Alfonso del Granado, administrator of the Covenant High Plains Surgery Center in Lubbock, Texas, shares his thoughts and expertise on improving infection control in ASCs.
Note: Responses have been lightly edited for style and clarity.
Question: What infection control techniques have you seen work at your ASC?
Alfonso del Granado: The three most important elements that I've looked at have been hand hygiene, prophylactic antibiotic timing and sterile processing. Hand hygiene is just a matter of putting in the work. We only follow standard recommendations. It's just that enforcing them becomes a tough thing. In prior jobs, I've had surgeons not disinfect their hands before examining a patient in front of the Joint Commission surveyor. I know it's a challenge, but what you have to do is remind them frequently.
You can be as friendly as you want, but it can't be anything less than firm. There were times I had hand-washing rates that exceeded 90 percent, and then three months later we're back down to the 50s. If you don't keep on top of it, you're not going to see continuing results.
Second thing is prophylactic antibiotic timing. Quite a few years ago, when a case was delayed there was a risk of missing the antibiotic window, so we came up with a very simple solution. You hang the bag when you're pushing the patient to the OR, and you don’t take the patient to the OR until the surgeon’s in there and ready to go. That way you'll always get it in the first hour, and we got effectively 100 percent success on the antibiotic timing.To be fair, most places are pretty successful today. If you look at the data reported to the government, I think we have something like 97 or 98 percent of ASCs able to report over 90 percent compliance with antibiotic timing. When I came here to my new job in Texas they had already adopted exactly the same policy, independently of anything that we had done.
Q: What do you think ASCs get wrong about infection control?
AG: No. 1 thing I have seen is improper hand hygiene. Surgeons and anesthesiologists are the absolute worst according to all published studies. It's not unusual to see surgeons and anesthesiologists having less than 50 percent compliance. They're going from patient to patient, bringing potential pathogens with them wherever they go, and transmitting them from one to another. Obviously it's understood that you're going to disinfect the incision site, but even that's not 100 percent. If you have just transferred a pathogen from one patient to another you can have serious consequences.
Q: Are there any overarching tips that you would give other ASCs that are looking to improve their infection-control policies?
AG: Anywhere you go, the policies are going to be written with the same set of standards. They're going to be policies from CDC, the WHO and others. So it's not so much the actual policy as much as it is the enforcement of the policy. Not long before moving to Texas I saw a surgeon blindly walking through a ward in street clothes. I almost had a heart attack. It's not malicious in this case. It's just inattention. I actually had that problem a couple of times myself, where I almost walked into a ward without a hat. I always wear a hat, but for some reason I took it off, and I just got up out of my office, walked over through the hallway into the immediately adjacent OR, and half a step in, one of the nurses looked up and yelled, "Stop."
And I love to see them do the same with everybody. What I had previously done with my staff was really put them in charge of maintaining safety by putting hard stops on everybody. It's not uncommon, especially when you have a surgical center that's on a hospital campus, to have people coming in street scrubs and trying to walk into your OR.
Again, that's another hard stop, but really, the policies themselves are generally understood. It's the implementation and the enforcement of the policies that is sometimes lagging, and I can understand it. It can be very intimidating, especially for independent ASCs where the surgeons are not employed and they're not owners, you're afraid of offending somebody who's bringing your organization a million or multiple millions of dollars. But what is the cost of a catastrophic infection? And I don't mean that just in dollars and cents, but in terms of humanity. How are you going to live with yourself where your failure to speak up caused someone to lose a limb or worse?
Q: How can organizations improve enforcing these policies?
AG: One of the main steps is really to empower staff. You've got to keep a close eye on your operating rooms. You may have to occasionally throw a little curveball at your own staff to see if they catch it, and if they speak up about it. Again, the OR culture has to be one where the rules reign, not the surgeon. It's not the nurses versus the surgeon, it's all the surgeons, all the nurses, all the techs, everybody versus the infection.
Q: What do you think ASCs should improve upon moving forward?
AG: I want to emphasize that I think that ASCs do a great job. ASCs are a safer environment than hospitals in great part because of the mix of patients that a hospital has to take. But that's a mandate, it’s not their fault. Even if they're doing everything right, they're going to have higher-acuity patients and higher potentially infectious patients, and so they're going to have some challenges that you just don't have in an ASC. A problem I see with ASCs is that they're not treated as respectfully as hospitals, it can feel easier to ignore policies.
I think that we're doing a better job, but we're also doing something that 10 years ago used to be done in the hospital, so you should be maintaining the same standards and the same attitude when you walk into the ASC. You should feel like you're walking into a hospital. It should be no different in your mind. It may be faster. It may be more efficient. But ASCs have fewer complications and fewer infections, and if you don't treat them seriously you're going to lower all of those. So I think informality in the ASC is one of our biggest things we have to watch out for.
