Infection Control Program

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;

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.

Infection Control Program

§ 416.51 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.

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

Minnesota Department of HealthInfectious Disease Epidemiology, Prevention and Control

651-201-5414 or 1-877-676-5414http://www.health.state.mn.us/divs/idep

c/dtopics/reportable

Infection Control Guidelines

42 CFR 416.51 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

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

Infection Control Program Designee

§42 CFR 416.51 (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

System to Identify Infections

§ 416.51 (b) (3)§ 416.44 (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

• Emails• Phone call

ASC Personnel

§ 416.51 (b) Infection Control training for staff

– Frequency– Same categories– Documentation of training

Evaluating ASC staff immunization statusPolicies articulating when infected ASC staff

are restricted from direct patient care

Infection Control and Related Practices

Hand Hygiene Injection PracticesSingle Use DevicesPoint of Care Devices (e.g. blood glucose

monitors)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 or

contaminated surfaces (even if gloves are worn).

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

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

Single Use Devices

§416.44(a)Single use devices are reprocessed

– Approved by FDA for reprocessing– Reprocessed by an FDA-approved

preprocessor.

Point of Care Devices

Manufacturer’s instructions indicate more than one patient use

Device is cleaned and disinfected before each use

Flash Sterilization

§416.51(a)S&C Program Memo-09-55Sterilization 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

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

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

Patient Admission Assessment and Discharge

§416.52The 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

Questions and Answers