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© Copyright, The Joint Commission Infection Prevention and Control Issues Related to Ambulatory Surgery Centers (ASC) Kathleen Dunn-Cane, MS, RN-BC Field Representative, Ambulatory Care The Joint Commission
© Copyright, The Joint Commission Learning Objectives At the conclusion of this presentation, the participant will be able to: 1. Identify elements that contribute to Infection Control findings in ASC’s 2. Identify specific infection control elements that contribute to an Immediate Threat to Life (ITL) determination
© Copyright, The Joint Commission Risk Assessment IC Risk Event Probability of Occurrence Likelihood of Infectious Transmission to Others Severity of Infectious Outcome Risk Level
© Copyright, The Joint Commission Risks for Acquiring and Transmitting Infection Organization-wide –Ambulatory Surgery Centers/Clinics –New programs –Whenever risks significantly change
© Copyright, The Joint Commission Risk Assessment Set Goals Plan “Best” Strategies Implement Strategies Evaluate Re- Evaluate ( Document/ Report) Collect Data: Internal/External Analyze Prioritize Explain Why? Collect Surveillance Data Measurable Timeframe How will you achieve the goals? Basic Steps
© Copyright, The Joint Commission Evaluating IC Plans IC evaluates annually and whenever risks significantly change Includes review of the following: –Prioritized risks –Goals –Implemented plan activities –Communicated at least annually (ie. Patient Safety Committee)
© Copyright, The Joint Commission Infection Prevention and Control Plan Risk assessment - Risk events - IC Program goal(s) - Strategies to meet goals - End of year evaluation - Status (Met or Not Met)
© Copyright, The Joint Commission IC related NPSG’s Goal 7 – Healthcare-associated infections Hand Hygiene- -CDC or WHO Guidelines -Set Goals for improving compliance -Assess compliance with established guidelines through a comprehensive program monitoring compliance and providing feedback -Improve compliance based on goals
© Copyright, The Joint Commission IC related NPSG’s Goal 7 – Healthcare-associated infections Surgical Site Infections (SSI) -Educate staff/patients on prevention -Implement policies/procedures on reducing risk of SSI -Conduct periodic assessments using evidence-based guidelines -Monitor compliance -Evaluate the effectiveness of prevention efforts
© Copyright, The Joint Commission IC Considerations during Emergency Management Emergency Management Scenario: EBOLA or Pandemic influenza –Surge of infectious patients ncy_management.aspx ncy_management.aspx –Additional Resources: Pandemic/Public Health –Ebola Preparedness ResourcesEbola Preparedness Resources
© Copyright, The Joint Commission Risk Reduction IC The organization reduces the risk of infections associated with medical equipment, devices, and supplies EP 2 Performing intermediate and high- level disinfection and sterilization of medical equipment, devices, and supplies
© Copyright, The Joint Commission Risks in Reprocessing Medical Equipment, Devices, and Supplies Not adhering to manufacturer’s instructions for use (IFUs) Not following recommended practices or evidence-based guidelines Lack of documented staff competency 12
© Copyright, The Joint Commission Reprocessing Process for Sterilization Point of Use/Removal of gross soil Transport to Processing Area Preparation for Cleaning/Cleaning Inspect/ Package SterilizationStorage Auto- mated Manual 13
© Copyright, The Joint Commission Spaulding Classification System Classification of devices, processes, and germicidal products Device ClassificationDevice (examples) Spaulding process classification EPA product classification Critical (enters sterile tissue or vascular system) Implants, scalpels, needles, other surgical instruments, etc. Sterilization – sporicidal chemical; prolonged contact Sterilant/disinfectant Semicritical (touches mucous membranes [except dental]) Flexible endoscopes, laryngoscopes, endotracheal tubes, and other similar instruments High-level disinfection – sporicidal chemical; short contact Sterilant/disinfectant Noncritical (touches intact skin) Thermometers, hydrotherapy tanks Intermediate-level disinfection Hospital disinfectant with label claim for tuberculocidal activity Noncritical (touches intact skin) Stethoscopes, tabletops, bedpans, etc. Low-level disinfectionHospital disinfectant without label claim for tuberculocidal activity Modified from Favero MS, Bond WW. Chemical disinfection of medical and surgical materials. In: Block SS. Ed. Disinfection, sterilization and preservation. 4th ed. Philadelphia: Lea & Febiger 1991:627 14
© Copyright, The Joint Commission Reprocessing Process for High- level Disinfection (HLD) Point of use/Removal of gross soil CleanHLDRinseDryStore 15 Transport to processing area
© Copyright, The Joint Commission Quality Monitoring of Sterilization Mechanical/Physical Indicators Displays, printouts Indicates if equipment working properly Not indicator of sterility 16
© Copyright, The Joint Commission Quality Monitoring of Sterilization Chemical Indicators Change color with timed exposure to heat, steam Used to show items have gone through sterilization process Not indicator of sterility 17
© Copyright, The Joint Commission Quality Monitoring of Sterilization Biological Indicators - Demonstrates bacterial spores on test strips or in vials/containers have all been killed - Indicator of sterility 18
© Copyright, The Joint Commission Quality Monitoring of HLD High-level disinfectants are prepared according to manufacturer’s instructions for use –Length of time –Temperature –Documentation/logs –Test strips – labeled, expiration date, follow instructions for use, correct test strip for solution 19
© Copyright, The Joint Commission Equipment storage and IC Considerations IC EP4 Storing of medical equipment, devices, and supplies –Sterile storage –Scope storage- –In a manner to prevent re-contamination after disinfection –policy on “hang time”, the maximum time scopes may be stored without being reprocessed
© Copyright, The Joint Commission To Do List: Monitoring Program: –Compliance to protocols –Assess if current P&P’s are effective –Document competency and training –Provide feedback to improve performance How do you investigate reprocessing breaches/lapses? What actions do you take?
© Copyright, The Joint Commission Immediate Threat to Health or Safety (ITL) Related to IC Situations identified on site Have or potentially may have serious adverse effects on the health or safety of patients
© Copyright, The Joint Commission ITL’s Identified while on survey Standards Interpretation Group (SIG) survey report review Office of Quality Management (OQM) submitted complaint Identified during Abatement Survey
© Copyright, The Joint Commission Frequent Noncompliant IC Standards IC The organization identifies risks for acquiring and transmitting infections IC The organization reduces the risk of infections associated with medical equipment, devices, and supplies
© Copyright, The Joint Commission ITL’s Potential risk of infection to patients associated with medical equipment, devices, and supplies Infection control breaches identified in the cleaning, disinfection, and sterilization process of endoscopes, surgical instruments and devices
© Copyright, The Joint Commission ITL’s Lack of knowledge, adherence, or availability of evidence-based guidelines pertaining to high-level disinfection (HLD)or sterilization Improper HLD product use- not following manufacturer’s instructions
© Copyright, The Joint Commission ITL’s No documentation (logs) on HLD and sterilization to allow for traceability back to the patient, a recall event, and for quality monitoring purposes not performed Incorrect use of biological indicators (BI’s) and controls; use of expired BI products
© Copyright, The Joint Commission ITL’s Lack of orientation, training, and competency of staff involved in the processing or handling of medical equipment, devices and supplies Lack of a qualified professional who has training in infection prevention and control and has responsibility for infection prevention and control within the ambulatory center
© Copyright, The Joint Commission Resources 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. ANSI/AAMI ST58:2013 Chemical Sterilization and high-level disinfection in healthcare facilities
© Copyright, The Joint Commission Resources ANSI/AAMI ST79:2010 & A1:2010 & A2:2011 & A3:2012 (Consolidated Text) Comprehensive guide to steam sterilization and sterility assurance in health care facilities
© Copyright, The Joint Commission Resources 2013 AORN Recommended Practices for Perioperative Nursing – Sterilization and Disinfection –Disinfection – High-level –Flexible Endoscopes – Cleaning and Processing
© Copyright, The Joint Commission Resources 2013 SGNA Guidelines for the Use of High Level Disinfectants & Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes 2012 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
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