Audits find infection control gaps at ambulatory surgical centers

Jun 9, 2010 (CIDRAP News) – An observational survey of infection control practices in ambulatory surgical centers (ASCs) in three states found that two thirds of the centers had at least one lapse and nearly 18% had three or more gaps in five reviewed areas, researchers from two federal agencies reported yesterday.

The survey, published in the Journal of the American Medical Association (JAMA), was sponsored by the Centers for Medicare & Medicaid Services (CMS) and conducted by its researchers, along with those from the US Centers for Disease Control and Prevention and health departments of the three states that took part in the survey—Maryland, North Carolina, and Oklahoma.

The CMS commissioned the review on the basis of previous reports identifying infection control problems in ASCs and other outpatient settings. For example, a hepatitis C outbreak at a Las Vegas ASC in 2008 prompted Nevada officials to review the state's other ASCs, which found lapses in about half. A shift toward greater use of ASCs over the past decade has focused more attention on infection control practices at the facilities, of which more than 5,000 participate in the Medicare system.

In their review of 68 ASCs, investigators used an audit tool that 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.

The investigators said that among the most troubling findings were those regarding medication handling and equipment reprocessing. For example, some facilities used single-dose vials and saline bags for multiple patients, 6% of facilities inappropriately reprocessed single-use devices such as syringes used to flush endoscopes during procedures and 21% reused a blood lancing penlet meant for single-use blood glucose testing.

Findings suggest the need for greater emphasis on infection control at the ASCs, the group wrote. "Ambulatory surgical centersare performing increasingly complex procedures and the volumeof procedures performed in these facilities continues to increaseas health care shifts to outpatient settings. Thus, a parallelincrease in emphasis and resource allocation toward infectioncontrol in ASCs is warranted," they noted.

The CMS is currently reviewing one third of the nation's ASCs, as suggested in a 2009 Government Accountability Office report.

The group urged ASCs to take a more active role in infection control activities and said it has made the audit tool it used available for facilities to review their own procedures and monitor compliance.

In an editorial that accompanied the report, Philip Barie, MD, MBA, of New York-Presbyterian Hospital/Weil Cornell Medical Center in New York City wrote that if the findings are symptomatic of infection control problems at other ASCs, millions of people could be at risk for healthcare-associated infections (HAIs) each year. He pointed out that new federal law requires centers to maintain infection control programs using specifically trained personnel, but federal stimulus money supporting the programs expires after fiscal year 2010, which could threaten the sustainability of the infection control efforts.

Health and Human Services (HHS) Secretary Kathleen Sebelius said in a statement yesterday that the findings underscore the urgency of the Obama administration's efforts to reduce HAIs and that the HHS will expand its efforts to reduce infections at ASCs and hemodialysis centers.

Meanwhile, the ASC industry said yesterday that they take the survey findings seriously and are committed to patient safety. The Ambulatory Surgery Center Association (ASCA), based in Washington, DC, said when the lapses were first noted in a 2009 CMS pilot study, the industry launched a national effort urging all facilities to adhere to CMS's new infection control standards; the effort, they said, is already addressing concerns raised in the latest report. "This study highlights the need for all levels of industry and government to be engaged in educating ASCs about these standards," the group's statement said.

Andrew Hayek, chairman of the ASCA's advocacy committee, said the group embraces the CMS audit tools and has implemented voluntary reporting standards and has asked the CMS to implement a nationwide quality reporting system using comparable data for ASCs and all healthcare facilities "so patients are able to make informed decisions about where to receive their healthcare."

David Shapiro, MD, chairman of the ASCA, said in the statement that data show that ASCs have low rates of complications and infections related to the procedures performed in the facilities. "We have a proven track record of outstanding surgical care and patient satisfaction," he added.

Schaefer MK, Jhung M, Dahl MA, et al. Infection control assessment of ambulatory surgical centers. JAMA 2010 Jun 9;303(22):2273-79 [Abstract]

Barie P. Infection control practices in ambulatory surgical centers (editorial). JAMA 2010 Jun 9;303(22):2295-97 [Abstract]

See also:

Jun 8 JAMA press release

Jun 8 Kathleen Sebelius statement

Jun 8 Ambulatory Surgery Center Association press release

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