Referrals of Infection Control Breaches to Public Health Authorities: Ambulatory Care Settings Experience, 2017

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Background

Beginning in October 2016, the Centers for Medicare & Medicaid Services (CMS) issued expanded guidance requiring accrediting organizations and state survey agencies to report serious infection control breaches to relevant state health departments. This project sought to characterize and summarize The Joint Commission's early experiences and findings in applying this guidance to facilities accredited under the ambulatory and office-based surgery programs in 2017.

Methods

Surveyor notes were retrospectively reviewed to identify individual breaches, and then the Centers for Disease Control and Prevention's Infection Prevention Checklist for Outpatient Settings was used to categorize and code documented breaches.

Results

Of 845 ambulatory organizations, 39 (4.6%) had breaches observed during the survey process and reported to health departments. Within these organizations, surveyors documented 356 breaches, representing 52 different breach codes. Common breach domains were sterilization of reusable devices, device reprocessing observation, device reprocessing, disinfection of reusable devices, and infection control program and infrastructure. Eight of the 39 facilities (20.5%) were cited for not performing the minimum level of reprocessing based on the items’ intended use, reusing single-use devices, and/or not using aseptic technique to prepare injections.

Conclusion

The CMS infection control breach reporting requirement has helped highlight some of the challenges faced by ambulatory facilities in providing a safe care environment for their patients. This analysis identified numerous opportunities for improved staff training and competencies as well as leadership oversight and investment in necessary resources. More systematic assessments of infection control practices, extending to both accredited and nonaccredited ambulatory facilities, are needed to inform oversight and prevention efforts.

Section snippets

Methods

This project was a retrospective review of IPC breaches reported to state health departments. We included facilities that were evaluated for accreditation by The Joint Commission between February 1 and December 31, 2017, under the Ambulatory Health Care Accreditation Program (n = 739) or Office-Based Surgery Accreditation Program (n = 106). Facilities eligible for ambulatory accreditation included those providing primary and specialty medical and dental services (for example, Federally

Results

During February–December 2017, 845 organizations were evaluated for accreditation, of which 39 (4.6%) had breaches that met the CMS reporting requirements. Of the 39 organizations, 18 were ambulatory surgery centers (13 under the deemed survey process), 7 were office-based surgery centers, 11 were medical and/or dental clinics, and 3 were other types (Table 1).

Twenty-eight of the 39 facilities with reported breaches (71.8%) provided multiple types of services (Table 2). The average number of

Commonly Identified Breaches

Across the 39 facilities, 356 breaches were coded using 52 different breach codes. There were on average 9.1 breaches per facility (SD = 5.5, median = 8, range: 1–24). Approximately 20% (n = 8) of facilities were cited for the most serious breaches, including not performing the minimum level of reprocessing based on the items’ intended use, reusing single-use devices, and/or not using aseptic technique to prepare injections.

The majority of breaches were coded under the following domains (as

Discussion

This project characterized and summarized the IPC breaches that were identified by Joint Commission surveyors during the ambulatory health care and office-based surgery accreditation process and were reported to state health departments in 2017. That year was the first full calendar year of experience with the expanded CMS guidance on infection control breach reporting. Surveyors identified several common breaches that could potentially cause patient harm and that can help outpatient facilities

Conclusion

This study shows that there are opportunities to improve IPC practices in ambulatory facilities, particularly in relation to device reprocessing, including sterilization and HLD, staff training and competency, and leadership oversight. Identification and remediation of existing weaknesses in systems and processes can prevent outbreaks and improve safety for both patients and staff. By highlighting the need for public health assessment of serious IPC breaches, including considerations for

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