Kathleen Dunn-Cane, MS, RN-BC
Field Representative, Ambulatory Care
The Joint Commission
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Infection Prevention and Control
Issues Related to Ambulatory
Surgery Centers (ASC)
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
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Learning Objectives
Risk Assessment
IC.01.03.01
Probability of
Occurrence
Likelihood of Infectious
Transmission to Others
Severity of
Infectious
Outcome
Risk
Level
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Risk
Event
Risks for Acquiring and
Transmitting Infection
Organization-wide
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– Ambulatory Surgery Centers/Clinics
– New programs
– Whenever risks significantly change
Basic Steps
Collect Data:
Internal/External
Risk
Analyze
Prioritize
Explain Why?
Assessment
Evaluate
(Document/Report)
Set
Goals
Measurable
Timeframe
Collect
Surveillance
Data
Implement
Strategies
Plan
“Best”
Strategies
How will you
achieve the
goals?
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Evaluate Re-
Evaluating IC Plans
– Prioritized risks
– Goals
– Implemented plan activities
– Communicated at least annually (ie.
Patient Safety Committee)
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IC.03.01.01 evaluates annually and
whenever risks significantly change
Includes review of the following:
Risk assessment
- Risk events
- IC Program goal(s)
- Strategies to meet goals
- End of year evaluation
- Status (Met or Not Met)
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Infection Prevention and Control
Plan
IC related NPSG’s Goal 7 –
Healthcare-associated infections
- 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
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Hand Hygiene-
IC related NPSG’s Goal 7 –
Healthcare-associated infections
- 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
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Surgical Site Infections (SSI)
IC Considerations during
Emergency Management
Emergency Management Scenario:
EBOLA or Pandemic influenza
– Surge of infectious patients
– Additional Resources: Pandemic/Public
Health
– Ebola Preparedness Resources
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http://www.jointcommission.org/emerge
ncy_management.aspx
IC.02.02.01 The organization reduces
the risk of infections associated with
medical equipment, devices, and
supplies
EP 2 Performing intermediate and highlevel disinfection and sterilization of
medical equipment, devices, and
supplies
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Risk Reduction
Not adhering to manufacturer’s
instructions for use (IFUs)
Not following recommended practices
or evidence-based guidelines
Lack of documented staff competency
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Risks in Reprocessing Medical
Equipment, Devices, and Supplies
Reprocessing Process
for Sterilization
Manual
Inspect/
Package
Sterilization
Storage
Automated
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Point of
Transport to
Preparation for
Use/Removal of Processing
Cleaning/Cleaning
gross soil
Area
Spaulding Classification System
Device Classification
Device (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 disinfection
Hospital 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
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Classification of devices, processes, and germicidal products
Reprocessing Process for Highlevel Disinfection (HLD)
Transport to
processing area
Clean
HLD
Rinse
Dry
Store
15
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Point of
use/Removal of
gross soil
Quality Monitoring of Sterilization
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Mechanical/Physical Indicators
• Displays, printouts
• Indicates if equipment working
properly
•Not indicator of sterility
Chemical Indicators
•Change color with timed exposure to
heat, steam
•Used to show items have gone
through sterilization process
•Not indicator of sterility
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Quality Monitoring of Sterilization
Biological Indicators
- Demonstrates bacterial spores on test
strips or in vials/containers have all
been killed
- Indicator of sterility
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Quality Monitoring of Sterilization
Quality Monitoring of HLD
– Length of time
– Temperature
– Documentation/logs
– Test strips – labeled, expiration date,
follow instructions for use, correct test strip
for solution
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High-level disinfectants are prepared
according to manufacturer’s
instructions for use
Equipment storage and
IC Considerations
– 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
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IC.02.02.01 EP4 Storing of medical
equipment, devices, and supplies
To Do List:
Monitoring Program:
How do you investigate reprocessing
breaches/lapses? What actions do you
take?
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– Compliance to protocols
– Assess if current P&P’s are effective
– Document competency and training
– Provide feedback to improve performance
Situations identified on site
Have or potentially may have serious
adverse effects on the health or safety
of patients
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Immediate Threat to Health
or Safety (ITL) Related to IC
Identified while on survey
Standards Interpretation Group (SIG)
survey report review
Office of Quality Management (OQM)
submitted complaint
Identified during Abatement Survey
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ITL’s
IC.01.03.01 The organization identifies
risks for acquiring and transmitting
infections
IC.02.02.01 The organization reduces
the risk of infections associated with
medical equipment, devices, and
supplies
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Frequent Noncompliant
IC Standards
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
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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
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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
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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
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ITL’s
2008 CDC Guideline for Disinfection
and Sterilization in Healthcare
Facilities.
ANSI/AAMI ST58:2013 Chemical
Sterilization and high-level disinfection
in healthcare facilities
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Resources
Resources
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ANSI/AAMI ST79:2010 & A1:2010 &
A2:2011 & A3:2012 (Consolidated Text)
Comprehensive guide to steam
sterilization and sterility assurance in
health care facilities
Resources
2013 AORN Recommended Practices
for Perioperative Nursing – Sterilization
and Disinfection
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– Disinfection – High-level
– Flexible Endoscopes – Cleaning and
Processing
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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Resources