By Chase Doyle

The global coronavirus pandemic has spotlighted the need for infection prevention programs that minimize communicable diseases while providing functional environments for surgical services. At the 2020 Association of periOperative Registered Nurses Virtual Global Surgical Conference, Terri Link, MPH, BSN, CNOR, discussed the Centers for Medicare & Medicaid Services requirements for ambulatory surgery centers, including proper risk assessment, prioritizing infection risks and using outcomes for internal benchmarking.

According to Ms. Link, an ambulatory education specialist at AORN, because infection rates may differ for each facility, surveillance is needed to determine where efforts should be concentrated during risk assessment. This can be accomplished by checking laboratory results, sending out emails to physicians, and performing chart reviews to produce baseline and endemic rates of infection.


Step-By-Step Guide

As Ms. Link reported, once this information is obtained, developing an infection control program based on a risk assessment requires several steps:

Form an infection prevention committee composed of an interdisciplinary team of nurses (pre- and postoperative), physicians, scrub personnel, environmental service, sterile processing and front desk.

List services provided by your facility (e.g., number of rooms, specialties, number of surgeons, staff, hours open). Agreements with referring hospitals, patient population analysis, risk for natural disasters, role in emergency preparedness in the community and underlying endemics should also be taken into consideration.


Find a template or develop your own. Potential risks/problems and the likelihood they may occur should be included on this template along with their potential impact (health, financial, legal and regulatory). The template should also assess preparedness (good, fair or poor).

Identify risks, problems and concerns based on your facility’s characteristics. These issues may be classified as patient care risks, health care personnel risks, environmental risks, site-specific risks and emergency management.

List a description of the risk as part of the risk assessment tool (e.g., safe injection practices, environmental cleaning, new procedure). For new procedures, surveillance should be used to establish a benchmark.

“It’s very important to have a standardized, objective way of prioritizing risks,” Ms. Link said, who added that construction projects should also be part of risk assessment. “A construction risk assessment tool should be used in determining how patients and staff will be protected from harm due to air contaminants from construction, such as Aspergillus.”


Prioritize by score those risks that will be part of your plan. Establish baseline data from an internal benchmark or a national benchmark, and identify regulatory requirements that must be included in an infection prevention plan.

“It’s really important to limit your scope at first because you can’t do everything,” Ms. Link said. “Prioritize according to regulatory requirements and then the highest score and highest impact.”

Choose goals and measurable objectives. Once risks have been prioritized, select three or four major goals to start with (e.g., improve hand hygiene or decrease an antibiotic-resistant infection). The outcome must be a measurable objective to assess the program’s effectiveness, said Ms. Link, who noted that having some “quick fixes” is a good place to start.