1. Infection Control Program

2. Infection Control Program
§416.51
The ASC Infection Control Program must:
Provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases;
Be based on nationally recognized infection control guidelines;

3. Infection Control Program (cont)
Be directed by a designated healthcare professional
Be integrated into ASC’s QAPI program;
Be ongoing
Include actions to prevent, identify and manage infections and communicable diseases, and
Include mechanism to immediately implement corrective actions and preventive measures to improve the control of infection within the ASC.

4. Infection Control Program§
The ASC must maintain an explicit infection control program
The program is responsible for providing a plan of action for preventing, identifying, and managing infections and communicable diseases.
The plan of action must include mechanisms that result in immediate action to take preventive or corrective measures that improve the ASC infection control program.

5. Activities of Infection Control Program
Development and implementation of infection control measures related to personnel
Identifying infections
Monitoring infection control program compliance and plan evaluation
Active surveillance
Compliance with reportable disease requirements of local health authorities

6. Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Controlor

7. Infection Control Guidelines
42 CFR
The infection control program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines
Follow nationally recognized infection control guidelines
Documentation that the ASC considered and selected national-recognized infection control guidelines for its program

8. Condition of Coverage-Infection Control Program
Examples of national recognized organizations include:
Centers for Disease Control and Prevention(CDC)
Associations for Professional in Infection Control and Epidemermiology (APIC)
Society for Healthcare Epidemiology of America (SHEA)
Association of Peri-Operative Registered Nurses

9. Infection Control Program Designee
§42 CFR (b) (1)
The ASC must designate in writing, a qualified licensed health professional with training, who will lead the facility’s infection control program
Leadership must be on-site
−Consultant may be used
− On-site time not specified: must be sufficient to ASC’s program size

10. System to Identify Infections
§ (b) (3) § (a) (3)
System to identify infections that may be related to procedures performed at the ASC
Follow up with primary care providers
Physician performing the procedure obtains information and reports to ASC
Contact with patient following discharge s
Phone call

11. ASC Personnel § 416.51 (b) Infection Control training for staff
Frequency
Same categories
Documentation of training
Evaluating ASC staff immunization status
Policies articulating when infected ASC staff are restricted from direct patient care

12. Infection Control and Related Practices
Hand Hygiene
Injection Practices
Single Use Devices
Point of Care Devices (e.g. blood glucose monitors)
Sterilization
High–Level Disinfection

13. Hand Hygiene §416.51 (a) Staff perform hand hygiene:
After removing gloves
After direct patient care
After contact with blood, body fluids or contaminated surfaces (even if gloves are worn).

14. Injection Practices §416.48(a) Needles are used for only one patient
Syringes are used for only one patient
Medication vials are always entered with a new needle
Manufactured prefilled syringes are used for only one patient
Multi-dose medications, used for more than one patient, are not stored or accessed in the immediate areas where direct patient care occurs

15. Injection Practices (cont)
Multi-dose medications used for more than one patient are dated when opened and discarded within 28 days or according to manufactures recommendations, whichever comes first

16. Single Use Devices §416.44(a) Single use devices are reprocessed
Approved by FDA for reprocessing
Reprocessed by an FDA-approved preprocessor.

17. Point of Care Devices
Manufacturer’s instructions indicate more than one patient use
Device is cleaned and disinfected before each use

18. Flash Sterilization §416.51(a) S&C Program Memo-09-55
Sterilization of unwrapped/uncontained loads should not be routine practice in ASCs but should be used for an urgent and unpredicted need for a specific device

19. High –Level Disinfection
High-level disinfection equipment should be maintained according to manufacturer instructions
Chemicals for high-level disinfection must
Be prepared appropriately
Be tested for appropriate concentration
Be replaced appropriately
Have documentation of preparation and replacement

20. High-level Disinfection (cont)
Equipment subject to high-level disinfection is:
Disinfected for appropriate amount of time
Disinfected at the correct temperature
Allowed to air dry before use
Stored in a designated clean area

21. Patient Admission Assessment and Discharge
§416.52
The ASC must ensure each patient has the appropriate pre-surgical and post-surgical assessments complete and that all elements of the discharge requirements are complete

36. Questions and Answers