Study Finds Lapses in Infection Control Practices at ASCs

An assessment of nearly 70 ambulatory surgical centers in three states found that lapses in infection control were common, including for practices such as hand hygiene, injection and medication safety and equipment reprocessing, according to a study in the June 9 issue of JAMA.

Healthcare delivery in the United States over the last several decades has shifted toward the outpatient setting; ambulatory surgery in particular has been an area of immense growth. “Ambulatory surgery centers (ASCs) are defined by the Centers for Medicare & Medicaid Services (CMS) as facilities that operate exclusively to provide surgical services to patients who do not require hospitalization or stays in a surgical facility longer than 24 hours. Between 2001 and 2008 there was a greater than 50 percent increase in the number of Medicare-certified ASCs in the United States; currently more than 5,000 ASCs participate in the Medicare program. In 2007, these facilities performed more than 6 million procedures with services extending beyond what is traditionally considered surgery to include endoscopy, pain injections, and dental procedures among others,” the authors write. “Little is known about infection control practices in ASCs.”

Melissa K. Schaefer, MD, of the Centers for Disease Control and Prevention (CDC), and colleagues conducted a study to assess compliance with basic infection control practices as well as with other Medicare health and safety standards in ASCs. The study included the inspection of ASCs in three states, selected based on geographic dispersion, number of ASCs each state committed to inspect, and relative cost per inspection. Sample size was based on the number of inspections each state estimated it could complete between June and October 2008. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma. Surveyors from CMS, trained in use of an audit tool, assessed compliance with specific infection control practices, focusing on five areas of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

Overall, 46 of 68 pilot ASCs (67.6 percent) had at least 1 lapse in infection control noted by surveyors and 17.6 percent of the facilities had lapses identified in 3 or more of the 5 infection control categories. Twelve of 62 facilities (19.4 percent) were noted to have a lapse in adherence to hand hygiene or appropriate use of personal protective equipment (i.e., gloves); 28.4 percent of 67 facilities had deficiencies related to injection practices or medication handling, primarily through use of single-dose vials for more than 1 patient.

Nineteen of 67 facilities (28.4 percent) failed to adhere to recommended practices regarding reprocessing of surgical equipment; 12 (18.8 percent) of 64 facilities did not appropriately clean high-touch surfaces in patient care areas; and 25 (46.3 percent) of 54 facilities had lapses in appropriate handling of equipment used for blood glucose monitoring.

The researchers also found that 39 (57.4 percent) of 68 pilot ASCs were ultimately cited for deficiencies in infection control and 20 of 68 ASCs (29.4 percent) were cited for deficiencies related to medication administration, including use of single-dose medications for multiple patients. The percentage of inspections with deficiencies related to infection control during this pilot was more than 6-fold greater than the number reported to CMS nationally during the 12-month period from October 1, 2006, to September 30, 2007.

“Although the inspection process plays an important role in assessing and improving infection control practices, ASCs must also take a more active role. To assist that effort, CMS has made the ASC infection control audit tool available online. Facilities should review the audit tool and evidence-based guidelines to ensure that their policies reflect best practices and that their staff understand and follow the procedures outlined in their written policies. Ambulatory surgical centers should also perform regular self-audits using the infection control tool and the tracer methodology described in this article. Finally, public health agencies at the state and federal levels must continue to work closely with ASCs to improve infection control practices in these facilities,” the authors conclude.

Philip S. Barie, MD, MBA, of New York-Presbyterian Hospital/Weil Cornell Medical Center, New York, writes in an accompanying editorial that these and other findings suggest that problems with infection control practices may be pervasive: “If the findings by Schaefer et al are generalizable, then among the estimated more than 6 million patients who undergo procedures in ASCs annually in the United States, it is possible that several million patients could be at potential risk for health care-associated infection each year. This risk is not acceptable and must be corrected immediately and definitively. Federal regulatory intervention is already occurring. Ambulatory surgical centers must now maintain infection control programs directed by a designated health care professional with training in infection control, and audited adherence will be conducted through a modified infection control tool, but programmatic sustainability after fiscal year 2010 is not assured when American Recovery and Reinvestment Act funding expires. Regardless, ASCs and practitioners are not absolved of individual and collective responsibility to do the right thing.”

Reference: JAMA. 2010;303[22]:2273-2279.