2 Infection Control Program §416.51The 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 professionalBe integrated into ASC’s QAPI program;Be ongoingInclude actions to prevent, identify and manage infections and communicable diseases, andInclude 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 programThe 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 personnelIdentifying infectionsMonitoring infection control program compliance and plan evaluationActive surveillanceCompliance with reportable disease requirements of local health authorities
6 Minnesota Department of Health Infectious Disease Epidemiology, Prevention and Control or
7 Infection Control Guidelines 42 CFRThe infection control program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelinesFollow nationally recognized infection control guidelinesDocumentation 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 programLeadership 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 ASCFollow up with primary care providersPhysician performing the procedure obtains information and reports to ASCContact with patient following dischargesPhone call
11 ASC Personnel § 416.51 (b) Infection Control training for staff FrequencySame categoriesDocumentation of trainingEvaluating ASC staff immunization statusPolicies articulating when infected ASC staff are restricted from direct patient care
12 Infection Control and Related Practices Hand HygieneInjection PracticesSingle Use DevicesPoint of Care Devices (e.g. blood glucose monitors)SterilizationHigh–Level Disinfection
13 Hand Hygiene §416.51 (a) Staff perform hand hygiene: After removing glovesAfter direct patient careAfter 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 patientMedication vials are always entered with a new needleManufactured prefilled syringes are used for only one patientMulti-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 reprocessingReprocessed by an FDA-approved preprocessor.
17 Point of Care DevicesManufacturer’s instructions indicate more than one patient useDevice 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 instructionsChemicals for high-level disinfection mustBe prepared appropriatelyBe tested for appropriate concentrationBe replaced appropriatelyHave documentation of preparation and replacement
20 High-level Disinfection (cont) Equipment subject to high-level disinfection is:Disinfected for appropriate amount of timeDisinfected at the correct temperatureAllowed to air dry before useStored in a designated clean area
21 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