3 Common ASC Infection Prevention and Control Areas of Confusion

At ASCA 2016, the annual meeting of the Ambulatory Surgery Center (ASC) Association, Phenelle Segal, RN, CIC, President of Infection Control Consulting Services (ICCS), presented a pre-meeting workshop on "The Role of Infection Prevention and Control in an ASC QAPI Program." More than 125 ASC representatives attended the session, during which Phenelle covered numerous ASC infection prevention and control issues, and discussed new rules and regulations as well as top areas of non-compliance.

Phenelle responded to many questions, both during and after the workshop. Here are three of the most common ASC infection prevention and control areas about which attendees had questions.

1. Laundering of scrubs. Confusion continues to reign in the ASC community as to what is expected of facilities with regard to laundering and wearing of scrubs in the outpatient setting. Attendees asked Phenelle to comment on expectations from the Centers for Medicare & Medicaid Services (CMS) and correct practice.

Phenelle's response is as follows: The CMS surveyor's worksheet, which is the gold standard used during an onsite visit by accreditation agencies and state surveyors, does not include a section on surgical attire. However, and this is where confusion sets in, the surveyors will ask many questions found on the worksheet which will determine what practices regarding surgical attire will be in compliance.

For example, question #16 on the worksheet asks the following: "Does the ASC's infection control program follow nationally recognized infection control guidelines?"

The note that follows includes this statement: "If the ASC does not follow nationally recognized infection control guidelines, a deficiency related to 42 CFR 416.51(b) must be cited. Depending on the scope of the lack of compliance with national guidelines, a condition-level citation may also be appropriate."

Question 16a and 16b are the key items that will tie in with laundering of scrubs. Question 16a asks the following: "Is there documentation that the ASC considered and selected nationally-recognized infection control guidelines for its program?"

The note that follows includes this statement: "If the ASC cannot document that it considered and selected specific guidelines for use in its infection control program, a deficiency related to 42 CFR 416.51(b) must be cited. This is the case even if the ASC's infection control practices comply with generally accepted standards of practice/national guidelines. If the ASC neither selected any nationally recognized guidelines nor complies with generally accepted infection control standards of practice, then the ASC should be cited for a condition-level deficiency related to 42 CFR 416.51."

16b goes on to ask the following: "If YES to (a), which nationally-recognized infection control guidelines has the ASC selected for its program? (Select all that apply)

  • CDC/HICPAC Guidelines
  • Perioperative Standards and Recommended Practices (AORN)
  • Guidelines issued by a specialty surgical society / organization (List)
  • Others (please specify)

In essence, what this all means is that CMS is expecting every ASC to follow nationally recognized infection control guidelines and all infection control practices will be determined by the guidelines chosen. The key to being compliant with laundering of scrubs in particular is studying the guidelines you have chosen to include in your infection control plan and complying with them 100%.

If you have chosen and are following AORN standards, then laundering of scrubs is not permitted outside the facility. The standards include the following: "All individuals who enter the semirestricted and restricted areas should wear freshly laundered surgical attire that is laundered at a health care accredited laundry facility or disposable surgical attire provided by the facility and intended for use within the perioperative setting."

Note: Phenelle notes that developing your own guidelines that are not in keeping with those guidelines you have chosen to follow, as per CMS requirements, will most likely result in a citation which can range from a minor to major deficiency.

2. Use of multi-dose eye drop bottles. Questions concerning this issue were asked by representatives from several surgery centers following the workshop. Unfortunately, this is a grey area in infection prevention as there are no clear-cut guidelines for use of these products.

Phenelle has the following suggestions:

  • As with all medications and products, the first rule is to follow manufacturer's directions for use (DFUs). If medication bottles, including eye drops, are labeled as "single-use" only, they should never be used for more than one patient.
  • Consider switching products to those provided by compounding pharmacies or companies whereby you cut down on the number of bottles needed for use for each case. Before discounting this option due to the fear of increased costs, conduct an overall analysis, including risk, when using multi-dose drops. It may turn out to be a cost savings in the long run.
  • If you continue to use multi-dose drops, then the following practices should be enforced:
  1. Store bottles in a sturdy container that is easy to clean.
  2. When carrying them from patient to patient, ensure the container has been cleaned with a disinfectant wipe between patients.
  3. Do not place the eye drop container on the patient's bed or chair, especially at the foot of the bed. Place the container on a clean surface.
  4. When accessing the drops to instill in the patient's eyes, perform hand hygiene and don gloves once hands are completely dry before you begin the instillation process.
  5. Be very cautious when instilling drops as you do not want to touch the eyelashes or eye. If you inadvertently contaminate the bottle by touching the patient's eye, discard the bottle after use on that patient.
  6. When finished instilling drops, place them back in the sturdy container, clean the outside of the container and perform hand hygiene before moving onto the next patient.
  7. Clean the inside of the container once a day or more often, if indicated, by removing the bottles, wiping down the container with a disinfectant wipe and replacing the bottles in the container for storage after the container is dry.

3. Eyewash stations. Based on attendee questions and recent facility visits by ICCS consultants, eyewash station placement, maintenance and testing has recently appeared as an area of citation under infection control standards during some surveys, despite typically falling under Environment of Care (EC) standards (particularly by The Joint Commission). Eyewash stations are required by OSHA, and may follow The American National Standards Institute (ANSI) that "establishes standards for minimum performance and use requirements for eyewash and shower equipment." ANSI Z358.1-2009 for emergency eyewash and shower equipment provides detailed guidelines to which the Occupational Safety and Health Administration (OSHA), state OSHA and other regulatory agencies commonly refer.

Phenelle recommends incorporating eyewash station monitoring as part of EC rounds. Your facilities management team should have the latest standards and requirements. If you would like additional information, please contact ICCS by emailing info@iccs-home.com or filling out this form.

ICCS will continue to share special reports, newsletters and items of interest as our consultants review processes during onsite visits and assist facilities with maintaining compliance, either as a preventive measure prior to a survey or after a deficiency report has been received. ICCS assists with corrective action plans (CAPs), infection prevention risk assessments and guidance for facilities to improve practices. To join the ICCS email list and receive periodic reports, news and announcements, click here.