Infection Control Standards and Reporting for Texas Ambulatory Surgery Centers

1. Infection Control Standards and Reporting for Texas Ambulatory Surgery Centers Texas ASCS 2013 Annual Meeting Laura Strohmeyer RN, CGRN, CASC AmSurg Corp Dallas, Texas

2. Objectives • Review the CMS regulations on infection control as they pertain to Ambulatory Surgery Centers • Identify the elements of a comprehensive ASC Infection Control Plan • Discuss how to maintain an ASC Infection Control Plan • Review required TDSHS Infection Control Reporting

3. CMS- Centers for Medicare Services • Implemented new regulations for Ambulatory Centers effective 5/18/09 • Individual responsible and trained in infection control • Infection Control Plan and Risk Assessment • Staff and Physician training • Center approved national guidelines • Conducting unannounced surveys to check for compliance • Implemented patient tracking to the survey process

4. Condition 416.51 (Q-240) The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases. • Standard 416.51a (Q-241)The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. • Standard 416.51b (Q-242) The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines. • Standard 416.51b1 (Q-243) The program is under the direction of a designated and qualified professional who has training in infection control. • Standard 416.51b2 (Q-244) The program is an integral part of the ASC’s quality assessment and performance improvement program. • Standard 416.51b3 (Q-245) Responsible for providing a plan of action for preventing, identifying and managing infections and communicable diseases and for immediately implementing corrective and preventative measures that result in improvement.

5. Summary of CMS Regulations • Develop and implement an Infection Control Program • Ongoing program to prevent, control and investigate infections and communicable diseases utilizing nationally recognized infection control guidelines • Designated professional with training in infection control • Part of QAPI Program • Plan for preventing, identifying and managing infections • Provide a sanitary environment

6. Other Conditions for Coverage • QAPI • Physical Environment • Administration of drugs • Privacy and Safety

7. Infection Control Program • Program Setup • Infection Control Program • Nationally Recognized Guidelines, policies and procedures • Training • Infection Control Professional • Staff training, credentialed staff • Implementation and Surveillance • Audit staff competency and compliance • Track patient/employee infections

8. Program Setup • Center Information • Patient population, types of procedures • Risk Assessment - Infection Control Issues • Scope Reprocessing, Surgical Site Infections • Safe Injection Practices • Environment cleaning and housekeeping • Identify Infection Control Professional • Job description, training, competency • Board Approval • Surveillance of patient and employee infections • Annual goals and evaluation of plan

9. Nationally Recognized Guidelines • Association of Perioperative Registered Nurses (AORN) • Society of Gastroenterology Nurses and Associates (SGNA) • American Society for GI Endoscopy (ASGE) • Association for Professionals in Infection Control and Epidemiology (APIC) • Centers for Disease Control and Prevention (CDC) • Healthcare Infection Control Practices Advisory Committee (HICPAC)

10. Training Infection Control Professional • National Society Membership (APIC) • Conferences • APIC: Infection Prevention for ASC’s: Meeting CMS Conditions for Coverage • Webinars • Ongoing: Stay informed of updates • Staff • Review of infection control policies • Review of guidelines • Bulletin Boards, Posters, Staff meetings • Physicians, anesthesia, contracted staff • Documentation

13. Surveillance- Patients • Track suspected and reported infections • Surgical Site Infections, Phlebitis, Diarrhea, Fever • Monthly patient list to physicians, post-op phone calls • Infection Control Breech • Scope reprocessing • Sterilization • Infection Control Outbreaks • Hepatitis, c.difficile, MRSA

16. Surveillance- Personnel • Track reported infections • GI infections • Flu • MRSA • Prevention • Hepatitis B Immunizations • TB skin tests • Flu vaccine-Texas Administrative Code (TAC), Title 25 Health Services, Part 1, Department of State Health Services, Chapter 1, Texas Board of Health, will be amended to add new Subchapter Z Adoption of Vaccine Preventable Disease Policy for hospitals and other facilities licensed under Subtitle B of Title 4 of the Health and Safety Code, including ASCs

17. Compliance • Competencies • Scope Reprocessing • Sterilization • Audits • Scope Reprocessing • Sterilization • Hand Hygiene • Safe Injection Practices • Housekeeping performance

18. ASC Infection Control Surveyor Worksheet (Exhibit 351) was revised 4/13 to improve clarity.

19. Reporting • Staff Meetings • Quality Assurance Performance Improvement • Infection Control Report • Infection Control Plan and evaluation • Infection Control focus studies • Policies and Procedures • Infection Control outbreak, concerns • Governing Board

20. Documentation • Infection Control Binder • Infection Control Plan, Policies • Infection Control Risk Assessment, Annual goals and evaluation, Quarterly reports • Infection Control Coordinator: Job Desc, Competency, Training • Nationally Recognized Guidelines • Surveillance • Training- Staff, Physicians, CRNA’s • Audits

21. Infection Control 4 ⅟₂ years later… Challenges • Turnover of the Infection Control Professional • Infection Control Professional not meeting expectations • Minimal ongoing education • Decrease in audit completion • Compliance in infection control practices decreases • Failure to implement infection control policies • Lack of physician and governing board involvement

22. Revive your Infection Control Plan • Continue Infection Control Training for all • Follow trends in infection control • Perform frequent audits, get more detailed • Hold staff accountable • Enforce policies- (mandatory Flu vaccine) • Network with other ASC’s • Governing Board, Administrators involvement

23. Administrator Involvement • Ask the Infection Control Professional to explain the Infection Control Plan and show documentation • What is the plan, how was it developed? • What training has been completed this year? • What audits have been performed this year? • Did we meet our infection control goals this year? • What infection control practices have we improved recently? Review the documentation • How many possible infections were reported this year? • Are all the employee and credentialed staff health files up to date? • Review quarterly reports

24. TDSHS Infection Control Reporting

27. Questions? Laura Strohmeyer RN, CGRN, CASC Laura Schneider RN, CGRN, CASC Laura.Schneider@AmSurg.com 214-406-3623