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Infection Control Program
Infection Control Program
 §416.51
 The ASC Infection Control Program must:
– Provide a functional and sanitary environment for
surgical services, to avoid sources and
transmission of infections and communicable
diseases;
– Be based on nationally recognized infection
control guidelines;
Infection Control Program (cont)
– Be directed by a designated healthcare
professional
– Be integrated into ASC’s QAPI program;
– Be ongoing
– Include actions to prevent, identify and manage
infections and communicable diseases, and
– Include mechanism to immediately implement
corrective actions and preventive measures to
improve the control of infection within the ASC.
Infection Control Program
 § 416.51
 The ASC must maintain an explicit infection control
program
 The program is responsible for providing a plan of
action for preventing, identifying, and managing
infections and communicable diseases.
– The plan of action must include mechanisms that result in
immediate action to take preventive or corrective measures
that improve the ASC infection control program.
Activities of Infection Control
Program
– Development and implementation of infection
control measures related to personnel
– Identifying infections
– Monitoring infection control program compliance
and plan evaluation
– Active surveillance
– Compliance with reportable disease
requirements of local health authorities
Minnesota Department of Health
Infectious Disease Epidemiology,
Prevention and Control
651-201-5414 or 1-877-676-5414
http://www.health.state.mn.us/divs/idep
c/dtopics/reportable
Infection Control Guidelines
 42 CFR 416.51
 The infection control program must include
documentation that the ASC has considered,
selected, and implemented nationally
recognized infection control guidelines
 Follow nationally recognized infection
control guidelines
 Documentation that the ASC considered
and selected national-recognized infection
control guidelines for its program
Condition of Coverage-Infection
Control Program
 Examples of national recognized
organizations include:
 Centers for Disease Control and Prevention(CDC)
 Associations for Professional in Infection Control
and Epidemermiology (APIC)
 Society for Healthcare Epidemiology of America
(SHEA)
 Association of Peri-Operative Registered Nurses
Infection Control Program Designee
 §42 CFR 416.51 (b) (1)
 The ASC must designate in writing, a
qualified licensed health professional with
training, who will lead the facility’s infection
control program
 Leadership must be on-site
−Consultant may be used
− On-site time not specified: must be
sufficient to ASC’s program size
System to Identify Infections
 § 416.51 (b) (3)
§ 416.44 (a) (3)
 System to identify infections that may be
related to procedures performed at the ASC
– Follow up with primary care providers
– Physician performing the procedure obtains
information and reports to ASC
– Contact with patient following discharge
• Emails
• Phone call
ASC Personnel
 § 416.51 (b)
 Infection Control training for staff
– Frequency
– Same categories
– Documentation of training
 Evaluating ASC staff immunization status
 Policies articulating when infected ASC staff
are restricted from direct patient care
Infection Control and Related
Practices
 Hand Hygiene
 Injection Practices
 Single Use Devices
 Point of Care Devices (e.g. blood glucose
monitors)
 Sterilization
 High–Level Disinfection
Hand Hygiene
§416.51 (a)
Staff perform hand hygiene:
– After removing gloves
– After direct patient care
– After contact with blood, body fluids or
contaminated surfaces (even if gloves are
worn).
Injection Practices
 §416.48(a)
 Needles are used for only one patient
 Syringes are used for only one patient
 Medication vials are always entered with a new
needle
 Manufactured prefilled syringes are used for only
one patient
 Multi-dose medications, used for more than one
patient, are not stored or accessed in the immediate
areas where direct patient care occurs
Injection Practices (cont)
Multi-dose medications used for more
than one patient are dated when
opened and discarded within 28 days
or according to manufactures
recommendations, whichever comes
first
Single Use Devices
§416.44(a)
Single use devices are reprocessed
– Approved by FDA for reprocessing
– Reprocessed by an FDA-approved
preprocessor.
Point of Care Devices
Manufacturer’s instructions indicate
more than one patient use
Device is cleaned and disinfected
before each use
Flash Sterilization
§416.51(a)
S&C Program Memo-09-55
Sterilization of unwrapped/uncontained
loads should not be routine practice in
ASCs but should be used for an urgent
and unpredicted need for a specific
device
High –Level Disinfection
 High-level disinfection equipment should be
maintained according to manufacturer
instructions
 Chemicals for high-level disinfection must
–
–
–
–
Be prepared appropriately
Be tested for appropriate concentration
Be replaced appropriately
Have documentation of preparation and
replacement
High-level Disinfection (cont)
Equipment subject to high-level
disinfection is:
– Disinfected for appropriate amount of time
– Disinfected at the correct temperature
– Allowed to air dry before use
– Stored in a designated clean area
Patient Admission Assessment and
Discharge
§416.52
The ASC must ensure each patient has
the appropriate pre-surgical and postsurgical assessments complete and
that all elements of the discharge
requirements are complete
Questions and Answers