We conduct monthly infection control rounds to assess that effective infection control and prevention best practice measures are in place. These rounds include hand hygiene compliance, PPE compliance, COVID-19 mitigation protocols, high-level disinfection and sterilization protocols, policies, environmental cleaning and disinfection, safe medication handling and injection practices, and patient infection surveillance and reporting procedures throughout the organization. These reports are forwarded to the Governing Body for review, recommendations, actions and approvals.
We also utilize the CMS Infection Control Surveyor Worksheet, Exhibit 351, for IC monitoring in the ASC setting. This is another excellent tool to measure:
- Hand hygiene compliance: before and after direct patient care activities; after removing gloves; before and after performing invasive procedures; wearing gloves for procedures that might involved contact with body fluids or blood; wearing gloves when handling potentially contaminated patient equipment; removing gloves before moving to the next task/patient care activity; and assessing personnel providing direct patient care to make sure they do not wear artificial fingernails and/or extenders when having direct contact with patients.
- Observation of safe injection practices: we observe activities by anesthesia care providers, RNs and physicians to make sure one needle and one syringe is used for one patient only; the rubber septum on medical vial is disinfected with alcohol prior to piercing; medical vials are always entered with a new needle and a new syringe; single-dose medical vials (SDV) are used for one patient only; multi-dose vials (MDV) are treated as SDVs when located in a patient care area (preop bay, PACU bay, procedure room or operating room); MDVs are appropriately labeled when first opened and discarded after 28 days unless manufacturer specifically states a different date; and pre-drawn medications are labeled with date and time of draw with the initials of the person drawing the medication, medication name, strength, and beyond-use date and time.
- Diligent sharps safety practices to prevent sharps exposure: appropriate use of puncture-resistant sharps safety disposal containers.
- Following manufacturer's instructions for use (IFU), current best practice protocols and organizational policy on single-use devices; if single-use devices are reprocessed, they are reprocessed by a FDA approved reprocessing company.
- Following manufacturer's IFU, current best practice guidelines and organizational policy for sterilization and high-level disinfection of equipment and instrumentation: a suggestion is to maintain a file with the manufacturers IFUs and processing instructions on instrumentation and equipment. Monitor for immediate use steam sterilization (IUSS) to ensure this method is not used for processing implants nor for devices that have not been validated to be processed using an IUSS cycle. If IUSS is performed, follow specific guidelines, manufacturers IFU and organizational policy.
- Follow manufacturers IFUs with environmental cleaning and disinfection; ensure disinfectants are EPA-registered for healthcare application; monitor for appropriate dwell times and observe healthcare workers using these products to determine knowledge and understanding for use; and ensure daily terminal cleaning of ORs and procedure rooms.
- Observe staff members performing point-of-care device testing, such as with a blood glucose meter. Ensure hand hygiene is performed before and after use of the device to obtain patient blood samples; observe for gloves worn by healthcare workers when performing blood glucose testing; ensure each finger stick device (lancet and single-use holding device as applicable by manufacturer) is used for only one patient.
We also share in the infection control monitoring and observations with different clinical staff members using these checklists and tools. Often, the preop and PACU teams will conduct observational assessments of the procedure room and operating rooms activities. The procedure rooms and operating rooms staff will conduct these assessments of the preop and PACU areas too.
We share and collaborate on findings at staff meetings and quarterly quality councils. This is a great way to support and reinforce infection control best practices throughout the entire team in your ASC.