Infection Control Standards and Reporting for Texas

Ambulatory Surgery Centers

Laura Strohmeyer RN, CGRN, CASCAmSurg Corp Dallas, Texas

Texas ASCS 2013 Annual Meeting

Objectives1. Review the CMS regulations on

infection control as they pertain to Ambulatory Surgery Centers

2. Identify the elements of a comprehensive ASC Infection Control Plan

3. Discuss how to maintain an ASC Infection Control Plan

4. Review required TDSHS Infection Control Reporting

CMS- Centers for Medicare ServicesImplemented new regulations for Ambulatory

Centers effective 5/18/09Individual responsible and trained in infection

controlInfection Control Plan and Risk AssessmentStaff and Physician trainingCenter approved national guidelinesConducting unannounced surveys to check for

complianceImplemented patient tracking to the survey

process

Condition 416.51 (Q-240) The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases.1. Standard 416.51a (Q-241) The ASC must provide a functional

and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.

2. Standard 416.51b (Q-242) The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines.

3. Standard 416.51b1 (Q-243) The program is under the direction of a designated and qualified professional who has training in infection control.

4. Standard 416.51b2 (Q-244) The program is an integral part of the ASC’s quality assessment and performance improvement program.

5. Standard 416.51b3 (Q-245) Responsible for providing a plan of action for preventing, identifying and managing infections and communicable diseases and for immediately implementing corrective and preventative measures that result in improvement.

Summary of CMS Regulations Develop and implement an Infection Control

ProgramOngoing program to prevent, control and

investigate infections and communicable diseases utilizing nationally recognized infection control guidelines

Designated professional with training in infection control

Part of QAPI ProgramPlan for preventing, identifying and

managing infections Provide a sanitary environment

Other Conditions for Coverage

QAPI

Physical Environment

Administration of drugs

Privacy and Safety

Infection Control ProgramProgram Setup

Infection Control ProgramNationally Recognized Guidelines, policies and

proceduresTraining

Infection Control ProfessionalStaff training, credentialed staff

Implementation and SurveillanceAudit staff competency and complianceTrack patient/employee infections

Program SetupCenter Information

Patient population, types of proceduresRisk Assessment - Infection Control Issues

Scope Reprocessing, Surgical Site InfectionsSafe Injection PracticesEnvironment cleaning and housekeeping

Identify Infection Control ProfessionalJob description, training, competencyBoard Approval

Surveillance of patient and employee infectionsAnnual goals and evaluation of plan

Nationally Recognized GuidelinesAssociation of Perioperative Registered

Nurses (AORN)Society of Gastroenterology Nurses and

Associates (SGNA)American Society for GI Endoscopy

(ASGE)Association for Professionals in Infection

Control and Epidemiology (APIC)Centers for Disease Control and

Prevention (CDC)Healthcare Infection Control Practices

Advisory Committee (HICPAC)

TrainingInfection Control Professional

National Society Membership (APIC)Conferences

APIC: Infection Prevention for ASC’s: Meeting CMS Conditions for Coverage

WebinarsOngoing: Stay informed of updates

StaffReview of infection control policiesReview of guidelinesBulletin Boards, Posters, Staff meetings

Physicians, anesthesia, contracted staffDocumentation

The Hands Give It Away

A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA) colonization of his anterior nares. He had no history of MRSA infection or colonization. To assess the potential implications of the patient's MRSA carriage for infection control, an imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient. The MRSA colonies grown from this handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the worker's fingers and thumb (Panel A). With the use of a polymerase-chain-reaction assay, the mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates. After the worker's hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA (Panel B). These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens.

Curtis J. Donskey, M.D. Brittany C. Eckstein, B.S.

Cleveland Veterans Affairs Medical Center Cleveland, OH 44106

Surveillance- PatientsTrack suspected and reported infections

Surgical Site Infections, Phlebitis, Diarrhea, Fever

Monthly patient list to physicians, post-op phone calls

Infection Control BreechScope reprocessingSterilization

Infection Control OutbreaksHepatitis, c.difficile, MRSA

Surveillance- PersonnelTrack reported infections

GI infectionsFluMRSA

PreventionHepatitis B ImmunizationsTB skin testsFlu vaccine- Texas Administrative Code (TAC), Title 25

Health Services, Part 1, Department of State Health Services, Chapter 1, Texas Board of Health, will be amended to add new Subchapter Z Adoption of Vaccine Preventable Disease Policy for hospitals and other facilities licensed under Subtitle B of Title 4 of the Health and Safety Code, including ASCs

ComplianceCompetencies

Scope ReprocessingSterilization

AuditsScope ReprocessingSterilizationHand HygieneSafe Injection PracticesHousekeeping performance

ASC Infection Control Surveyor Worksheet (Exhibit 351) was revised 4/13 to improve clarity.

ReportingStaff MeetingsQuality Assurance Performance Improvement

Infection Control ReportInfection Control Plan and evaluationInfection Control focus studiesPolicies and ProceduresInfection Control outbreak, concerns

Governing Board

DocumentationInfection Control Binder

Infection Control Plan, PoliciesInfection Control Risk Assessment, Annual

goals and evaluation, Quarterly reportsInfection Control Coordinator: Job Desc,

Competency, TrainingNationally Recognized GuidelinesSurveillance Training- Staff, Physicians, CRNA’sAudits

Infection Control 4 ⅟₂ years later…ChallengesTurnover of the Infection Control

ProfessionalInfection Control Professional not meeting

expectationsMinimal ongoing educationDecrease in audit completionCompliance in infection control practices

decreasesFailure to implement infection control

policiesLack of physician and governing board

involvement

Revive your Infection Control Plan

Continue Infection Control Training for allFollow trends in infection controlPerform frequent audits, get more

detailedHold staff accountableEnforce policies- (mandatory Flu vaccine)Network with other ASC’sGoverning Board, Administrators

involvement

Administrator InvolvementAsk the Infection Control Professional to

explain the Infection Control Plan and show documentationWhat is the plan, how was it developed?What training has been completed this year?What audits have been performed this year?Did we meet our infection control goals this

year?What infection control practices have we

improved recently? Review the documentationHow many possible infections were reported

this year?Are all the employee and credentialed staff

health files up to date?Review quarterly reports

TDSHS Infection Control Reporting

MOLD REMEDIATION NOTIFICATION FORM

SECTION 1: TYPE OF NOTIFICATION TYPE OF NOTIFICATION: (Select one and fill in the requested information) ORIGINAL: The DSHS Central Office was notified by: Fax E-mail Hand Delivery Mail Date sent: ___/___/___ Time sent: _________________ a.m. p.m. AMENDMENT No.____ OR CANCELLATION Amendment/Cancellation Notification Required Information: Was the Environmental Health Notifications Group (EHNG) notified by phone between 8:00 a.m. and 5:00 p.m. Central Time of any project date changes or cancellation prior to the original start and/or original stop date? Yes No. If yes, provide the name of the person you spoke with: ________________________________________________ Was the original amended notification faxed/e-mailed/overnight-mailed within 24 hours of the phone call? Yes No. Date: _____/_____/_____ Time: __________ a.m. p.m. Additional Required Notice for Date Changes Less Than 5 Days from Original Start/Stop Date:

Was the appropriate Regional Office notified by e-mail/phone between 8:00 a.m. and 5:00 p.m. Central Time of any project date changes or cancellation prior to the original start and/or original stop date? Yes No

If yes, provide the name of the person you spoke with: _____________________________________________________ Date: ___/___/___ Time: _____________________ a.m. p.m. Was a copy of the amended notification faxed/e-mailed/overnight-mailed to the appropriate Regional Office within 24 hours of the phone call? Yes No. Give a description of the reason for this amendment or cancellation:___________________________________________ ___________________________________________________________________________________________________________________________

EMERGENCY Was emergency request made to the Regional Office or (EHNG) by phone? Yes No If yes, provide the DSHS reference number:_________________ and name of the person you spoke with: _____________________________________ Date: ___/___/___ Time: __________ a.m. p.m. Describe the reason for emergency remediation: ___________________________________________________________ ___________________________________________________________________________________________________

(x) Below if

Amended FACILITY INFORMATION 1. Facility Location/Description of Area

……. Facility/Residence Name:______________________________________________________________________________ ……. Physical Address:____________________________________________________________________________________ ……. County:_____________________ City:___________________________________ Zip:__________________________ ……. Facility Contact Person: _____________________________________ Phone #: ( )____________________________ ……. Description of area/room number:________________________________________________________________________

___________________________________________________________________________________________________ ……. Area of mold to be remediated: ______________________________________ Number of floors:_____________________

2. Type of Facility (Select one)

……. Owner-occupied Residential Dwelling Unit Other WORK SCHEDULE/DESCRIPTION OF WORK TO BE CONDUCTED 1. Scheduled dates of mold remediation:

……. Start date: ___/___/___ and Stop date: ___/___/__ ……. Work days: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. ……. Working hours: ___________________ a.m. p.m. to ______________________ a.m. p.m.

2. Description of work to be conducted

……. Description of mold remediation to be conducted:___________________________________________________________ ____________________________________________________________________________________________________________________________

DO NOT WRITE IN THIS BOX- FOR DEPARTMENT USE ONLY Date Received:___/___/___ Source: ___Fax ___E-mail ___Mail ___Walk-in

For Office Use Only: Notification #:___________________

AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the left-hand side of form below to indicate amended information.

Laura Strohmeyer RN, CGRN, CASCLaura Schneider RN, CGRN, CASC

Laura.Schneider@AmSurg.com214-406-3623

Questions?