized infection control and prevention guidelines
• A designated healthcare professional to lead the ASC's infection prevention and control program
• An infection prevention and control program integrated into the ASC's quality assessment and performance improvement program
• An HAI management program, inclusive of SSIs

The section on ASCs in the U.S. Health and Human Services' (HHS) April 2013 "National Action Plan to Prevent Health Care-Associated Infections: Roadmap to Elimination,"--referred to as the HAI Action Plan--acknowledges the presence of diversity within ASCs. Some ambulatory centers only perform endoscopy procedures. Others only do eye surgeries. Some are free-standing entities. Some are associated with hospitals.

These differences make HAI monitoring a challenge since no "one size fits all" design works.  The HAI Action Plan recognizes the ambulatory setting has specific needs. It supports collaboration with ASC stakeholders to "set forth a proposed series of next steps, priority areas, and actions."

Meeting Federal Requirements: Professional Organizations Can Help
In order for ASCs to meet regulations, the HAI Action Plan recommends looking to nationally recognized infection control and prevention guidelines. Educational programs sponsored by professional organizations such as the Association of periOperative Registered Nurses (AORN) or Association or the Professionals in Infection Control and Epidemiology (APIC) meet CMS standards.

Jan Davidson, MSN, RN, CNOR, CASC, AORN's ambulatory surgery division director, says about one year ago, AORN created an ambulatory surgery section since a little less than half of the organization's membership identified themselves as ambulatory nurses. Many of these professionals may be serving as ICP specialists within their ACSs, she says.

"Hospitals usually have one to two individuals overseeing infection control, but in the ASC, no such luxury," says Davidson. "Usually it is an individual doing that job in addition to their regular job."

AORN's ambulatory education specialist, Terri Link, MPH, BSN, CNOR, CIC, says three challenges have been brought to AORN's attention regarding surgical site infections: ASC-specific infection preventionists training, difficulties in an ASC's self-reporting of surveillance data, and a need to standardize an SSI definition for providers.

AORN is helping to meet these front line needs by creating educational modules for designated ICP individuals within the ASC setting.

"We have fabulous infection prevention training modules that meet the national regulatory requirements," Link says about AORN's programs.
Two programs are currently offered, according to Link. One program is online and allows the learner to self-pace until completion. The second is AORN's first live program being held as a preconference day-long session at AORN's annual conference being held March 29 to April 2 in Chicago. She says though registration suggests significant interest, it is too early to tell how frequently the live program will be offered.

Link says she believes that AORN is a go-to organization for SSI prevention because it is a nationally recognized organization. "We are producing and providing evidenced-based standards and recommended practices for perioperative registered nurses. These standards are written by our own AORN experts and everything in our perioperative standards and recommended practices book is written with the intention of keeping our patients safe, including prevention of surgical site infections. In addition, we collaborate with other nationally recognized organizations and serve on various advisory committees. An example of that is one of our infection preventionists is a liaison on the Healthcare Infection Control Practices Advisory Committee (HICPAC) that writes and approves CDC guidelines."

Davidson says that AORN representatives are also part of the technical expert panel for HHS's Agency for Healthcare Research and Quality (AHRQ) projects. "They're [AHRQ] funding a national quality improvement collaborative in which ambulatory surgery centers can participate to measurably reduce surgical site infections and other complications. By doing this, it will allow ASCs who are enrolled in the program to receive peer-to-peer learning through web conferences, in-person meetings and coaching sessions with expert faculty. AORN is privileged to be part of the expert faculty. Other organizations that are on the technical expert panel are Harvard School of Public Health, the American College of Surgeons, just to name a few, so the AORN feels quite honored to have been asked to be part of that," she says.

AHRQ Offers Additional Help and Insight Into SSIs
To help ASCs implement their ICP, AHRQ is promoting the use of its toolkit, the Comprehensive Unit-based Safety Program (CUSP), a part of its Safety Program for Ambulatory Surgery. The agency says the toolkit is "a proven method" for HAI prevention and SSI reduction in addition to other surgical complications. The toolkit contains strategies to promote teamwork and help ambulatory organizations address safety issues by melding clinical best practices with proven safety methods.

To further information about ambulatory SSIs, AHRQ recently funded a retrospective analysis of SSIs within ASCs. Using information from eight states contained within AHRQ's Healthcare Cost and Utilization Project databases, the study focused on the incidence of clinically significant surgical site infections. The results were published in the Feb. 19, 2014 issue of The Journal of the American Medical Association, "Surgical Site Infections Following Ambulatory Surgery Procedures."

The study found that within 14 days, a rate nearing a little more than three of every 1000 patients experienced an SSI. At 30 days, the rate had increased to almost five of every 1000 patients.

"Healthcare-associated infections remain a common complication of care following ambulatory surgery," says AHRQ director Richard Kronick PhD in the agency's press release. "The number of patients experiencing these serious infections is an important consideration, and work should continue to make outpatient surgery safer."

Updated SSI Guidelines
The CDC is now updating its 1999 SSI prevention guidelines with input from HICPAC's review of recent evidenced based studies based on factors associated with SSIs. The guidelines have been submitted for public comments through Feb. 28, 2014. Core section updates, those applicable to common adult and pediatric surgical procedures, include antimicrobial prophylaxis issues, antisepsis, glycemic control, normothermia and oxygenation. In a special joint arthroplasty section, seven issues are offered for comment: blood transfusion, systemic immunosupressive therapy, intra-articular steroid injections, anticoagulation, orthopedic space suit use, antibiotic prophylaxis with drains and biofilm.