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Introduction: Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit

The Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit is specifically designed to provide guidance on the development and implementation of infection prevention programs that meet infection control standards outlined in Medicare‚Äôs Conditions of Coverage and State of Oregon administrative rules. The toolkit was developed by the Oregon Patient Safety Commission to help Oregon’s ambulatory surgery centers (ASCs) implement infection prevention quality improvement projects, reduce infection risks, and better protect patients.

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Toolkit Instructions

Toolkit resources are designed to be customized by each ASC to ensure they address each ASC’s unique characteristics such as patient population and scope of services, and reflect current ASC policies and practices.

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Section 1: Infection Prevention Program Development

The Centers for Medicare and Medicaid Services and the State of Oregon mandate that ASCs have an infection prevention program (IPP). Ambulatory surgery centers (ASCs) can use the tools in this section to ensure that an effective infection prevention program is established and quality improvement efforts are maintained. Resources provided in this section build upon one another and can be used to:

  • Assess compliance with infection control practices
  • Document assessment findings
  • Use identified deficiencies to select areas for improvement
  • Organize and analyze survey findings and surveillance data
  • Establish and evaluate goals
  • Conduct a complete infection prevention program evaluation and planning process

The planning process and annual assessment of the ASCs infection prevention program is critical. ASCs can use these tools and resources as documentation of the process used to perform annual program assessments, as a reference for future planning efforts, and as documentation of an ASC’s process for regulatory survey review. Web links provide additional information, resources, and tools.

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Section 2: General Infection Prevention Practice

These materials can help ASCs comply with basic infection practices such as hand hygiene, surgical hand antisepsis, standard precautions, management of patients with potentially transmissible infectious diseases, Oregon’s reporting requirements for infectious diseases, and waste management. Web links provide additional information on applicable standards and helpful tools.

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Section 3: Sterilization and Disinfection Practice

Learn about current regulatory standards and best practices for processing re-usable surgical instruments and equipment. This section includes sample policies, procedures, competency checklists, guidelines, and documentation forms for instrument/equipment cleaning, disinfection and preparation. Web links provide additional information, resources, and tools.

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Section 4: Environmental Hygiene

Policies, procedures and tools provide information on appropriate cleaning and disinfection requirements and can be adapted for the ASC. Checklists can also be used for training purposes as well as to assure environmental hygiene quality. Web links provide additional information, resources, and tools.

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Section 5: Safe Injection Practices

Materials in this section support the safe handling and use of needles and syringes, cannulae that replace needles, single-dose and multi-dose vials, and intravenous delivery systems and eye drops (where applicable). The section includes materials and references that address recommended practices for the safe handling and disinfection of blood glucose monitoring devices and medications. Web links provide additional information, resources, and tools.

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Section 6: Employee Health Program

An ASC’s employee health program is an essential component of the infection prevention program. These sample policies and documentation forms include: healthcare worker communicable disease screening and immunization requirements, occupational exposure to communicable diseases, and blood and body fluid exposures. This section contains sample declination forms for Hepatitis B and Influenza immunizations. Web links provide additional information, resources, and tools.

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Section 7: Quality Improvement

Tools in this section can assist ASCs in implementing changes at their facility and contain an example of a safe surgery checklist (based on one published by the World Health Organization) that was developed by an Oregon-based group representing multiple state professional organizations and agencies. Web links provide multiple patient/family educational tools that may be used at the ASC.

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