Infection Control Program§416.51 The ASC Infection Control Program must:– Provide a functional and sanitary environment forsurgical services, to avoid sources andtransmission of infections and communicablediseases;– Be based on nationally recognized infectioncontrol guidelines;
Infection Control Program (cont)– Be directed by a designated healthcareprofessional– Be integrated into ASC’s QAPI program;– Be ongoing– Include actions to prevent, identify and manageinfections and communicable diseases, and– Include mechanism to immediately implementcorrective actions and preventive measures toimprove the control of infection within the ASC.
Infection Control Program § 416.51 The ASC must maintain an explicit infection controlprogram The program is responsible for providing a plan ofaction for preventing, identifying, and managinginfections and communicable diseases.– The plan of action must include mechanisms that result inimmediate action to take preventive or corrective measuresthat improve the ASC infection control program.
Activities of Infection ControlProgram– Development and implementation of infectioncontrol measures related to personnel– Identifying infections– Monitoring infection control program complianceand plan evaluation– Active surveillance– Compliance with reportable disease requirementsof local health authorities
Minnesota Department of HealthInfectious Disease Epidemiology,Prevention and Control651-201-5414 or 1-877-676-5414http://www.health.state.mn.us/divs/idepc
Infection Control Guidelines42 CFR 416.51The infection control program must includedocumentation that the ASC has considered,selected, and implemented nationallyrecognized infection control guidelines Follow nationally recognized infectioncontrol guidelines Documentation that the ASC consideredand selected national-recognized infectioncontrol guidelines for its program
Condition of Coverage-InfectionControl ProgramExamples of national recognizedorganizations include: Centers for Disease Control and Prevention(CDC) Associations for Professional in Infection Controland Epidemermiology (APIC) Society for Healthcare Epidemiology of America(SHEA) Association of Peri-Operative Registered Nurses
Infection Control Program Designee§42 CFR 416.51 (b) (1)The ASC must designate in writing, aqualified licensed health professional withtraining, who will lead the facility’s infectioncontrol programLeadership must be on-site−Consultant may be used− On-site time not specified: must besufficient to ASC’s program size
System to Identify Infections§ 416.51 (b) (3)§ 416.44 (a) (3)System to identify infections that may berelated to procedures performed at the ASC– Follow up with primary care providers– Physician performing the procedure obtainsinformation and reports to ASC– Contact with patient following discharge• Emails• Phone call
ASC Personnel§ 416.51 (b)Infection Control training for staff– Frequency– Same categories– Documentation of trainingEvaluating ASC staff immunization statusPolicies articulating when infected ASC staffare restricted from direct patient care
Infection Control and RelatedPracticesHand HygieneInjection PracticesSingle Use DevicesPoint of Care Devices (e.g. blood glucosemonitors)SterilizationHigh–Level Disinfection
Hand Hygiene§416.51 (a)Staff perform hand hygiene:– After removing gloves– After direct patient care– After contact with blood, body fluids orcontaminated surfaces (even if gloves areworn).
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 newneedle Manufactured prefilled syringes are used for onlyone patient Multi-dose medications, used for more than onepatient, are not stored or accessed in the immediateareas where direct patient care occurs
Injection Practices (cont)Multi-dose medications used for morethan one patient are dated whenopened and discarded within 28 daysor according to manufacturesrecommendations, whichever comesfirst
Single Use Devices§416.44(a)Single use devices are reprocessed– Approved by FDA for reprocessing– Reprocessed by an FDA-approvedpreprocessor.
Point of Care DevicesManufacturer’s instructions indicatemore than one patient useDevice is cleaned and disinfectedbefore each use
Flash Sterilization§416.51(a)S&C Program Memo-09-55Sterilization of unwrapped/uncontainedloads should not be routine practice inASCs but should be used for an urgentand unpredicted need for a specificdevice
High –Level DisinfectionHigh-level disinfection equipment should bemaintained according to manufacturerinstructionsChemicals for high-level disinfection must– Be prepared appropriately– Be tested for appropriate concentration– Be replaced appropriately– Have documentation of preparation andreplacement
High-level Disinfection (cont)Equipment subject to high-leveldisinfection is:– Disinfected for appropriate amount of time– Disinfected at the correct temperature– Allowed to air dry before use– Stored in a designated clean area
Patient Admission Assessment andDischarge§416.52The ASC must ensure each patienthas the appropriate pre-surgical andpost-surgical assessments completeand that all elements of the dischargerequirements are complete