Becker's ASC Review

47 QUALITY & ACCREDITATION ASC Infection Control: 3 Main Surveyor Focus Areas in 2016 By Anuja Vaidya T his year, accreditation bodies are focusing on three main infection control areas in ASCs, according to Jennifer Eason, RN, CASC, regional vice president at SurgCenter Development. The three areas are: 1. Airflow. Surveyors are focused on ensuring the airflow is working as designed, particularly in the operating room and sterile processing rooms, to ensure the airflow systems are providing a sanitary environment. Test the airflow in your ASC's ORs and sterile processing rooms frequently to ensure positive air pressure in these locations, says Ms. Eason. 2. Multi-dose vial medication preparation. Surveyors are scrutinizing multi-dose vial use and preparation this year. Multi-dose vials must be prepared in a pharmacy-des- ignated area. Once these vials enter the operating room or are accessed in patient care areas, they are no longer considered a multi-dose vial and can only be used for one patient, says Ms. Eason. Also, if multi-dose vials are stored and accessed appropriately, they must be discarded within 28 days unless the manufacturer specifies differently. "Surveyors [will] want to review the ASC's policy on the ex- piration date labeling of multi-dose vials," says Ms. Eason. "Be consistent with following your center's policy." 3. Hand-washing. Thorough and frequent hand-washing is critical for the success of infection control practices at all healthcare facilities. Infection control guidelines recom- mend that staff members wash their hands before and after each patient encounter. Have a plan in place to moni- tor hand washing monthly or at least several times a year at your facility, says Ms. Eason. n 6 Steps to Create & Maintain an Outstanding ASC Infection Control Program By Anuja Vaidya E ffective quality improvement and infec- tion control programs are the corner- stone of an ASC's reputation. ey are also an essential aspect of gaining and maintaining accreditation or certification. Here are six important steps for creating and implementing an infection control program in an ASC: 1. Gain familiarity with regulations and standards. According to Jennifer Eason, RN, CASC, regional vice president at SurgCenter Development, it is important for administrators to be familiar with state and CMS regulations as well as accreditation standards to ensure they are developing and implementing an infection control program that meets all requirements. 2. Look to infection control societies for guidance. Include guidelines from nationally recognized infection control societies such as the CDC, Association of periOperative Registered Nurses and Association for Professionals in Infection Control and Epidemiology, in your infection control program, says Ms. Eason. Also, make sure ASC staff members have access to those guidelines. 3. Identify an infection control cham- pion in your organization. In 2009, CMS began requiring ASCs to train one licensed staff member, typically a registered nurse, to oversee the center's infection control pro- gram. Initial and ongoing training is required for this individual to effectively manage the program. "A number of organizations provide training for the infection control RN, such as APIC for example," Ms. Eason says. 4. Follow the plan you put in place. Once you have an infection control plan that meets all requirements, the next step is to implement it. Ms. Eason suggests taking time to observe your staff, including physicians, to see if they are following the policies and pro- cedures your center has put in place to meet the infection control program's objections. Ensure postoperative infection reports are collected and analyzed monthly and conduct audits for surveillance of processes, includ- ing hand washing, injection practices and the use of personal protective equipment. Ms. Eason says to be sure the results of this data are routinely shared with the center's quality council, medical executive committee and governing body. 5. Annually review the program. CMS requires that ASCs annually evaluate the infection control program and gain approval from their governing body, says Ms. Eason. It is important that the infection control nurse collaborate with the center's quality council and medical executive committee to review the plan's effectiveness and make recommen- dations to the governing body. 6. Create a culture around infection control. Involve the entire team. Ensure the entire team is aware of the infection control program and its goals and objectives. Get your team's buy-in and input when creating the program. "Celebrate your successes," says Ms. Eason. "By engaging physicians and staff in infection control efforts, you can ensure your facility has an infection prevention culture and is committed to providing quality care." n

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