Cooper Clinic Ambulatory Surgery Center Infection Prevention and Control Plan 2009
Demographics Cooper Clinics Ambulatory Surgery Center is located in Fort Smith, Arkansas. The primary areas served are a five-county area including three Arkansas counties and two Oklahoma counties. The total MSA (metropolitan statistical area) population in 2000 was 273,170 people, estimated by the Bureau to have grown to 289,693 people by 2007. Other major cities in the area include Van Buren, Arkansas, Ozark, Arkansas, Poteau, Oklahoma, and Sallisaw, Oklahoma. As of the census of 2000, there were 273,170 people, 104,506 households, and 75,005 families residing within the MSA. The racial makeup of the MSA was 82.78% White, 3.46% African American, 5.80% Native American, 1.80% Asian, 0.04% Pacific Islander, 2.26% from other races, and 3.87% from two or more races. Hispanic or Latino of any race was 4.54% of the population. 12% - 14% of the population is over the age of 65. 24%26% of the MSA is under the age of 18. The median income for a household in the MSA was $30,500, and the median income for a family was $35,902. Males had a median income of $28,074 versus $20,182 for females. The per capita income for the MSA was $15,039. 53% of all insured Arkansans are covered by employer-sponsored health insurance, 6% are covered under individual plans, 16% are covered under Medicaid, and 4% are covered under other public health insurance plans and options, leaving 21% of Arkansas uninsured or unaccounted for between the years 2004 and 2006, according to the recently released CPS data and updated historical tables. Over this two-year time span approximately 502,000 (18.2%) of all Arkansans have had no health insurance – this is ~140,000 more uninsured individuals than during the 1999-2000 period. Opened in 1995, the Ambulatory Surgery Center (ASC) is located on the 2nd floor of the Main Cooper Clinic location, 6801 Rogers Avenue. More than 6,500 outpatient procedures are performed in this facility each year. The ASC is licensed by the Arkansas State Board of Health and Medicare Health Facility Services. Their staff includes Registered Nurses certified in Advanced Cardiac Life Support, a Certified Nurse’s Aide, and Endoscopy Scope Technicians. Procedures performed in the ASC by Cooper Clinic specialists include:
EGD/Gastroscopy Colonoscopy Laparoscopic Tubal Ligation YAG Laser Capsulotomy
Vision The vision of the Cooper Clinic Ambulatory Surgery Center is to discourage the occurrence and spread of facility-acquired infections. Mission The mission of the Infection Prevention and Control program is to prevent the entry of pathogens into the ASC, rapidly identify contagious illness through active surveillance and interrupt the transmission through measures such as hand washing, environmental decontamination and education. Goal The major goal of the practice of infection control is to minimize the morbidity, mortality, and the economic burdens associated with healthcareassociated infections. Using epidemiologic principles, the Infection Preventionist and Infection Prevention Liaison collects and analyzes pertinent data in order to determine risk factors associated with endemic and epidemic infections and to define mechanisms of transmission. Epidemiologic data is used to plan, implement and evaluate infection control strategies in order to minimize risk of infection in patients, staff, students, visitors, volunteers, and contractor personnel. “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.” Responsibility The Infection Control Committee has the responsibility for directing and monitoring the overall infection control program for the ASC. The Infection Preventionist and the Infection Prevention Liaison have responsibility for the day-to-day management of the program and instituting any measures necessary to ensure the protection of the patient and/or staff. The Director of the ASC has responsibility to insure compliance with the infection control policies and procedures for all ASC staff. Employee Health will notify the ASC Director of any infectious conditions that may pose a risk for patients, visitors and staff. Notify local, state, and federal public health agencies of reportable illnesses and outbreaks as required by law. Surveillance Goals are to identify opportunities to reduce risk, establish baseline infection rates for specified infections, provide a mechanism to detect increased incidence of infection, to measure effectiveness of control measures, and to identify infections and communicable diseases with high potential for transmission early and take appropriate actions. Criteria used to identify health care associated infections in patients are those established by the Centers for Disease Control and Prevention and can be found on the internet at www.cdc.gov/NHSN. All positive microbiology cultures of ASC patients are reviewed to identify clusters or outbreaks of infection, the presence of antibiotic resistant organisms, and pathogens that are communicable among patients and personnel and which may require isolation precautions to prevent transmission. Isolation Precautions will be implemented per CDC’s Guidelines for Isolation Precautions: www.cdc.gov/ncidod/dhqp/gl_isolation.html Infections in patients can be identified by a variety of sources including physician reports, direct examination of the patient by the physician, medical records, ancillary reports such as laboratory and radiology, communication with staff and patient follow-up reports.
Construction/Renovation A proactive approach using risk assessment with risk criteria to identify hazards that could potentially compromise patient care is used to reduce the risk of healthcare-associated infection during hospital demolition, renovation or construction projects.
OUTCOME AND PROCESS MEASURES
Process Goal Opportunities to Reduce Risk Assessment Measure of Success Responsible Party
Hand Hygiene
Staff will perform hand hygiene at every opportunity following CDC guidelines with an observation rate > 80%.
Staff will perform hand hygiene with Alcohol Hand Rub or Soap & Water before & after patient contact. After removing gloves and after contact with blood, body fluids or contaminated surfaces. Gloves changed between patients/activities. Gloves are worn when coming in contact with a potentially infectious patients or blood/body fluids or contaminated surfaces.
Observation
All opportunities for hand hygiene were taken. Observation rate is > 80%.
All staff and visitors
Healthcare Associated Infections: SSI The rate of SSI’s will be < 1% with a target of 0%. Hand Hygiene/Scrub Patient preparation. Surgical attire procedures are followed. Sterile Field requirements are met. All per AORN guidelines. Environmental cleaning is done per CDC requirements. Observation Reported breaches of surgical asepsis. The ASC rate of SSI’s is < 1%. All opportunities to reduce the risk of SSI’s are being practiced. All Staff
Outcome and Process Measures
Process Goal Opportunities to Reduce Risk Limiting operating room traffic. Continuing education. Endoscopes will be processed per manufacturer’s directions. Staff will wear appropriate PPE during reprocessing. Continuing education & competency assessment will be done at least annually. Follow APIC’s/CDC’s guidelines for safe injection practices which include: Never use medication in a syringe for more than one patient even if the needle is changed between patients. Utilize sharps safety devices whenever possible. Discard syringes, needles and cannulas after used directly on an individual patient or in their IV administration system. Dispose of used needles at the point of use in an approved sharps container. http://www.apic.org/Content /NavigationMenu/Governm entAdvocacy/PublicPolicyLi brary/SafeInjections_final.p df . Assessment Measure of Success Responsible Party
Endoscope Reprocessing
Prevent HAIs’ due to improper processing of endoscopes which can result in cross contamination or outbreaks. Rate will be < 1% with a target rate of 0%.
Reprocessing logs are monitored. Observation of cleaning.
No crosscontamination or outbreaks are reported.
Staff
Injection Practices
Reduction/elimination of exposure to blood borne pathogens. Rate will be < 0.5% with a target rate of 0%.
Observe staffs injection practices. Vials are labeled with expiration date. Safety devices are activated when available.
Employee health nurse reports a rate of 0% exposure to BBP through unsafe injection practices.
All Staff
Outcome and Process Measures
Process Goal Opportunities to Reduce Risk Assessment Measure of Success Responsible Party
Sterilization
Medical and surgical instruments do not transmit infectious pathogens to patients or staff. The ASC is sterilizing equipment using standard methods per guidelines of APIC, AAMI, AORN & CDC.
Sterilized equipment is cleaned and visually inspected prior to sterilization. All parameters of steam sterilization are met i.e. time, temperature level, pressure and moisture. Chemical indicators are placed in each load and inspected for integrity and reprocessed if there is any doubt of improper sterilization. Biological indicators are done at least once a week. Flash sterilization is limited to emergency use per policy. Records are kept of testing. Education and competency of staff.
Packages pass visual inspection and chemical parameters. Flash sterilization is <1% of loads.
No cases of transmission of pathogens to patient or staff.
All staff