Post on 24-Feb-2016
description
Infection Control Standards and Reporting for Texas
Ambulatory Surgery Centers
Laura Strohmeyer RN, CGRN, CASCAmSurg Corp Dallas, Texas
Texas ASCS 2013 Annual Meeting
Objectives1. Review the CMS regulations on
infection control as they pertain to Ambulatory Surgery Centers
2. Identify the elements of a comprehensive ASC Infection Control Plan
3. Discuss how to maintain an ASC Infection Control Plan
4. Review required TDSHS Infection Control Reporting
CMS- Centers for Medicare ServicesImplemented new regulations for Ambulatory
Centers effective 5/18/09Individual responsible and trained in infection
controlInfection Control Plan and Risk AssessmentStaff and Physician trainingCenter approved national guidelinesConducting unannounced surveys to check for
complianceImplemented patient tracking to the survey
process
Condition 416.51 (Q-240) The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases.1. Standard 416.51a (Q-241) The ASC must provide a functional
and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.
2. Standard 416.51b (Q-242) The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines.
3. Standard 416.51b1 (Q-243) The program is under the direction of a designated and qualified professional who has training in infection control.
4. Standard 416.51b2 (Q-244) The program is an integral part of the ASC’s quality assessment and performance improvement program.
5. Standard 416.51b3 (Q-245) Responsible for providing a plan of action for preventing, identifying and managing infections and communicable diseases and for immediately implementing corrective and preventative measures that result in improvement.
Summary of CMS Regulations Develop and implement an Infection Control
ProgramOngoing program to prevent, control and
investigate infections and communicable diseases utilizing nationally recognized infection control guidelines
Designated professional with training in infection control
Part of QAPI ProgramPlan for preventing, identifying and
managing infections Provide a sanitary environment
Other Conditions for Coverage
QAPI
Physical Environment
Administration of drugs
Privacy and Safety
Infection Control ProgramProgram Setup
Infection Control ProgramNationally Recognized Guidelines, policies and
proceduresTraining
Infection Control ProfessionalStaff training, credentialed staff
Implementation and SurveillanceAudit staff competency and complianceTrack patient/employee infections
Program SetupCenter Information
Patient population, types of proceduresRisk Assessment - Infection Control Issues
Scope Reprocessing, Surgical Site InfectionsSafe Injection PracticesEnvironment cleaning and housekeeping
Identify Infection Control ProfessionalJob description, training, competencyBoard Approval
Surveillance of patient and employee infectionsAnnual goals and evaluation of plan
Nationally Recognized GuidelinesAssociation of Perioperative Registered
Nurses (AORN)Society of Gastroenterology Nurses and
Associates (SGNA)American Society for GI Endoscopy
(ASGE)Association for Professionals in Infection
Control and Epidemiology (APIC)Centers for Disease Control and
Prevention (CDC)Healthcare Infection Control Practices
Advisory Committee (HICPAC)
TrainingInfection Control Professional
National Society Membership (APIC)Conferences
APIC: Infection Prevention for ASC’s: Meeting CMS Conditions for Coverage
WebinarsOngoing: Stay informed of updates
StaffReview of infection control policiesReview of guidelinesBulletin Boards, Posters, Staff meetings
Physicians, anesthesia, contracted staffDocumentation
The Hands Give It Away
A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA) colonization of his anterior nares. He had no history of MRSA infection or colonization. To assess the potential implications of the patient's MRSA carriage for infection control, an imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient. The MRSA colonies grown from this handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the worker's fingers and thumb (Panel A). With the use of a polymerase-chain-reaction assay, the mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates. After the worker's hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA (Panel B). These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens.
Curtis J. Donskey, M.D. Brittany C. Eckstein, B.S.
Cleveland Veterans Affairs Medical Center Cleveland, OH 44106
Surveillance- PatientsTrack suspected and reported infections
Surgical Site Infections, Phlebitis, Diarrhea, Fever
Monthly patient list to physicians, post-op phone calls
Infection Control BreechScope reprocessingSterilization
Infection Control OutbreaksHepatitis, c.difficile, MRSA
Surveillance- PersonnelTrack reported infections
GI infectionsFluMRSA
PreventionHepatitis B ImmunizationsTB skin testsFlu vaccine- Texas Administrative Code (TAC), Title 25
Health Services, Part 1, Department of State Health Services, Chapter 1, Texas Board of Health, will be amended to add new Subchapter Z Adoption of Vaccine Preventable Disease Policy for hospitals and other facilities licensed under Subtitle B of Title 4 of the Health and Safety Code, including ASCs
ComplianceCompetencies
Scope ReprocessingSterilization
AuditsScope ReprocessingSterilizationHand HygieneSafe Injection PracticesHousekeeping performance
ASC Infection Control Surveyor Worksheet (Exhibit 351) was revised 4/13 to improve clarity.
ReportingStaff MeetingsQuality Assurance Performance Improvement
Infection Control ReportInfection Control Plan and evaluationInfection Control focus studiesPolicies and ProceduresInfection Control outbreak, concerns
Governing Board
DocumentationInfection Control Binder
Infection Control Plan, PoliciesInfection Control Risk Assessment, Annual
goals and evaluation, Quarterly reportsInfection Control Coordinator: Job Desc,
Competency, TrainingNationally Recognized GuidelinesSurveillance Training- Staff, Physicians, CRNA’sAudits
Infection Control 4 ⅟₂ years later…ChallengesTurnover of the Infection Control
ProfessionalInfection Control Professional not meeting
expectationsMinimal ongoing educationDecrease in audit completionCompliance in infection control practices
decreasesFailure to implement infection control
policiesLack of physician and governing board
involvement
Revive your Infection Control Plan
Continue Infection Control Training for allFollow trends in infection controlPerform frequent audits, get more
detailedHold staff accountableEnforce policies- (mandatory Flu vaccine)Network with other ASC’sGoverning Board, Administrators
involvement
Administrator InvolvementAsk the Infection Control Professional to
explain the Infection Control Plan and show documentationWhat is the plan, how was it developed?What training has been completed this year?What audits have been performed this year?Did we meet our infection control goals this
year?What infection control practices have we
improved recently? Review the documentationHow many possible infections were reported
this year?Are all the employee and credentialed staff
health files up to date?Review quarterly reports
TDSHS Infection Control Reporting
MOLD REMEDIATION NOTIFICATION FORM
SECTION 1: TYPE OF NOTIFICATION TYPE OF NOTIFICATION: (Select one and fill in the requested information) ORIGINAL: The DSHS Central Office was notified by: Fax E-mail Hand Delivery Mail Date sent: ___/___/___ Time sent: _________________ a.m. p.m. AMENDMENT No.____ OR CANCELLATION Amendment/Cancellation Notification Required Information: Was the Environmental Health Notifications Group (EHNG) notified by phone between 8:00 a.m. and 5:00 p.m. Central Time of any project date changes or cancellation prior to the original start and/or original stop date? Yes No. If yes, provide the name of the person you spoke with: ________________________________________________ Was the original amended notification faxed/e-mailed/overnight-mailed within 24 hours of the phone call? Yes No. Date: _____/_____/_____ Time: __________ a.m. p.m. Additional Required Notice for Date Changes Less Than 5 Days from Original Start/Stop Date:
Was the appropriate Regional Office notified by e-mail/phone between 8:00 a.m. and 5:00 p.m. Central Time of any project date changes or cancellation prior to the original start and/or original stop date? Yes No
If yes, provide the name of the person you spoke with: _____________________________________________________ Date: ___/___/___ Time: _____________________ a.m. p.m. Was a copy of the amended notification faxed/e-mailed/overnight-mailed to the appropriate Regional Office within 24 hours of the phone call? Yes No. Give a description of the reason for this amendment or cancellation:___________________________________________ ___________________________________________________________________________________________________________________________
EMERGENCY Was emergency request made to the Regional Office or (EHNG) by phone? Yes No If yes, provide the DSHS reference number:_________________ and name of the person you spoke with: _____________________________________ Date: ___/___/___ Time: __________ a.m. p.m. Describe the reason for emergency remediation: ___________________________________________________________ ___________________________________________________________________________________________________
(x) Below if
Amended FACILITY INFORMATION 1. Facility Location/Description of Area
……. Facility/Residence Name:______________________________________________________________________________ ……. Physical Address:____________________________________________________________________________________ ……. County:_____________________ City:___________________________________ Zip:__________________________ ……. Facility Contact Person: _____________________________________ Phone #: ( )____________________________ ……. Description of area/room number:________________________________________________________________________
___________________________________________________________________________________________________ ……. Area of mold to be remediated: ______________________________________ Number of floors:_____________________
2. Type of Facility (Select one)
……. Owner-occupied Residential Dwelling Unit Other WORK SCHEDULE/DESCRIPTION OF WORK TO BE CONDUCTED 1. Scheduled dates of mold remediation:
……. Start date: ___/___/___ and Stop date: ___/___/__ ……. Work days: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. ……. Working hours: ___________________ a.m. p.m. to ______________________ a.m. p.m.
2. Description of work to be conducted
……. Description of mold remediation to be conducted:___________________________________________________________ ____________________________________________________________________________________________________________________________
DO NOT WRITE IN THIS BOX- FOR DEPARTMENT USE ONLY Date Received:___/___/___ Source: ___Fax ___E-mail ___Mail ___Walk-in
For Office Use Only: Notification #:___________________
AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the left-hand side of form below to indicate amended information.
Laura Strohmeyer RN, CGRN, CASCLaura Schneider RN, CGRN, CASC
Laura.Schneider@AmSurg.com214-406-3623
Questions?