Inspecting Outpatient Surgery Centers – Lapses in Infection Prevention

Posted on by CDC's Safe Healthcare Blog
Dr. Melissa Schaefer
Dr. Melissa Schaefer

Dr. Melissa Schaefer, Medical Officer
CDC’s Division of Healthcare Quality Promotion

When patients seek care in any setting, they should feel confident that their healthcare providers are following basic infection control practices. Ambulatory surgical centers (ASCs), or outpatient surgery centers, are one setting where there has been significant growth in recent years both in number and in the type and complexity of procedures performed. Ensuring patient safety in all settings is a priority for CDC as a whole, and something I take very seriously in my own work.

As part of efforts to better define infection control practices in ASCs and target prevention efforts, CDC and the Centers for Medicare & Medicaid Services (CMS) recently piloted an infection control audit tool during almost 70 ASC inspections in three states. This week, my colleagues and I reported findings from these inspections in study published in the Journal of the American Medical Association (JAMA). The bottom line is that we identified infection control lapses in two-thirds of the pilot facilities.

I find these results disappointing since infection control lapses in any healthcare setting put patients at risk. While our study focused on Medicare-certified ASCs, similar procedures are being performed in doctor’s offices and other outpatient facilities that are not subject to the same oversight and do not undergo inspections like ASCs. Just because procedures are being performed outside the hospital doesn’t mean the same standards and attention to infection control don’t need to be met. All healthcare facilities should take this as an opportunity to evaluate their current infection control policies and, more importantly, make sure their staff understands and follows them.

In the end, we are all patients at some point. We all deserve safe care.

To view the infection control survey tool used in our study go to:
http://totalsol.vo.llnwd.net/o29/data/1080/infection_control_surveyor_worksheet.pdf

Posted on by CDC's Safe Healthcare Blog

29 comments on “Inspecting Outpatient Surgery Centers – Lapses in Infection Prevention”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    All the recommendations for preventing are the first specifically targeted at reducing infection risk in primary care settings where operations or any kind of surgery procedure are performed. Fully performing and effective features in surgical centers are important.

    It’s a shame you don’t have a donate button! I’d most certainly donate to this fantastic blog! I guess for now i’ll settle for bookmarking and adding your RSS feed to my Google account. I look forward to fresh updates and will share this website with my Facebook group. Talk soon!

    Not sure if anyone is still commenting on hai, but was wondering if it is possible that a magnet hospital along with its support staff including Doctors would not do cultures on a patient they suspect has a HA for a number of economic reasons. Your comments or simular experience would be very appreciated

    Alcohol degermers are great for hand hygiene in medical office exam rooms when there is no sink. There is no national requirement or guideline about sinks in medical office exam rooms that I am aware of. My understanding is that it us up to the individual state. If your state requires a sink in every exam room you might try investigating the Office of Statewide Health Planning and Development (OSHPD) this is what it is called in California.

    I think that in general people don’t give consideration to infection prevention at outpatient facilities due to the perception that outpatient procedures just aren’t as “serious” as inpatient procedures. I recently had Laser Eye Surgery and though I came away from it without complications, I found the facility to be not quite as up to par hygiene-wise as a hospital for example. Good food for thought here!

    I am not sure which HICPAC guidelines you are referring to in regards to sinks in exam rooms. I have searched the Guide for Environmental Infection control without success. Can you please be more clear and which section?

    Hello Judith,

    I have researched your questions and would llike to point you to the extensive and effective Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines. These guidelines can be found on their website: http://www.cdc.gov/hicpac/pubs.html

    I am sorry for the delay in responding to this question. I can assure you that it was not that we did not intend to respond. CDC is working toward elimination of all healthcare-associated infections through study, development, and implementation of improvements to healthcare. Your comments, observations, and recommendations are considered important and valuable to us.

    Thank you for your participation in CDC’s Safe Healthcare Blog,
    Anne Meyers

    Some excellent comments made. I am still awaiting a response to my inquiries regarding MERSA and cultures of hospital/direct care givers which would include physicians, nurses, radiology, etc., carriers who can spread this disease to hospital patients. I mentioned masks at the least should be required, but better yet if cannot be cleared of MERSA they not be in any patient area. Expected to hear your opinion on the feasibility of this since MERSA is such a growing problem.
    Also I asked whether a medical examination room used by physicians for various exams should have a handwashing sink. What is your opinion when you make your inspections? Still waiting a response to that as well. The most recent response to mine was very thoughtful and thorough requiring hospitals to give culture results to patients before they are discharged. The other points were excellent as well. Are you just taking issues or are you going to respond? I keep checking back but nothing has been added by CDC.

    The hosp. patient needs to be made a “strong” part of the medical process. No longer can we trust others with our medical care especially since approx. 94,000 patients die from HAI’s yearly and many family members will never know the true cause of death of their loved one because doctors are omitting HAI’s on the Death Certificates. Suggestion: Our Government needs to make it mandatory that every hospital patient “prior” to discharge from the hospital get copies of: their Microbiology Reports (in understandable language since our hosp. uses Coagulase Positive Staff in place of MRSA); their Blood Work Reports; their X-Ray Reports and other test results (all of which should be easily accessable from the hospital computer). Insurance companies and patients pay out a lot of money for medical services and should be provided with the details. Also, within 2 weeks the discharged hosp. patient must get an “itemized” hosp. invoice which will show medications used together with Diagnosis. As of 2 years ago, Medicare patients were only getting a Statement of Amt. owed with no Diagnosis attached. These measures mandated by our Government would assist a patient to manage their medical care and if something is not right they can question it with their doctor or Medicare. Failure to provide these documents by the hosp. would incur a penalty until compliance or refusal by the insurer to reimburse the claim(s). Further, HAI’s need to be declared a “national Emergency” by our U.S. Gov’t since more Americans die from HAI’s than from AIDS. Also, it should be made mandatory that hospitals adhere to strict cleaning guidelines that have been proven (by well respected doctors) to drop HAI’s nearly to Zero. According to our Hosp. Licensing Agreement the State can go in at any time to audit documents which should include the Microbiology Reports, Blood Work Reports; Doctor Notes; Billing to Medicare with Diagnosis that shows medications used AND the patient should be asked if they were made aware of their full condition especially with regards to HAI’s.

    Who will ensure that the doctors and hospitals tell the “truth” about their healthcare associated infections and who will take action against them when they do not? Case in Point: A family member was infected with 4 invasive hosp. acquired infections as documented on their Microbiology Reports (Blood Work Reports also show infection), however, the doctors did not tell our family member about any of the infections and for over 2 1/2 years (from July 2005 – March 16, 2008) kept it secret from them although they lived with family and MRSA is communicable, deadly and for which there is no vaccine. These doctors and administrators omitted these HAI’s on their hosp. diagnosis, hospital doctor notes and initially tried to omit it on the Death Cert. and did not administer the recommened antibiotic Vancomycin for MRSA until 27 hours before death although the infection started in July 2005. They were in violation of the state Hospital Licensing Agreement as to patient rights and yet our Medical Examiners Office says this is Standard Medical Treatment and the Health and Senior Services Dept. says there is No Deficit Process. So, who will protect hosp. patients from the doctors working out of the hospital and hosp. administrators who work together to cover up the “truth” of HAI’s?

    Another question about infection control that I left at another web site but would love to get your comments on is that MERSA is an ongoing problem that is getting worse. It is know that many people habor this organism in their nares without getting ill and that it can be transmitted to other who will get ill. Why are not health care workers cultured to determine if they are carriers? If they are they should be treated if possible, but if not, they should not be direct care givers to any patient who has open wounds, IV’s, post surgical, immune compromise, etc., or better yet no patient contact. Mask should required to be worn when in the medical setting where patients pass through or are contained in waiting rooms, exam rooms, therapy rooms etc. There needs to be more effort to reduce the exposure of patients to potential risks. I think this is an issue that has been neglected for just too long under the pretenses it is too much work and too expensive, or violates the workers rights, or whatever. People are dying from this infection as you well know. As you must have noted I am very concerned and hope that more can be done. Please respond with your opinion. Thank you.

    Thank you for your response to my initial question. The reference will be nice to reference. One thing about the antiseptic hand cleansers. It seems I have read recently that those cleanser have not been as reliable or effective and that hand washing with soap and water is the preferred method. My question was really more directed to the physical plant requirements of a health care setting. It would seem reasonable and necessary to have hand washing sinks with soap and water available in each exam room. My doctor said that the health group has approved the antiseptic cleansers, and that there was a central sink, perhaps in the bathroom, I am not sure now.
    This is the year 2010 and the building is not very old, and it seems if it was built to accommodate medical exams that hand washing sinks should have been required in the building plan. I do not like the risk this situation imposes. Does the CDC have recommendations about the physical plant requirements for exam rooms that would address infection control. At least door knob covers?

    You are absolutely right that hand hygiene is key to patient safety. Healthcare workers should also protect themselves through following the standards and guidelines published by so many groups and agencies.
    The link below will take you to some information that might help you to help your physcian’s office to understand the importance of this issue. As a patient, it’s sometimes difficult to ask a provider to wash their hands, but it is your health that’s most important.
    http://www.cdc.gov/handhygiene/index.html

    These guidelines (the link is below) should be helpful. We hope you continue to read our blog and find the topics useful to you. Please feel free to ask questions or make suggestions regarding topics you would like addressed. The website listed below has links to Infection Control Guidelines for keeping patients and healthcare workers in healthcare settings protected from infectious diseases.
    http://www.cdc.gov/ncidod/dhqp

    It is important that infection control and elimination be a key part of the organizational culture of every health facility doing any surgical proceedures regardless of the size or history of the facility. Also, facilities should be treated the same when it comes to inspections and to training of their staffs. The quality of the inspections and of the staff training will be two critical parts to reducing and eliminating healthcare related infections. This pilot that was done is a major step forward in the process; but the pilot can always be refined and improved on to be even better than it is now.

    I SO APPRECIATE ALL THE INFO & EFFORTS BEING MADE IN THE INVESTAGATIONS OF HOSPITAL & CARE FACILITIES…I BELIEVE THEY SHOULD CHECK THEM ALL STATE-BY-STATE…CITY-BY-CITY! IT IS A PROBLEM THAT WITH PROPER KNOWLEDGE & CARE, WE CAN CHANGE THAT THE STASTICS OF THE OUT COME…DEATH!
    YOU SEE I RECENTLY LOST MY SON TO A BLOOD INFECTION/BLOOD POISONING/MRSA/SEPSIS, ON SEPTEMBER 26, 2009. HE SUFFERED GREATLY WHILE THE DRS. TRY TO FIGURE OUT WHAT WAS WRONG WITH HIM…THEY MESSED WITH EACH FAILING ORGAN ON A SEPERATE SCOPE, INSTEAD OF SEEING WHAT WAS REALLY HAPPENING UNTIL THE LAST TWO WEEKS OF HIS LIFE…IT WAS TOO LATE BY THEN, THE INFECTION HAD SPREAD THROUGHOUT HIS ENTIRE BODY & SYSTEM…THE ANTIBIOTICS DIDN’T WORK!
    I SAY, KEEP UP THE INSPECTIONS…HELPING THE DRS & STAFF BE MORE EDUCATED ABOUT THESE INFECTIONS WILL BE A GREAT START IN SOLVING THE PROBLEM…
    BEST REGARDS,
    COLLEEN S.

    Dear all thanks alot for many skillfull ideas, really Iam from IRAQ, Ineed to know your GUIDE LINES applied to minimize the hospital aquired infection,as it is as you know ,aproblem of major concern ,please can I have some help in giving me the shorthand GUIDLINES
    THIS WILL MADE ME APPRECIAT YOUR HELP

    As a hospital ICP in a state with public reporting of surgical infections, I can say we do not have a problem, and we are very closely scrutinized! I agree with some of your comments about SSI rates in hospital surgery – however, please remember that many of our patients having emergency and other surgeries have multiple co-morbidities and risk factors. When we compare apples to apples…elective Class 1 ASA 1 cases show little variation in Infection Rates either as Inpatient or in Short Stay Ambulatory Units. We have used a CMS-type tool for quite awhile as part of QI processes and JCAH/State inspections and surveys for our facilities. Infection Control in general seems to be a target in every setting and media opportunity, valid or not.

    What really causes concern is the complete lack of a system for reporting infection control violations by the general public. I have been dealing with friends who have been directly impacted by a health care facility’s complete disregard for even the basic Universal Precautions. Yet, every phone call I made, from the local to the Federal level, resulted in “you need to call . . blah blah blah.” In other words, no one is willing to even investigate. We are now in the process of bringing this issue to the local media in hopes that publicly outing the uncaring professionals and “not my problem” officials will force someone to take action before another person is killed by an unnecessary and easily controlled infection.

    My physician’s exam rooms do not have handwashing facilities. Shouldn’t this be an intregal part of an exam room? She does physical and pelvic exams to me as well as burned three growths I had on my skin. I am a registered nurse and am very concerned about this. She said that the healthgroup (NAME OF GROUP WAS REMOVED) doesn’t require it.
    Please respond with your recommendations.

    I agree that Infection Control practices and training are essential in every care setting, licensed, accredited, private, public, ambulatory, hospital, day care and so on. I have been an Infection Control Nurse, Coordinator, Preventionist and Consultant with a long career in pursuit of eliminating HAI and the risks which are the setting for them. In many of those years, Infection Control was a field populated by dedicated solo hospital ICP’s primarily. Inspections, surveys, and training in Infection Control for non-acute care settings was limited or non existent. In the last few years, CMS and others have entered the Infection Control arena, training deeming accreditation surveyors to inspect for and document Infection Control practices thoroughly. This is a good approach, and a start. As an ICP I am a member of a group of ICP Consultants (IPCNJ) working with our Ambulatory facilities to provide education, standards and practices modeled on our acute care IC Programs. We are a small affiliation of highly qualified and Certified Infection Control Professionals, members of APIC, working together and in collaboration, as we always have, to assure the safety of patients and staff from risks of HAI. This is where Infection Control for hospitals began over 35 years ago – we are reaching out to assure the same for ASC’s, to teach them and guide them in the rationales, practices and elimination of HAI.

    Having just gone through a CMS initial “Deemed Status Survey” for CMS Certification, our Ambulatory Surgery Center was audited with this pilot audit tool. The surveyor and the tool were very comprehensive, thorough and appropriate in determining compliance with infecton control Conditions for Coverage for an ASC. We do feel that this same scrutinization should be place on hospitals as the infection rates for surgical patients whose procedures are performed at a hospital have been shown to be almost double what those same infection rates would be if the procedures were done at an ASC.

    “While our study focused on Medicare-certified ASCs, similar procedures are being performed in doctor’s offices and other outpatient facilities that are not subject to the same oversight and do not undergo inspections like ASCs. Just because procedures are being performed outside the hospital doesn’t mean the same standards and attention to infection control don’t need to be met.” We feel that to be fair, these same “standards and attention to infection control” needs to be scrutinized at the hospital level also and those hospitals should be held accountable for their results.

    ASC’s provide safe, competent, efficient and cost-effective care to patients and the negative press from this report appears unjustified considering the care provided and outcomes. As stated in the MSN report from June 8, 2010, Poor infection control at many surgery centers, “The study didn’t look at whether any of the lapses actually led to infections in patients.”

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Page last reviewed: March 26, 2019
Page last updated: March 26, 2019