Supporting ASCs With Multiple Layers of Defense

Today, ambulatory surgery centers (ASCs) are playing an increasingly important role in the country’s healthcare system, with almost 70% of surgical procedures being performed in the ambulatory setting, many performed in a same-day surgery center.¹ It is essential that innovations continue to improve the quality of care in this environment. Cleanliness is vital in ASCs, and no single approach can eliminate all microorganisms, so multiple layers of defense are needed to ensure the highest level of cleanliness in high-risk areas.

PDI offers a broad range of evidence-based, market-led, interventional care, environment of care, and patient care solutions, all designed to help reduce preventable infections, control healthcare costs and ultimately save lives.

Outpatient Surgery Magazine (OSM) spoke to industry expert Marc Oliver Wright, MT(ASCP), MS, CIC, FAPIC, Clinical Science Liaison, PDI, in a wide-ranging interview to assess the current ASC market, where it is headed and how PDI engages with this important healthcare community.

OSM: Where do you see the ASC market heading in 2024 in general?
M. Wright: Continued projected year-over-year growth is expected. Sometime between 2024 and 2026, the percent of total joint replacements done in ambulatory care settings is expected to cross the 50% threshold. As volume increases, so too does scrutiny.²

MedPAC has recommended to Congress for the past two years that the Secretary of Health and Human Services require ASCs to report cost data. Although the Centers for Medicare & Medicaid Services (CMS) has considered a Surgical Site Infection (SSI) measure for ASCs in the past, it is not currently working to develop one. It does, however, mandate quality indicator ASC-17, which measures hospital visits post-orthopedic ASC procedures serving as a de facto indicator of severe SSI occurrence.³

OSM: How important is patient safety and what does PDI offer to support that effort?
M. Wright: Patient safety is the most important thing we do in healthcare and is at the center of PDI’s mission and vision. Across the company portfolio, every product is designed to be an effective solution to the potential risk of healthcare-associated infections – from keeping the environment germ-free to reducing individual patient risk for surgical site infections or bloodstream infections.

At PDI’s core is surface disinfection and cleaning, which includes the #1 brand of wipes in healthcare, Sani-Cloth® wipes, with a variety of formulations and formats to meet the needs of facilities across the continuum ofcare. Five years ago, PDI’s portfolio expanded with the majority acquisition of Tru-D® SmartUVC. The addition of UVC technology is an excellent adjunct to manual cleaning in the peri-operative space, making disinfection more manageable, even in smaller areas, and reducing human error in the disinfection process.

At the individual patient level, PDI invested in nasal decolonization as a strategy for reducing the risk of surgical site infections (SSIs) and aligning with the busy schedule of an ambulatory procedure setting: Profend® swabsticks are a povidone iodine intranasal antiseptic that is 99.7% effective within 10 minutes of application. While nasal decolonization has been a well-established practice for three decades, historically the front-runner methodology for this practice required patient self-application of an intranasal antibiotic ointment twice daily for five days before a scheduled surgical procedure. Antiseptic nasal decolonization with Profend® swabs affords similar efficacy, but in minutes instead of days. The application is done by clinicians rather than relying on the patient themselves to rigorously adhere to a scheduled self-application over many days.

At PDI, we know Products Kill Bugs, But People Prevent Infections®. That’s why PDI provides best practices in infection prevention through digital products and in-service resources, our blog and podcast, free continuing education courses, and an extensive clinical resource library. Our associates are dedicated to being trusted advisors to our customers and are committed to working together to optimize healthcare delivery to the safest extent possible.

OSM: As the market grows, is there a need for infection prevention protocols across the board?
M. Wright: There is a need for infection prevention protocols in every setting where health care is being provided. With that said, just because there’s a need does not mean there’s an easy answer. It is tempting to say that as more procedures transition from acute care settings to ambulatory care settings, the protocols established in acute care should just be transferred over with the procedure itself. And sometimes, that may be true. For example, showing that a particular infection prevention protocol such as hand hygiene is important does not require us to reinvent the wheel. Taking acute care protocols and dropping them in on ASCs, however, can feel a little like trying to pound a round peg into a square hole.

It is important to carefully evaluate what is known about the procedures and the risk mitigation strategies that have been established historically, and then evaluate any similarities or differences when that procedure is taken out of the acute care setting and put into the ASC space. Some prevention strategies will readily translate, while others may need to be amended. Enhanced Recovery After Surgery (ERAS) programs look very different when you have several post-op recovery inpatient days to monitor the patient than when you’re sending them home the same day and require a different approach.

OSM: Are there specific types of high-risk surgeries that would benefit from infection prevention innovations?

M. Wright: Every surgery comes with a risk for infection. When surgeries are performed, the incision to the skin bypasses the body’s own best natural defense against infection. With that said, some surgeries are considered higher risk than others, often as a result of a combination of various factors including size and anatomical location of the incision, duration of the procedure, and whether or not devices are implanted during the procedure.

A specific innovation to avert this risk is skin and nares decolonization. Studies over the past 20 years have consistently demonstrated that upwards of 80% of organisms causing surgical site infections originate from a patient’s own microbiome.^4-7 In other words, the organisms that live in and on the human body – and don’t usually make people sick – can cause an infection with an incision.

Decolonization is a treatment used to suppress these organisms during the highest risk period - during the procedure itself. Decolonization has shown a benefit in reducing infections and as a result, the American Academy of Orthopedic Surgeons recommends decolonization for orthopedic procedures involving implants, such as hip and knee replacements. Meanwhile, as a core strategy for preventing infections, the Centers for Disease Control and Prevention (CDC)⁸ recommends decolonizing orthopedic, cardiac and neurosurgery patients, specifically using chlorhexidine gluconate (CHG) or CHG baths for the skin and either an antibiotic or povidone iodine for decolonizing the nose. It is important to note that all surgical procedures carry some risk and using antiseptics like CHG and iodine do not have the risk of antibiotic resistance.

OSM: What do you see as the biggest challenges in acute and non-acute healthcare settings today?
M. Wright: First and foremost, the biggest challenge is staffing issues. The past few years have been especially challenging with an exodus of seasoned medical professionals, and a dynamic market of demand where if ‘you’re not happy today in your place of employment finding something different isn’t too hard.’ It’s important to continue to stabilize or right the ship if you will.

Financial strains for healthcare settings are very real. There are not many organizations or facilities who would self-describe as better off financially today than they were five years ago. These strains are compounding, leading to ongoing mergers and acquisitions as well as cost containment efforts across the board – and that is not going to go away anytime soon.

For more information visit www.pdihc.com/asc-trend. OSM

References:
1. Cullen KA, Hall MJ, Golosinskiy A, Statistics NCfH. Ambulatory surgery in the United States, 2006. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Human Statistics, 2009
2. Beckers ASC Review: 14 Things to Know About total Joint Replacement and ASCs For 2020. January 29, 2020 3. https://www.medpac.gov/document/march-2023-report-to-the-congress-medicare-payment-policy/ Accessed December 19, 2023
4. Skråmm I, Fossum Moen AE, Årøen A, Bukholm G: Surgical site infections in orthopaedic surgery demonstrate clones similar to those in orthopaedic Staphylococcus aureus nasal carriers. J Bone Joint Surg Am 2014; 96:882-8
5. Moremi N, Claus H, Vogel U, Mshana SE: The role of patients and healthcare workers Staphylococcus aureus nasal colonization in occurrence of surgical site infection among patients admitted in two centers in Tanzania. Antimicrob Resist Infect Control 2019; 8:102
6. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box AT, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC: Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010; 362:9-17
7. Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, Pfaller MA, Sheppard D, Twombley J, French PP, Herwaldt LA; Mupirocin and the Risk of Staphylococcus aureus Study Team: Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002; 346:1871-7 [PubMed] [Google Scholar]
8. (https://www.cdc.gov/hai/prevent/staph-prevention-strategies.html)