Study finds lapses in infection control practices at ambulatory surgical centers

An assessment of nearly 70 ambulatory surgical centers in three states found that lapses in infection control were common, including for practices such as hand hygiene, injection and medication safety and equipment reprocessing, according to a study in the June 9 issue of the Journal of the American Medical Association (JAMA).

Health care delivery in the United States over the last several decades has shifted toward the outpatient setting; ambulatory surgery in particular has been an area of immense growth, according to an American Medical Association (AMA) press release.

Little known of ASC infections

“Ambulatory surgical centers (ASCs) are defined by the Centers for Medicare & Medicaid Services (CMS) as facilities that operate exclusively to provide surgical services to patients who do not require hospitalization or stays in a surgical facility longer than 24 hours,” the authors of the study wrote. “Between 2001 and 2008 there was a greater than 50% increase in the number of Medicare-certified ASCs in the United States; currently more than 5,000 ASCs participate in the Medicare program. In 2007, these facilities performed more than 6 million procedures with services extending beyond what is traditionally considered surgery to include endoscopy, pain injections, and dental procedures among others. Little is known about infection control practices in ASCs.”

Melissa K. Schaefer, MD, of the Centers for Disease Control and Prevention, and colleagues conducted a study to assess compliance with basic infection control practices as well as with other Medicare health and safety standards in ASCs.

Multi-state assessment

The study included the inspection of ASCs in three states, selected based on geographic dispersion, number of ASCs each state committed to inspect, and relative cost per inspection. Sample size was based on the number of inspections each state estimated it could complete between June and October 2008. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma. Surveyors from CMS, trained in use of an audit tool, assessed compliance with specific infection control practices, focusing on five areas of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

Overall, 46 of 68 pilot ASCs (67.6%) had at least one lapse in infection control noted by surveyors and 17.6% of the facilities had lapses identified in three or more of the five infection control categories. Twelve of 62 facilities (19.4%) were noted to have a lapse in adherence to hand hygiene or appropriate use of personal protective equipment and 28.4% of 67 facilities had deficiencies related to injection practices or medication handling, primarily through use of single-dose vials for more than one patient.

Nineteen of 67 facilities (28.4%) failed to adhere to recommended practices regarding reprocessing of surgical equipment; 12 (18.8%) of 64 facilities did not appropriately clean high-touch surfaces in patient care areas; and 25 (46.3%) of 54 facilities had lapses in appropriate handling of equipment used for blood glucose monitoring.

The researchers also found that 39 (57.4%) of 68 pilot ASCs were ultimately cited for deficiencies in infection control and 20 of 68 ASCs (29.4%) were cited for deficiencies related to medication administration, including use of single-dose medications for multiple patients. The percentage of inspections with deficiencies related to infection control during this pilot was more than six fold greater than the number reported to CMS nationally during the 12-month period from October 1, 2006, to September 30, 2007.

More active role

"Although the inspection process plays an important role in assessing and improving infection control practices, ASCs must also take a more active role. To assist that effort, CMS has made the ASC infection control audit tool available online. Facilities should review the audit tool and evidence-based guidelines to ensure that their policies reflect best practices and that their staff understand and follow the procedures outlined in their written policies,” the authors wrote. “Ambulatory surgical centers should also perform regular self-audits using the infection control tool and the tracer methodology described in this article. Finally, public health agencies at the state and federal levels must continue to work closely with ASCs to improve infection control practices in these facilities.”

Reference:
Schaefer MK, Jhung M, Dahl M, et al. Infection Control Assessment of Ambulatory Surgical Centers. JAMA. 2010;303[22]:2273-2279.

The Hawthorne effect, although perhaps given more credence by generalists than professional social scientists, suggests that knowingly being observed can improve task-oriented performance, even if only transiently (as in the case of a relatively brief ASC facility inspection). Poor performance or compliance with even the basics of infection control while aware of being under direct observation becomes all the more astonishing in context.

– Philip Barie, MD, MBA
New York-Presbyterian Hospital/Weil Cornell Medical Center,
New York City
In an accompanying editorial to the study

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