Excellentia Advisory Group
ImPaCTInfection Prevention and Control Trends for ASC's 
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This Month's Training Opportunities
Critter Craze
Word on the Street
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Robin Novak, RN, CIC
Director of Infection Prevention

636.875.5088 ext. 101
This Month's Training Opportunities
Building Antibiotic Stewardship into the ASC Setting

Measures Used to Evaluate a Compounding Pharmacy 

Emergency Preparedness Rule / Emergency Operations Plan

Over 70 Infection Prevention
 topics/presentations available in our library.
Volume 1, Number 10
August 2017

Do news titles like this: Did Compounded Antibiotic-steroid Formulation Cause Cataract Patients' Vision Problems ?, give you pause?  In this particular case, 50 patients that received cataract surgery have reported worsening visual acuity and will possibly sustain long term vision loss.  According to the report in Outpatient Surgery magazine the cause may be related to a compounding pharmacy.

Join me for a review of best practice recommendations for compounding pharmacies in our upcoming webinar.  Remember, CMS standard 416.41 contracted services -states the governing body is responsible to oversee the delivery of services provided to the ASC.  Services must be provided safely and effectively.  Contracted services must be part of the QAPI program.

Registered Nurse, Certified Infection Preventionist dedicated to disease prevention and high quality healthcare.  Strong decision maker who understands the importance of patient, visitor and staff safety following evidence based best practices.
Driven and compassionate healthcare professional with 30 years hands-on experience in fast-paced ambulatory surgery center and hospital environments.  Accountable and responsible with an additional focus on Quality Assurance Process Improvement .
In the past, Robin has served as the SGNA Carolina Chapter President, involved in SGNA Practice Committee as well as a Regional Committee member.  Robin has been active with APIC and is a current member of APIC PALMETTO. Robin was prior employed at the Ambulatory Surgery Center of Spartanburg since 2004 and held roles of Endoscopy Nurse, Endoscopy Charge Nurse and most recently the Quality Assurance Process Improvement Coordinator.  Robin has worked on several infection prevention projects for Excellentia Advisory Group including a key role as a faculty speaker at our annual Infection Prevention Strategies for ASC's conference in Las Vegas.  Robin is now Excellentia's Director of Infection Prevention & Endoscopy.
Subscriber Question &  My Answer

The Question: We know there is community acquired MRSA in our area.  Can we see these patients in our facility?


  • This is a challenging question and one which will require your governing body and infection preventionist to perform a risk assessment to determine the risk to the facility.   Will they see patients with a history of MRSA or will it be patients with active MRSA?
    • We know that MRSA is a drug resistant form of Staphylococcus aureus that is transmitted through direct contact.  Improper hand hygiene and ineffectively cleaned surfaces can harbor the MRSA bacteria for extended periods of time.
    • Per the CDC, we know that approximately 33% of the population carries the MRSA condition with knowledge.
    • What does the local, state and national data demonstrate regarding community acquired MRSA?
  • If the collaborative team decides to proceed with seeing patients with a history or active MRSA, then very specific infection prevention and control methodologies will need to be put into place.
    • Means to identify the potentially infective patient
    • Means to provide care with standard and contact precautions including hand hygiene, gloves, gowns, masks, goggles, patient placement, patient care equipment
    • Means to ensure PROPER HAND HYGIENE 100% of the time and frequent surveillance and education
    • Means to ensure and evaluate EFFECTIVE ENVIRONMENTAL CLEANING strategies 100% of the time between patients in all areas of the facility and terminal cleaning of all areas of the facility.
    • Means to provide dedicated equipment for those in contact precautions
    • Means to ensure and evaluate EFFECTIVE CLEANING OF PATIENT CARE EQUIPMENT following Manufacturer instructions for use
    • Means to educate staff and practitioners, and communicate expectations and infectivity while remaining HIPAA compliant
    • Surveillance methodologies to assess current MRSA transmission rates versus on-going MRSA transmission rates in not only patients, but staff also.  Staff will be susceptible to acquiring MRSA.
    • Investigation and Control Plan in the event there is a MRSA transmission. 
  • Develop a written MRSA policy and procedure outlining expectations and procedures.

Critter Craze
By Robin O. Novak, RN, CIC
Who am I? -
  1. I am a parasite
  2. I am excreted in feces
  3. I cause watery diarrhea, stomach cramps, dehydration, nausea, vomiting, fever and weight loss
  4. My symptoms will last about 1-2 weeks
  5. I most commonly affect the small intestine
  6. I am protected by an outer shell that allows me to live for long periods of time outside of the body
  7. I am spread through water (drinking and recreational)
  8. I am the leading cause of waterborne disease among humans in the US 

Email Robin at robin@excellentiagroup.com with your response.  You will receive a personalized reply with validation of the correct answer.

Word on the Street
  • At least one state has implemented the requirement for an ASC to have an antibiotic stewardship program.  Do you have yours prepared?
  • ASC Quality Reporting Specifications Manual-version 7.0 is available and goes into effect 1/1/2018 
    • Added measures include ASC 13:  normothermia, ASC 14:  unplanned anterior vitrectomy
    • Updated ASC 9:  Endoscopy/ Polyp surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients
    • PREVIEW of ASC 16:  Toxic Anterior Segment Syndrome
If you are in need of assistance with your infection prevention program, Robin will be able to assist with everything from setting up your program, training your Infection Preventionist, writing or editing Policies & Procedures or just simple telephonic consultation.  Robin is taking on-site requests for 2017 at this time.  Secure a date on her calendar now.

Please let us know how we can help.

Cathy Montgomery, RN, CASC                Robin Novak, RN, CIC
636-875-5088 extension 102                    636-875-5088 ext. 101

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