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Study Found Serious Infection Control Problems at Many Outpatient Surgical Centers

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June 9, 2010

A new study found that many ambulatory surgical centers (ASCs), also called outpatient or same-day surgery centers had serious lapses of practices designed to prevent the spread of infections.

ASCs are medical facilities that perform surgeries and procedures that do not require hospital admission. According to the Ambulatory Surgery Center Association, ASC facilities across the United States perform over eight million surgeries each year. Procedures in these centers include those in the fields of ophthalmology, gastroenterology, orthopedic, ENT (ear, nose & throat), gynecology and plastic surgery.

In an effort to reduce rising health care costs, low risk surgeries or procedures once performed only in the hospital are now shifting to ASC facilities. Consequently, the ASC industry has seen dramatic growth in recent years.

“More than 5000 ambulatory surgical centers (ASCs) in the United States participate in the Medicare program,” the study researchers said. “Little is known about infection control practices in ASCs.”

Trained surveyors from the Centers for Medicare & Medicaid Services (CMS) assessed sixty-eight ASCs in three states between June and October 2008 for compliance with specific infection control practices. 32 ASC facilities in Maryland, 16 in North Carolina and 20 in Oklahoma. Assessments focused on five categories of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

Melissa K. Schaefer, M.D., of the Centers for Disease Control and Prevention in Atlanta, and colleagues analyzed the assessments, finding that CMS surveyors observed at least one lapse in the infection control categories in 46 of the 68 of the facilities surveyed. 17% of facilities had lapses in three of the five areas of infection control.

Results by Category

Hand Hygiene: 19.4% of facilities had lapses in hand hygiene or the appropriate use of personal protective equipment such as gloves.

Injection Safety and Medication Handling: 28.4% had improper injection practices or medication handling, such as using single dose vials for more than one patient.

Equipment Reprocessing: 28.4% did not follow recommended practices regarding reprocessing of surgical equipment.

Environmental Cleaning: 18.8% failed to clean high-touch surfaces in patient care areas adequately.

Handling of Blood Glucose Monitoring Equipment: 46.3% inappropriately handled blood glucose monitoring equipment.

"These are basic fundamentals of infection control, things like cleaning your hands, cleaning surfaces in patient care areas," study author Dr. Melissa Schaefer told the Associated Press. "It’s all surprising and somewhat disappointing."

The study appears in the June 9, 2010 issue of The Journal of the American Medical Association (JAMA).

“As an integral member of the health care system, ASCs are committed to providing the highest quality care in the safest environment possible for our patients,” said Kathy Bryant, President of the Ambulatory Surgery Center Association in response to the study. “Improving infection control practices is a significant matter facing all health care settings. All health care providers strive toward 100 percent compliance with infection control standards, and this report highlights that we must continue to work diligently toward improved performance.”

The ASC Association is a national, nonprofit association that represents the interests of those who own, operate and seek the services of ASCs throughout the nation. The organization represents more than 2,600 ASCs across the U.S.

“Data show that we have low rates of complications and infections related to procedures performed in our thousands of facilities across the country, and ASC quality and safety are regulated by several rigorous, independent processes – including Medicare certification, state licensure and voluntary accreditation,” said David Shapiro M.D., Chair of the Ambulatory Surgery Center Association and a Partner at the Ambulatory Surgery Company. “We successfully treat tens of thousands of Americans every day, and as the data demonstrate, we have a proven track record of outstanding surgical care and patient satisfaction.”

Results of this study suggest that these lapses in infection control place millions of Americans at risk each year.

“If the findings by Schaefer et al are generalizable, then among the estimated more than 6 million patients who undergo procedures in ASCs annually in the United States, it is possible that several million patients could be at potential risk for health care-associated infection each year,” Philip S. Barie, M.D., M.B.A., of New York-Presbyterian Hospital/Weil Cornell Medical Center, wrote in an editorial accompanying the study. “This risk is not acceptable and must be corrected immediately and definitively.”

A HealthDay article reports that Dr. Schaefer and Dr. Barie could not say with any certainty why these lapses were occurring, but Barie said it was particularly troubling that the problems occurred even though these centers were aware they were being evaluated. "People knew they were being observed, so there was every opportunity for them to modify their behavior," noted Barie."

2 Comments

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    To combat the types of infections discussed in this article, Consumer Reports recommends that patients ask health care staff to “give you (patients) an antibiotic within 60 minutes of surgery.”

    This is a salient recommendation that, respectfully, would appear at times to be improper and inconsistent with CDC guidelines. As I have published, “According to the CDC and FDA, the request by patients for an antibiotic is a major impetus for doctors to over-prescribe these drugs. To reduce patient demand for them, the CDC and FDA have cautioned consumers about the misuse of antibiotics. A top concern of the CDC, the over-prescribing of antibiotics is reported to be a significant contributor to the emergence of antibiotic-resistant microorganisms. Strict control of antibiotic use is warranted, and if adequate infection controls are in place, then the risk of an HAI for most healthy patients and for many types of surgical procedures should be low. Indeed, the blanket and routine administration of pre-surgical antibiotics is potentially unnecessary and insidious. For example, guidelines contraindicate the routine use of vancomycin for antimicrobial prophylaxis.”

    What Consumer Reports might have more appropriately recommended would have been something of the type that I have published: “A more appropriate instruction might have been to have advised patients to ensure that an antibiotic previously determined by their doctors to be indicated, based solely on clinical need and empirical data and not prescribed because of impromptu persuasion by patients, is timely administered prior to surgery.”

    Other publications by Consumer Reports in this field of infection control are similarly confusing, if misleading. For example, in this MartchWatch blog, a Consumer Reports spokesperson states: “I would definitely ask an outpatient center what’s your [infection] rate, tell me what you do to prevent infections in your facility in general and what are you going to do to prevent infections for me?” she said. “Those are really open-ended questions they should be able to answer.”

    As I have also published (see my comments in the British Medical Journal), “disclosed” infection rates are not necessarily reliable or the same as “true” infection rates, a consideration that Consumer Reports has, to date and for unclear reasons, overlooked. Consumer Reports has overlooked other crucial discussions, too, including the possible contribution of the use of misbranded sterilizing devices (without patient disclosure) in today’s operating rooms and surgery centers to hospital infections.

    Lessons need to be better taught and learned in the field of infection control, and a more committed adoption of the principles, not of convenience and mollification, but of science is cleared warranted.

  2. Rajiv Nath says:
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    Technology is one way To bring self discipline into healthcare workers habits for stopping reuse of syringes and unsafe injection practices.
    The developing world have been using Auto disable syringes which get automatically locked and disabled on giving an injection . CDC has been advocating their usage for the MMIS(Making Medical Injections Safe) project in Africa under PEPFAR . Wonder why this is not being considered as an option for USA?
    Cost is only 0.50$-1.00$ per hundred higher than standard disposable syringes.