Infection Prevention in ASCs (October 6, 2021)




ASCA Chief Executive Officer Bill Prentice talks with Cindy Young, administrator of the Surgery Center of Farmington in Farmington, Missouri, and Rebecca Craig, chief executive officer of Harmony Surgery Center in Fort Collins, Colorado, about keeping surgical patients safe from infections. Both Young and Craig are registered nurses, CASC-certified administrators and past ASCA Board members. They currently chair ASCA’s Education and Programs Committee and Quality and Patient Safety Committee, respectively. This highly informative discussion considers sterilization of the surgical room, regulatory inspections, accreditation and the importance of antibiotic therapies in fighting and remedying common infections.

Narrator: 0:06
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice: 0:37
Hi, I’m Bill Prentice, CEO of the Ambulatory Surgery Center Association, or ASCA, and host of this episode of the Advancing Surgical Care Podcast. In just a moment, I’ll be joined by two of my favorite former ASCA Board members for a discussion about infection prevention in ambulatory surgery centers. Since the onset of the COVID-19 pandemic, I’m sure patients at all sites of care have noticed that all their healthcare providers have been taking extra precautions to prevent the spread of viral infections. Testing requirements, patient masking, social distancing and fewer patients in waiting rooms have become the new norm in most healthcare settings. As an organization, ASCA wholeheartedly supports these measures as well as encouraging everyone who is eligible to be vaccinated. But we also want patients to know that infection prevention in ASCs is not new. In fact, fighting and preventing infections of every kind has always been an essential component of safe surgery. Preventing infections of any kind, either during or after a procedure, is an essential element of safe surgery and a patient’s ability to make a full and swift recovery. So thankfully, like so many facets of modern medicine, our understanding of how to prevent surgical site infections, or SSIs, has improved exponentially over time. According to the Johns Hopkins School of Medicine, the risk of developing an infection during or after surgery today is less than 3 percent, and because we also now have such highly effective antibiotic medications, most of those infections are quickly remedied. Still, because we can never eliminate entirely the bacteria and viruses that exist in our environment and the risks that they pose, the practice of infection prevention in ambulatory surgery centers today is a perpetual cycle of educating and training surgical teams, educating patients, as well as maintaining a strict adherence to specific sets of procedures and protocols before, during and after every surgery. It also means being completely transparent in the reporting of serious complications, however rare, so that both patients and regulators can benefit from that information. Well, joining me to talk about these subjects and more, I have the pleasure of welcoming two highly skilled and highly knowledgeable practitioners of infection prevention at the surgery center level, as well as both being national leaders in ASCA’s education and patient safety and quality initiatives. My first guest is Cindy Young, a registered nurse and CASC-certified administrator of the Surgery Center of Farmington in Missouri. Cindy is also a past board member of ASCA and currently chairs our Education and Programs Committee. My second guest is Rebecca Craig, who is also a registered nurse and a CASC-certified chief executive of Harmony Surgery Center in Fort Collins, Colorado. Rebecca is also a past board member of ASCA as well as a past president, and she currently chairs ASCA’s Quality and Patient Safety Committee. Cindy and Rebecca, thank you for taking time to come on the podcast and share your knowledge and experience with our listeners.

Cindy Young: 3:33
Thank you, Bill. I really appreciate being asked to participate in the call today. It’s an honor and a privilege.

Rebecca Craig: 3:40
Thank you, Bill. It’s my pleasure to be here with everybody.

Bill Prentice: 3:43
Thanks to you both. So, Cindy and Rebecca, let me start by asking each of you to talk a little bit about what your medical teams do each day to prepare your operating rooms for surgery to eliminate, as much as possible, the risk of surgery-related infections. We can talk about postoperative care in a minute or two. So, Rebecca, why don’t you go first.

Rebecca Craig: 4:02
Thank you, Bill. It begins with hand hygiene. As we have seen during this pandemic, the importance of hand hygiene cannot be overstated. Each member of our healthcare team performs hand hygiene before each and every patient contact, contact with the equipment utilized for that patient’s care, and throughout the procedure and recovery phases. We follow the World Health Organization’s protocols on hand hygiene, which are so extensive it is difficult to summarize them during this brief podcast. In addition to hand hygiene, our medical teams follow our infection prevention policies and protocols, which are based on stringent recommendations from multiple associations and healthcare authorities, such as terminally cleaning our operating rooms before and after every patient with cleaning agents that kill bacteria and viruses. In addition, administering preop IV antibiotics within 60 minutes of the surgical procedure and our highly regulated sterile processing practices are just a few of the things I’d like to name.

Bill Prentice: 5:10
That’s great. Cindy, do you have anything you’d like to add to that?

Cindy Young: 5:14
Yes. With our surgery center, I’ve always prided ourselves and told each of the staff members to treat every patient as if they are the ones having surgery or their most cherished family member is the one that’s laying on the table and prepare the room how they would want it done, for the instruments to be cleaned and prepped and the outcome that they would expect. With that being said, at the beginning of each day, my staff wipe down everything that’s in the operating room with an EPA-registered cleaning solution. The staff makes sure that each supply and all instruments and instrument trays brought into the surgical suite are sterilized and the integrity of the package is intact to ensure the products are sterile. And the staff do not wear outside clothes in the operating room. The surgery center provides scrubs for the staff to change into upon arrival to the surgery center each morning, and the scrubs are laundered by a professional cleaning company. Regarding medications, we follow the guidelines of one syringe, one patient, one time, and any medication we open during the surgical procedure is only used on the patient present in the room, even if that medication is labeled for multiuse and could be used on more than one patient. Since COVID, we’ve had to put in place a new policy where no employee is allowed to work while they’re sick. The staff knows if they have any signs or symptoms of COVID, they’re not allowed to report to work unless they have been tested and can show a negative COVID test. The days of staff showing up to work sick are over and the days the employer holds the staff to strict rules regarding multiple call outs do not apply to us anymore. After every surgical procedure, we clean the room and at the end of the day we make sure that the housekeeping company comes in and they terminally clean each operating room, wiping down the walls, the ceilings and mopping the floors.

Bill Prentice: 7:05
Well, that’s a lot. And Cindy, just for our listeners, when you say terminally clean, what does that mean?

Cindy Young: 7:12
Terminally clean means wiping down the walls with the EPA-registered solution, the ceiling, everything that’s in the room and mopping the room. Every instrument, every equipment that’s in the room, the anesthesia machine, the beds, all of the tables that are in the room—everything is wiped down to assure that nothing remains from the prior patient. There’s not even any dust in the room that could interfere or cause infection.

Bill Prentice: 7:40
Great, thank you for that. Well, Cindy and Rebecca, I’m going to ask you both as well as our listeners to pause for just a moment and standby while we take a short break and hear a message from our podcast sponsor. We’ll be right back.

Narrator: 7:53
Funding for the Advancing Surgical Care Podcast is provided by HealthCare Appraisers, a national healthcare valuation and advisory firm recognized for its proven track record in ASC valuation. HealthCare Appraisers’ skilled team has valued thousands of ASCs for purchasers, investors and real estate transactions. Experience how HealthCare Appraisers thinks differently by visiting

Bill Prentice: 8:26
Well, I think it would also be beneficial for our listeners, particularly any prospective patients, to have a better sense of the regulatory oversight of surgery centers by both the government and the several accrediting bodies, particularly as it relates to infection prevention efforts. Cindy, can you tell us a little bit about the government oversight of your infection prevention programs? And Rebecca, maybe you could speak to the accreditation process. So, Cindy, go first.

Cindy Young: 8:49
Sure, Bill. We follow the CDC guidelines for all of our infection prevention measures and when CMS, that’s the Centers for Medicare & Medicaid Services, they’re the ones that actually give us our state license allowing us to perform surgery, they come in and do audits on us and they assure that we are following the CDC guidelines as we have written in our policies. If CMS finds out one thing we are doing that does not follow our written policies or does not go along with the CDC guidelines, they’ll give us a written citation and then the written citation will appear in the report and we must perform what’s called a plan of correction. The plan of correction is a detailed explanation that we have to write up to assure that this measure is taken care of, addressed and corrected so it doesn’t happen again. For an example, we did have a sign hanging in a patient bathroom regarding proper hand hygiene. As Rebecca mentioned, proper hand hygiene is of great importance, especially in today’s day and age. So, we wanted to make sure that everyone that’s in the bathroom follows that particular guideline. I’m sure you’ve seen them hanging in many public bathrooms. The sign was taped to the wall instead of putting it in a plastic sleeve or in a hard plastic frame. We were cited because tape is porous and can harbor bacteria, therefore, the tape is not cleanable. We have several other areas where tape was visible because we thought we were doing the right thing with notices and various other labeling on containers. We had to remove all the tape and come up with a new way of labeling bins and hanging signs. All that to say, CMS does assure that all of our infection control practices are being carried out per our policy and per CDC guidelines for our facility.

Rebecca Craig: 10:42
As Cindy pointed out, ambulatory surgery centers are highly regulated healthcare facilities, equal to or, in some instances, more regulated than the hospital environment. To be accredited is a step above federal or state regulations. So, you can imagine, to build on what Cindy said, it is that going above and beyond, even above the regulations that we have to follow from a state and federal level. There are hundreds of accreditation standards that a surgery center has to comply with. We embed those standards, the environment of care and infection prevention standards and practices, into everything we do each and every day. Processes involving infection prevention are monitored on a daily, monthly, quarterly and annual basis to ensure all of our practices are keeping our patients safe, and that everything is working well. In addition, our governing bodies of all of our surgery centers, they have the oversight of our quality assurance programs, which include reviewing the facilities’ outcomes data, compared to national benchmarks, and all corrective action taken, again, just to ensure that continuous improvement and quality and safety for our patients. And then every three years or even sooner, we get a survey, and it is an extensive and thorough survey process when the accrediting body comes in to perform those surveys. Usually they’re with us for at least three days, they do a deep dive, and they confirm that we are meeting all of the accrediting standards. And many times, the CMS regulations are also done at the same time. So, it is extremely thorough, but that is just one more way that we are always reaching for that high bar in quality and safety for our patients.

Bill Prentice: 12:35
Well, that’s great to hear. And I know another way that you all do that is through the education and training that medical professionals, such as yourselves and your staffs, receive. And we know that that doesn’t end at graduation, and it’s an ongoing requirement throughout your careers. And I guess it’s how you stay current with the latest methods and advances in all facets of surgery and patient care, and that would include infection prevention, that helps to keep patients safe every day. So, Cindy, you personally chair ASCA’s Education and Programs Committee. Can you tell our listeners a little bit about the kinds of education courses that your staff enroll in each year to help them stay current with things like this? And also, a little bit of advertising, the extent of the educational programming that ASCA offers?

Cindy Young: 13:24
Yes. Well, we make sure at our surgery center to do an annual education and we touch everything from OSHA, bloodborne pathogens, infection control, HIPAA, patient safety, active shooter, emergency preparedness in our area. Tornadoes are common and so we practice what we would do in the event of a tornado. The staff simulate fire drills once a quarter, we do an annual code blue drill and a malignant hyperthermia drill. We do have monthly staff meetings and we incorporate training at each of these meetings to assure our staff meets at least the minimum education required annually. But we always go above and beyond the minimum. ASCA has so many opportunities for everyone in the ASC environment. Our biggest educational event is our annual meeting, which is held in person next year in Dallas, Texas. The annual conference will have a variety of educational sessions in areas of advocacy, business office management, infection control, regulatory compliance and my favorite, which is networking with my peers. Oftentimes networking with peers brings so much to your facility because you have other people you can talk to who’s going through the same thing you are, and many times around that lunch table or between sessions, you solve problems of your surgery center at home just by talking with someone else. ASCA also offers a coding conference, infection control conference—we held one this year which was very beneficial—and monthly webinars which can be shared with your staff. One webinar I can remember in particular was on instrument processing. I would love to take my staff each year to the annual conference, but unfortunately, due to money and time constraints, it’s not possible. But on this particular session, I was able to pull my key staff members in who process the instruments. We watched that webinar together and it was very beneficial to them; they got a lot of information from that webinar. ASCA also supports the credentials for the administrator of the surgery center, which is the CASC, and infection preventionist, which is the CAIP certification. ASCA offers so many educational opportunities, Bill, and each year, they seem to do better than the last.

Bill Prentice: 15:47
Well, thank you for all that—that was a lot. Early on, I think I mentioned that we’re going to talk about postoperative care and how important that is in terms of infection prevention as well. And so, Rebecca, I’m going to turn to you for that. As I briefly mentioned, modern antibiotics play an essential role in helping to prevent and remedy many common infections, and this is especially true for surgical patients. Can you speak to the importance of antibiotics in caring for surgical patients and why part of determining a patient’s eligibility for outpatient surgery depends upon their ability, or their caregiver’s ability, to take all their medications as prescribed, both before and after surgery?

Rebecca Craig: 16:28
Yes, Bill. Before talking about the patient’s responsibility, I think I just need to touch about what the surgery center does, and that basically, research has proven the importance of antibiotic timing prior to the patient surgical procedure, and the specific antibiotic administered plays a significant role in decreasing the risk of the postoperative infections. So, your surgical team when you come to the surgery center, they’re going to ensure that at least 30 minutes before but no greater than 60 minutes before the skin incision is made, a preoperative antibiotic will be administered by IV. So, the concentration in the tissue is at its highest at the time the surgery is beginning and then during the procedure. So, I wanted to touch on that point because that is, again, patients need to take their medications as directed before the procedure, like you were saying that’s extremely important, and anesthesia will definitely review all that before they go into the operating room. We do our part in the preoperative and intraoperative sessions and phases to ensure that we follow that research-based administration of the antibiotic. And then after a patient has been discharged, it is extremely important that they and their caregiver follow the surgeon’s postoperative instructions very specifically—they’re all based on research and they’re for good reasons, and each physician has specific postoperative instructions, such as dressing or wound care. Extremely important, like you said, taking all your antibiotics and other prescribed medications exactly as directed postoperatively. And then another point I just want to highlight is recovering in a clean environment. Sometimes we try to get that message out but we’re not always extremely specific in our discharge instructions. But that is very important, that clean environment for patients when they go home also makes a big difference. And then contacting their surgeon or the surgery center if they have any questions, we always really like to encourage that open communication and dialogue. We want to address any concerns that come up right away to avoid any complications and just take care of our patients. Like Cindy said, we treat everybody as a family member, and that two-way communication is extremely important. There are wonderful outcomes that they get at the surgery center.

Bill Prentice: 18:53
Well, that’s really excellent and really important information, and something, myself as a patient, that’s really good to realize that those instructions really are critical to protecting your safety and helping you to heal as quickly and as well as possible. So, thank you for that. Well, Cindy and Rebecca, I know that I appreciate all that you do for your patients as well as all that you do for ASCA. So, I thank you for taking the time to come on this podcast and share your knowledge and experience with us. I know I learned a lot today and I’m sure that our listeners and prospective patients did as well. And now I can let you both get back to the important business of running your surgery centers rather than just talking to me about it. But before we sign off, I would once again like to acknowledge the support of HealthCare Appraisers, the national healthcare valuation and advisory firm that’s recognized for its proven track record in ASC valuation. HealthCare Appraisers has valued thousands of ASCs for purchasers, investors and real estate transactions, and we welcome their support as an ASCA affiliate. So, until next time, please continue to follow the guidance of your local public health professionals and we’ll talk to you again soon.