Infection Prevention Standards Challenge AAAHC-Accredited Facilities

Infection prevention and safe injection practice standards are among those with high deficiency percentages for organizations accredited by the Accreditation Association for Ambulatory Health Care (AAAHC).

This is according to the 2020 AAAHC Quality Roadmap, the accreditor's annual review and analysis of AAAHC standards compliance. The 2020 report reflects data from nearly 1,500 surveys conducted against AAAHC's 2018 standards, which were applied in 2019. Surveyed organizations include Medicare deemed status ambulatory surgery centers (ASCs), office-based surgery practices, and primary care settings.

Medicare Deemed Status Ambulatory Surgery Centers

For the 360 Medicare deemed status ambulatory surgery centers included in the surveys, standards rated as deficient on at least 15% of the surveys were identified. The following infection prevention and safe injection practice standards met this parameter (with approximate % deficient included in parentheses):

• 7.I.C.2 (27%) — The infection control and prevention program reduces the risk of healthcare-acquired infection as evidenced by education and active surveillance, consistent with: (2) Centers for Disease Control and Prevention (CDC) or other nationally recognized guidelines for safe injection practices.

• 9.S (24%) — A safe environment for providing anesthesia services is ensured through the provision of adequate space, equipment, supplies, medications, and appropriately trained personnel. Written policies must be in place for safe use of injectables and single-use syringes and needles. All equipment should be maintained, tested, and inspected according to the manufacturer's specifications. A log is kept of regular preventive maintenance.

• 11.J (22%) — The organization must have policies in place for safe use of injectables and single-use syringes and needles that, at minimum, include the CDC or comparable guidelines for safe injection practices. [416.51(a)]

• 11.B.1 (18%) — Pharmaceutical services are provided in accordance with ethical and professional practice and applicable federal and state laws. [416.48(a)] (1) Drugs are prepared and administered according to established policies and acceptable standards of practice. [416.48(a)]

• 7.I.C (17%) — The infection prevention and control program is under the direction of a designated and qualified healthcare professional with training and current competence in infection prevention and control.

• 11.M (16%) — If look-alike or sound-alike medications are present, the organization identifies and maintains a current list of these medications, and actions to prevent errors are evident.

Office-Based Surgery Practices

For the 138 office-based surgery practices included in the surveys, standards rated as deficient on at least 10% of the surveys were identified. The following infection prevention and safe injection practice standards met this parameter (with approximate % deficient included in parentheses):

• 7.II.E (14%) — All products, including medications, reagents, solutions, and supplies that have a manufacturer's printed expiration date are monitored and disposed of in compliance with facility policy and manufacturers' guidelines.

• 11.F (10%) — Procedures are in place to prevent errors from look-alike, sound-alike and high-alert medications, if present.

• 7.I.B (10%) — The written infection prevention and control program describes how infections and communicable diseases are prevented, identified, and managed.

• 7.I.C (10%) — The infection prevention and control program is under the direction of a designated and qualified healthcare professional with training and current competence in infection prevention and control.

Primary Care Settings

For the 161 primary care organizations included in the surveys, standards rated as deficient on at least 10% of the surveys were identified. The following infection prevention and safe injection practice standards met this parameter (with approximate % deficient included in parentheses):

• 7.II.E (14%) — All products, including medications, reagents, solutions, and supplies that have a manufacturer's printed expiration date are monitored and disposed of in compliance with facility policy and manufacturers' guidelines.

• 7.I.C (11%) — The infection prevention and control program is under the direction of a designated and qualified healthcare professional with training and current competence in infection prevention and control.

Noel Adachi, president and CEO of AAAHC, states in a news release, "The AAAHC Standards focused on infection prevention and control have never been more important. Today, healthcare organizations need to be even more vigilant about adherence to these practices to promote employee and patient safety."

The 2020 report is available for free download after filling out a form here.

Infection Control Consulting Services (ICCS), a national infection control and prevention consulting firm, reports that its findings during onsite visits and review of written programs in the outpatient setting, including ambulatory surgery centers and outpatient clinics, are generally consistent with this report.

Patient and Staff Safety During COVID-19: Waiting and Break Room Tips

As healthcare facilities are reopening, Infection Control Consulting Services is receiving questions from clients concerning recommended practices for waiting rooms and break rooms. Here we provide guidance for both areas.

8 Waiting Room Infection Prevention Tips

In the early stages of reopening, facilities were asking visitors to wait in their cars in facility parking areas as patients underwent procedures and receive treatment. Now that summer has arrived, facilities are concerned about asking visitors to wait in cars that will become hot and potentially unsafe.

If you are located in an area whereby visitors cannot go home and wait for your call after care is completed or are unable to go to an indoor place such as a coffee shop, mall, or restaurant, you may have no choice but to allow visitors in your waiting rooms.

Consider implementing the following in your waiting room:

1. No children allowed.

2. Only one visitor per patient. However, if there are extenuating circumstances, these tips are suggestions, not mandates. You will ultimately need to decide how many visitors to allow under such circumstances.

3. Patient is required to wear a face covering (preferably a medical mask, and if you have enough, you could provide one). Nobody is permitted to enter the facility without faces covered. If you will be providing the visitor with a mask, the patient should receive the mask from you and take it outside to the visitor before the visitor is permitted to enter.

4. When screening patients for symptoms and temperature, consider asking the visitor if he/she is feeling ill. You may want to do a quick thermal scan of the visitor to check for a temperature. You do not want anyone sitting in your facility who is not well. You may want to mention to the patient during the telephone screening that their accompanying visitor will be waiting in the facility, and will not be permitted if they are not feeling well. Also mention that if the visitor is staying, they need to wear a face covering before entering and for the duration of their visit.

5. Spatial separation including chair placement should include grouping two chairs together: one for patient waiting to be taken back, if you are not taking them back immediately upon arrival, and one for the visitor. If you are not having patients sit in the waiting room, single chairs are acceptable as long as they are at least 6 feet apart. For facilities with large waiting rooms, it is best to space chairs out further than 6 feet apart, if possible. Removing chairs from the waiting room to make space for separating chairs may be necessary.

6. Place alcohol hand sanitizer dispensers in the waiting room. The number of dispensers should depend upon how many people can be accommodated. As part of proper respiratory hygiene prior to COVID-19, you should have made tissues and trash cans available in the waiting room. However, people who are visibly ill, especially with runny noses or sneezing, should not be in the waiting room even if they are wearing a mask.

Surveyors will look for the tissues and trash cans. If you are concerned that tissues will be "stolen," you may need to keep them at the receptionist's desk and post notices in your waiting area about the availability of tissues at the desk.

7. Remove all reading material.

8. Assign staff to sanitize the room, particularly chairs, doorknobs, and other high-touch surfaces, and increase the amount of times they perform sanitizing. Each facility is different and will need to determine a feasible and appropriate rotation for disinfection.

6 Break Room Infection Prevention Tips

1. Depending on the size of your break room, you may want to stagger breaks and assign times to staff to take breaks, if possible, taking into consideration their assignment schedules. If your break room is very small, permit only one person in at a time.

2. In larger break rooms, keeping people 6 feet away from each other at a minimum and limiting the number of employees in the room at one time is advisable. Block off seats or remove chairs to encourage such practices.

3. Advise employees to do their best to socially distance themselves when masks are off for eating and drinking.

4. Encourage staff to keep their masks on until they are sitting down and ready to eat. Heating up food, going to the refrigerator, and moving around the break room for other various reasons before sitting down is best performed while wearing a mask. Staff should be advised to remove their masks as little as possible and for as short amount a time as possible.

5. Ask each employee to wipe down the space they came into contact with while in the break room, including the table and chair, upon completing their break. Provide wipes for this purpose.

6. If possible, keep the break room door open to allow for circulation of air, if safe to do so. Some facilities have their break room within visual range of patients or located in other areas that may not be desirable for an open door. The virus will not be pushed out of the room as the break room is not under positive pressure but allowing air in to circulate is a good idea.

Joint Commission Resuming Survey and Review Activities: Key Takeaways

The Joint Commission recently announced it was resuming some survey and review activities beginning this month. Here are key takeaways:

• Surveyors will work to conduct a thorough assessment that seeks to understand how organizations adapted to the health crisis and will review current practices to assure the provision of safe care in a safe environment.

• Surveys will not retroactively review compliance.

• An organization's emergency operations plan will not be the focus of this survey activity.

• Low-risk organizations where surveyors can go in safely will be prioritized.

• Organizations will be expected to provide masks and/or other personal protective equipment (PPE) to surveyors and reviewers during on-site visits.

• Technology will be used to reduce the number of people required to sit next to one another for an extended time (e.g., conducting electronic medical record reviews using screensharing or projecting the record, simulating an activity if surveyors are unable to access a high-risk space, interviewing patients/staff by phone).

• Organizations can ask to use audio and/or video conferencing if they want to expand their number of attendees participating in the process.

The Joint Commission is holding regular webinars to share updates on its survey and review activity plans. At least one or more members of the Infection Control Consulting Services (ICCS) team participants in these programs. Any significant updates issued by The Joint Commission and other accreditation agencies will be shared via the ICCS LinkedIn page. ICCS encourages facilities to reach out to their account executive to discuss survey schedules and upcoming visits, if applicable.

CMS Increases Infection Control Noncompliance Penalties for Nursing Homes

The Centers for Medicare & Medicaid Services has announced it is increasing the civil penalties for nursing homes that fail to comply with infection control requirements.

The federal agency stated it was enhancing enforcement for facilities with persistent infection control violations and imposing enforcement actions on lower level infection control deficiencies to help ensure they are addressed with greater urgency.

CMS also announced it has implemented a new COVID-19 reporting requirement for nursing homes. Furthermore, the agency is partnering with CDC's federal disease surveillance system to quickly identify problem areas and inform future infection control actions.

The announcement from CMS included several other developments, including the tying of some Coronavirus Aid, Relief and Economic Security (CARES) Act funding to state completion of focused infection control nursing home surveys, requiring states to implement revised and expanded survey activities, and refocusing the approach of quality improvement organizations (QIO) to assist in combating COVID-19 within nursing homes.

These changes took effect when they were issued on June 1.

The announcement from CMS comes following the release of U.S. government data showing that nearly 26,000 nursing home residents have died from COVID-19 and more than 60,000 have fallen ill.

COVID-19 Update: Phase 1 Reopening and Ongoing Masks Shortage

As the country begins to phase in an economic recovery plan which includes reopening ambulatory surgery centers (ASCs) and other outpatient offices, significant issues continue with an extreme shortage of personal protective equipment (PPE), including respirator and other masks for healthcare workers. Hospitals have found themselves in crisis mode since the first cases were identified in the United States as stocks of N95 respirator masks continue to be in short supply. Here is an update on a few of the most significant recent developments concerning the pandemic and infection prevention and control.

Reprocessing N95 Masks

Hospitals in desperation have resorted to reprocessing N95 respirator masks that were intended for single use prior to the COVID-19 crisis. The Food and Drug Administration (FDA) evaluated several methods of reprocessing and has issued emergency use authorization (EUA) documents to companies to reprocess and recycle used N95 masks. In a previous post from Infection Control Consulting Services (ICCS), accessible here, ICCS provided the methods and companies responsible for providing these services.

Guidelines for Aerosol-Generating Procedures

As noted, ASCs and other outpatient settings are slowly resuming and working to ramp up operations to conduct elective procedures and routine visits. These services include several aerosol-generating procedures (AGPs) that put frontline workers at potential risk. The list of approved procedures continues to grow as the Centers for Disease Control (CDC), various medical societies, organizations and associations add to it.

CDC advises that clinicians providing direct care for patients likely to undergo an AGP must, at a minimum, don N95 respirator masks that are National Institute for Occupational Safety and Health (NIOSH) approved and fit tested as per the Occupational Safety and Health Administration (OSHA) (29 CFR 1910.134). In addition to respirator masks, additional PPE is necessary to protect the staff. This includes eye protection and face shields.

Examples of resources concerning aerosol-generating procedures include the following:

• Minnesota Department of Health

• American Society for Gastrointestinal Endoscopy

• American Speech-Language-Hearing Association

Challenges for Outpatient Settings

NIOSH N95 respirator masks were not typically worn by staff in outpatient settings until COVID-19 emerged. In the early days of the pandemic, the CDC requested outpatient surgery centers withhold ordering these masks to allow hospitals to maximize their inventory. They were needed for hospital critical care and emergency department staff whose exposure to droplets is highest.

Priority has and continues to be given to hospitals and other service providers who have kept inventory in the past. By the time ASCs and outpatient providers began reopening at the beginning of May, there were very few supplies within the United States to distribute. Pressure to ease the shortage of respirator masks in New York and elsewhere led the FDA to add Chinese-made N95 masks to their suggestions for additional supplies even though they were not approved by NIOSH. As a result, on April 3, the Food and Drug Administration (FDA) issued EUAs for masks from China, which eased the flow of supplies and allowed outpatient and hospital providers to obtain much needed supplies.

In addition to these respirator masks from China, the FDA issued EUAs for KN95 masks that were not considered respirator masks but were often confused with the N95 products. Several hospitals were attempting to fit test the KN95 masks, but these masks were failing the tests. It soon became apparent that KN95s should be used as facemasks only and not as a means to protect healthcare personnel from aerosol-generating procedures.

Unfortunately, the FDA recently became aware of issues associated with the N95 masks from China. Based on filtration performance testing conducted by NIOSH, it was determined that certain respirator masks did not provide adequate and consistent protection for users. This forced FDA to issue a revised EUA on May 7, removing respirators that did not meet certain standards and were therefore, no longer eligible nor authorized to be marketed or distributed as respirator masks within the US.

The FDA advised that Chinese manufacturers can relabel their N95 masks if they meet certain criteria. The KN95 masks list is undergoing continuous updates as companies are added or deleted.

Guidance from Infection Control Consulting Services

Since the announcement that outpatient facilities are resuming services, ICCS has advised its ambulatory surgery center and outpatient provider clients that N95 respirator masks must be fit tested before being used for aerosol-generating procedures. Furthermore, KN95 respirator masks should be considered as face masks only and not as respirator masks as they were not NIOSH approved.

In addition, ICCS has been assisting outpatient facilities with reusing, repurposing and reprocessing NIOSH-approved N95 masks, particularly those surgery centers fortunate to have some supplies and the use of ASP’s Sterrad sterilizer that utilizes hydrogen peroxide and is authorized by the FDA for reprocessing, as per manufacturer’s instructions for use. Providing a certain number of approved N95 masks to each staff member who will be potentially exposed to AGPs and having them rotate their supplies (using various methods) is an option as well.

COVID-19 Assistance from Infection Control Consulting Services

The team of consultants with Infection Control Consulting Services, led by ICCS President and Founder Phenelle Segal, continues to monitor updates and changes as they arise. ICCS provides clients with updates weekly or more frequently, when significant developments occur. Learn more about ICCS COVID-19 assistance services.