How to Develop an ASC Infection Control Program

By July 26, 2017 June 11th, 2019 ASC Management
ASC Infection Control Program

Surveillance, prevention, and control of infection in ambulatory surgery centers is a frequent deficiency cited in state, Medicare, and accreditation surveys. ASCs are required to have an infection control program that outlines purpose, goals, specific risks, methods of data collection, and strategies used. The program also must identify how and when the infection control program is evaluated. Because most centers do not have a full-time infection control nurse or officer solely dedicated to this role, this requirement can seem daunting. With some luck, the Infection Control Officer (ICO) might get to a meeting once a year and complete the training required to hold this position.

The purpose of infection prevention is to protect the patient, health care workers, visitors, and others in the health care environment. In an ASC especially, it needs to do so in a cost-effective manner. How can you effectively and efficiently ensure infection prevention in your setting?

1. Start by setting infection control program goals.

  • Identify and reduce the risk of endemic and epidemic facility-associated infections.
  • Report appropriate information to internal surgery center leadership and public health authorities.
  • Develop communication linkage between professional and health care workers, patients, families, public health professionals, and the community.
  • Create plans to respond to emerging infections and bioterrorism.
  • Promote a zero tolerance of hospital acquired infections (HAIs).

2. Explain how infection control is embedded in your organization. Spell out how the ICO integrates with committees, the reporting structure, and the sources utilized for evidence-based practices. For example:

  • The ICO is part of the Continuous Assurance Committee and oversees the infection control program.
  • Under the direction of the Medical Director, the ICO investigates all suspected outbreaks. This occurs in collaboration with the appropriate medical and administrative staff.
  • Using the most correct and useful statistical process, data is collected, analyzed, and reported.
  • The ICO has access to comparable community data to determine if rates within the center are above or below those in the community.
  • The ICO develops this plan using data from CDC/NHSN/NNIS.
  • The board of managers approves the infection control program, types and scopes of activities, and training materials. They review this plan at least annually to evaluate its effectiveness in the center.

3. Create a prioritized risk assessment. The risk assessment should focus on internal and external factors. This helps form a complete picture of the risks that exist. Prioritize the identified risks based on the potential impact, probability, and the organization’s preparedness. This is your base for determining what activities you should perform and at what intervals.

  • External: Consider patient populations and cultural reactions to health care. Examples are community issues, such as high rates of TB. These factors are not fixed. As situations arise in the community, a new risk assessment may be necessary.
  • Internal: Focus on your high volume/high acuity cases. Think about instrumentation and the associated cleaning problems (i.e., long, luminated). Consider the physical plant in which you provide care. Are there risks? Do you have a water feature in your lobby?

4. Identify and summarize your activities.

  • Remember to take credit for activities you already perform. This can include monthly and 90-day SSI surveillance, prophylactic ABO administration tracking, and bloodborne pathogen exposure monitoring/reporting and outcomes.
  • Based on your risk assessment, you may track things like monthly monitoring of SPD logs, environment of care items, and hand hygiene. Ensure each one of these activities has a summary explaining the process, frequency of tasks, and documentation undertaken.

5. Spend time discussing and documenting the strategies you will use.

  • A good general statement is “TJC, AAAHC, OSHA and pertinent federal, state, and local regulations pertaining to infection control are being implemented and followed.”
  • Include items such as staff training on PPE, TB, hand hygiene, and cleaning. In addition, list the local, state, and federal contacts and reporting requirements, as well as communication with other health care facilities and providers in your community.

It is important to formally evaluate and revise your goals and program, or portions of the program, at least annually and whenever risks significantly change. Make sure your evaluation addresses the assessment of the success or failure of interventions for preventing and controlling infections and responds to concerns raised by leadership or others. The evaluation should always address how relevant infection prevention and control guidelines are based on evidence and have evolved. In the absence of evidence, cite expert consensus.

Oftentimes, daunting tasks are made less so when you have a framework to follow. Once you get the ball rolling, you are more likely to find an internal champion to serve in the ICO role. Ensure you support your ICO as they tackle program specifics by allocating the funds necessary to secure appropriate training and advance program goals. Before you know it, you’ll have a thriving program and your ASC will significantly reduce the likelihood of being cited for an infection control related deficiency.


Jovanna Grissom, VP of Operations

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