Infection Control Lacking at Ambulatory Surgical Centers

Nancy Fowler Larson

June 08, 2010

June 8, 2010 — Lapses in infection control are widespread in ambulatory surgical centers (ASCs), according to an article published June 9 in the Journal of the American Medical Association.

ASCs offer surgical services to those who require fewer than 24 hours of care after their procedures, and their use has skyrocketed amid a growing trend toward outpatient surgery. From 2001 to 2008, the number of ASCs certified by Medicaid in the United States more than doubled, and today they number more than 5000. More than 6 million procedures took place in such centers in 2007, including not only surgeries but also pain-relief injections, endoscopy, and other nonsurgical procedures.

"Despite this shift in health care delivery, attention to infection control in ASCs might be lacking, as evidenced by the increased identification of outbreaks of health care–associated infections...and patient notifications resulting from lapses in infection control in these and other outpatient settings," write Melissa Schaefer, MD, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues.

The investigators sought to assess infection-control practices in areas: hand cleanliness, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of equipment for blood glucose monitoring. They examined 68 ASCs in Maryland, North Carolina, and Oklahoma between June and October 2008, using an audit tool created by the Centers for Medicaid and Medicare Services.

Lapses Found in More Than Two Thirds of ASCs

The investigation turned up a number of lapses in infection control, including the following:

  • 46 of the 68 ASCs (67.6%; 95% confidence interval [CI], 55.9% - 77.9%) evidenced at least 1 infection-control lapse;

  • 12 ASCs (17.6%; 95% CI, 9.9% - 28.1%) demonstrated lapses in at least 3 categories;

  • the most frequently occurring lapses included reuse of a single-dose medication vial (18/64 [28.1%]; 95% CI, 18.2% - 40.0%), improper equipment reprocessing (19/67 [28.4%]; 95% CI, 18.6% - 40.0%), and mishandling blood glucose monitoring equipment (25/54 [46.3%]; 95% CI, 33.4% - 59.6%);

  • no meaningful connection was found between the occurrence of a lapse and the number of procedures performed per month in the areas of hand cleanliness (P = .54), injection safety/medication handling (P = .57), equipment reprocessing (P = .85), environmental cleaning (P = .90), or blood glucose monitoring equipment handling (P = .34).

The researchers were particularly concerned about the widespread repeat use of single-dose medication vials. Noting that the medications contain no bacterial growth–inhibiting preservatives, the investigators said the practice has caused bloodstream infections outbreaks in the past. They speculated that ASCs are reusing the vials to save money.

"In what could be a cost-saving measure, facilities have purchased single-dose medications in packaging larger than that required for single-patient use and then used the contents for multiple patients," the authors write.

The investigators stated 5 limitations to their study:

  • the number of reported lapses may be an underestimate because of the limited amount of observed procedures and caregivers,

  • narrow capabilities of the audit tool prevented the researchers from determining whether the facilities had multiple or single lapses in any category,

  • the number of healthcare-associated infections was not assessed,

  • inspectors' varied levels of expertise regarding the audit tool likely influenced the findings, and

  • the generalization of findings is hampered by the small sample size.

ASCs, Regulatory Agencies Must Look for Lapses in Infection Control

Using the audit tool, which is available online, ASCs must begin policing themselves with regard to infection control, according to the researchers. Government agencies should also pay closer attention to such centers, they say.

"Finally, public health agencies at the state and federal levels must continue to work closely with ASCs to improve infection control practices in these facilities," the authors write.

In an editorial accompanying the study, Philip Barie, MD, MBA, from New York-Presbyterian Hospital/Weil Cornell Medical Center, New York City, calculated that if the findings can be generalized, several million US patients may be at risk for infections in ASCs. Dr. Barie also noted that ASC staff members were aware of the inspectors' presence as they worked. He cited a phenomenon known as the Hawthorne effect, which would typically result in greater conformity to best practices.

"The Hawthorne effect, although perhaps given more credence by generalists than professional social scientists, suggests that knowingly being observed can improve task-oriented performance, even if only transiently (as in the case of a relatively brief ASC facility inspection)," Dr. Barie said. "Poor performance or compliance with even the basics of infection control while aware of being under direct observation becomes all the more astonishing in context."

The study was supported by the Centers for Medicare and Medicaid Services. Study coauthor Dr. Sarah Schillie owns stock in Pfizer, Eli Lilly, Monsanto, General Electric, and Walgreens. The study authors have disclosed no other relevant financial relationships.

JAMA. 2010;303(22):2273-2279, 2295-2297.