Infection Control and Prevention Under Heightened Scrutiny: 10 Key Reminders

If you followed the national news over the past week, you likely heard about the alarming matter associated with a New Jersey ambulatory surgery center. To summarize, alleged lapses in proper infection control practices may have exposed nearly 3,800 patients to hepatitis B, hepatitis C and human immunodeficiency virus (HIV) at this facility over a more than eight-month period earlier this year (you can read more about what happened here).

In just the past few days, we have learned from news outlets (including NBC News) that problems at this ASC allegedly included the use of rusty equipment, improperly cleaned bed sheets and a failure to cover beards and facial hair during procedures. A former patient has filed a class-action lawsuit against the facility.

Prior to this incident, infection prevention and control practices in the perioperative setting were already coming under increased scrutiny by regulators. The national press coverage of this ASC will likely put an even brighter spotlight on practices.

To help ensure your facility delivers safe, compliant care and avoids unwanted media attention, Infection Control Consulting Services (ICCS) offers the following 10 critical reminders about infection prevention and control practices.

1. The Centers for Medicare & Medicaid Services (CMS) requires that healthcare facilities, including hospitals, ASCs and outpatient clinic settings, follow "nationally recognized guidelines and standards." The specific organization standards chosen by a facility should be documented (e.g., AORN perioperative standards, ANSI/AAMI ST79) and implemented via development of policies and procedures.

2. Once policies and procedures are developed, a record of when a policy was approved with governing body minutes documenting approval must be available. This can be accomplished with a list of policies and date of approval attached to minutes. Keeping a notebook or file of the list of policies with date of governing board approval (a cross-reference to board minutes) also helps when a surveyor asks for approval dates and line of authority. ICCS repeatedly finds policies that are outdated, unsigned and not fully implemented, which puts the facility at risk for suboptimal compliance.

3. Education is paramount. At new hire orientation, facility-specific practices and protocols should be addressed. This includes hand hygiene and standard precautions, which incorporate safe injection practices and bloodborne pathogen exposure control. Annual infection control updates should highlight practices and protocols again, along with any new items that require addressing. Ad hoc educational updates are important as well if new items or issues arise. This could be as small as the introduction of a new product or piece of equipment.

4. Documentation is a key factor in maintaining compliance. That includes protocols that are followed by way of checklists and audit sheets.

5. Sign-in sheets for education are important. Documentation should include, at a minimum, the in-service title, date and time education was provided, duration and signatures of attendees.

6. Monitoring/auditing of processes is vital to patient safety and keeping tabs on staff compliance. In addition, if there is an issue that arises, such as a surgical site- or perioperative- related infection, proving due diligence in the auditing process will alleviate a lot of angst when having to produce evidence of appropriate "best practices."

7. Competencies, particularly for staff members and independent contractors providing central processing services and anesthesia, should be performed on an annual basis or more often if indicated. Additional competencies such as environmental services are also encouraged.

8. Areas that often fall short of appropriate documentation as identified by recent ICCS on-site visits include monitoring of sterilization processes and safe injection practices. Poor practices and failed compliance in these areas frequently subject facilities to immediate jeopardy/facility shutdown.

9. Central processing technicians require certification in the following states: Connecticut, New Jersey, New York and Tennessee, according to information provided by the International Association of Healthcare Central Service Material Management (IAHCSSM). ICCS anticipates that this will expand to other states in the future, as failure in processes continue to be identified. ICCS suggests that facilities look into certification for technicians regardless of location.

10. The goal of every facility is to deliver an infection-free experience for patients and staff. However, if processes are not followed and a breach in practice occurs, you may find your facility at the center of a legal situation, as evidenced by the situation in New Jersey. ICCS encourages all facilities to remain fastidious in reviewing their infection control program and reach out for assistance if there is any uncertainty about practices and protocols.

Request a Consultation

If your matter is urgent,
please call (215) 692-3485.