Medicare s ASC Infection Control Worksheet: Friend, Foe or Both? Tammeria Tyler, RN CIC Infection Preventionist Learning Objectives To understand outlined Conditions for Coverage in the ASC Infection Control Surveyor Worksheet Exhibit 351 Using the CMS 351 tool to assess current infection control prevention policies, procedures and identify areas for improvement 1
EXHIBIT 351 To follow along on the document please go to: https://www.cms.gov/regulations and Guidance/.../som107_exhibit_351.pdf Part 1 ASC Characteristics Basically Demographics Name, Address, CMS certification number Year opened, Most recent CMS surveys Deemed status and by who and when? Ownership Types of procedures performed Population served 2
ASC Characteristics con t Average number of procedures performed Number of OR/Procedure rooms and Number actively maintained How services such as Anesthesia, EVS, Linen, Nursing, Pharmacy, Sterilization/Reprocessing and Waste are maintained contract or employee Infection Control Program Does the ASC have an explicit infection control program? Does the program follow nationally recognized infection control guidelines? Whose CDC/HICPAC,AORN,SGNA,APIC,AAMI, SHEA, etc. 3
Infection Control Program con t Does the ASC have a licensed health care professional directing the program? Employee or Contractor? Certified? Training? Hours per week sent on Infection Control Infection Control Program con t System to actively identify infections? How and supporting documentation Policy/procedure to comply with state notifiable disease reporting requirements 4
Infection Control Program con t Do staff receive infection control training? How? Who? Same for each category of worker? How often? Is there documentation of training? Infection Control Program con t How many procedures were observed during the site visit? 5
Part 2 IC & Related Practices Hand Hygiene Practices to be Assessed All patient care areas have: Soap and water available Alcohol based hand rubs Does the alcohol based hand rubs comply with the Life Safety Code? Part 2 IC & Related Practices Staff performs Hand Hygiene: After removing gloves Before direct patient contact After direct patient contact Before performing invasive procedures After contact with blood, body fluids or contaminated surfaces 6
Part 2 IC & Related Practice con t Gloves: Wear for procedures that might involve any body fluids When handling contaminated objects Remove prior to next task or patient II. Injection Practices Practices to be Assessed Needles are used for only one patient Syringes are used for only one patient Septum on medication vials are disinfected prior to piercing Vials are always entered with a new needle Vials are always entered with a new syringe 7
II. Injection Practices con t Medications that are pre drawn are labeled with date/time of draw, initials of person drawing, medication name, strength and discard date and time. Note: may not be done in a patient care area! II. Injection Practices con t Single dose medications are used for only one patient Manufactured prefilled syringes are single patient IV solutions are single patient use IV tubing and connectors are single patient use 8
II. Injection Practices con t Multi dose injectable medications are used for only one patient if no (which is best practice) Dated and discarded 28 days after opening Stored and accessed away from patient areas II. Injection Practices con t Sharps Are disposed of in puncture resistant containers Containers are replaced once fill line is reached 9
III. Single Use/Sterilization/Disinfection Practices to be Assessed Single Use Devices: If single use devices are reprocessed, are they approved by FDA for reprocessing? Is the reprocessor FDA approved? III. Single Use/Sterilization/Disinfection Sterilization: Is critical equipment sterilized and is it performed on site? What type? 10
III. Single Use/Sterilization/Disinfection Sterilization con t Practices to be assessed: Items pre cleaned according to IFUs or evidence based guidelines Visually inspected for residual soil/recleaned before packaging and sterilization Chemical indicator in each load III. Single Use/Sterilization/Disinfection Sterilization con t A biologic indicator performed at least weekly Each load monitored with mechanical indicators Documentation on each piece of sterilized equipment is logged including results from each load 11
III. Single Use/Sterilization/Disinfection Sterilization con t Items are contained and handled during process to assure sterility prior to use Stored appropriately Are inspected for integrity if compromised are reprocessed III. Single Use/Sterilization/Disinfection High level Disinfection Practices to be Assessed: Semi critical equipment is high level disinfection or sterilization Is it performed on site? If yes, type of method 12
III. Single Use/Sterilization/Disinfection Semi critical con t Items are precleaned according to IFUs or evidence based guidelines prior to disinfection Visually inspected for residual soil and recleaned before high level disinfection High level disinfection per IFUs III. Single Use/Sterilization/Disinfection High Level Disinfection con t Chemicals used prepared according to IFUs Concentrations tested per IFUs Replaced according to IFUs Documentation to have been prepared/replaced according to IFUs 13
III. Single Use/Sterilization/Disinfection High Level Disinfection con t Items undergoing high level disinfection are treated the appropriate amount of time as specified by IFUs or evidence based guidelines Disinfected at the appropriate temperature per IFUs or evidence based guidelines Allowed to dry before use and stored appropriately IV. Environmental Infection Control Practices to be Assessed OR/procedure room is cleaned/disinfected after each procedure with an EPA registered disinfectant OR are terminally cleaned daily documented? High touch surfaces in patient care areas cleaned/disinfected with EPA disinfectant 14
IV. Environmental Infection Control Environmental Infection Control con t ASC has a procedure for decontamination of gross blood spills V. Point of Care Devices Practices to be Assessed Does ASC have a POC device? A new single use lancet auto disabling device is used for each patient Cleaned per IFUs between each patient. 15
Take Aways! Use this tool to guide you. Do this annually and be honest! Follow the One and Only campaign for safe injection practices No rips or tears in pillows, mattresses, IV prep chair padding, surgical jelly rolls, etc. if so then replace! Take Aways! con t Vinyl is your friend in waiting areas it can be cleaned and disinfected whereas cloth seats can t. Make sure preps are allowed to dry prior to draping. Only medications needed for the current case should be out in the pt. care area 16
Take Aways! con t If medications are removed from the original container label correctly! Linens are always covered. Supply carts are always covered. Any supplies that are opened for a case are discarded at the end of the case used or not Know dry times for all products Take Aways! con t Know validations of sterilization of chemicals used and chemicals used Have all IFUs on hand Always disinfect needle less ports and septums of medication vials the contents within the vial are sterile but under the cap isn t 17
Take Aways! con t Hand Hygiene, Hand Hygiene, Hand Hygiene And lastly Document everything think like a lawyer! 18