Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

Appendix D, Table D1B

D1-b. Facility Features

Process Step / Facility Feature Academic Hospital, Off-Site ASC Community Hospital, Co-Located ASC Free-Standing ASC Pediatric Hospital, Off-Site ASC

Scrubbing/ gloving/ clothing policy for staff


Outside clothes worn into ASC then change into scrubs provided by hospital. First scrub of day is full scrub with brush, disposable brush and impregnated with chlorohexadine or iodine, later scrubs do hand sanitizer 'sterilium' for rest of day, scrub and go into OR and then gown and get gloves, everyone scrubbed into sterile field gets glove. Not all surgeons will double glove and can't mandate since not employee. Many will but not all.  Nurses not do scrub since remain from sterile field even if in room. Anesthesia provider not scrubbed but at head of patient, gowned. Unless have dedicated shoes only in this department will wear shoe covers. If messy case or from outside wear shoe covers, none do this in pre-op only beyond red lines in OR have to gown, no open toed shoes allowed, leather is best. Head cover, scrub, shoe and mask. Total joint cases require full wash and scrub regardless of case.

Booties, gowns, cap. There are signs on doors about where can and can not go without proper attire, extra scrubs here, dedicated OR shoes or booties required, all have head covering, including patients. If go outside then change when come in. Hand washing use aberguard(?) It is a brushless scrub, that's what we use between cases but some not like it so they do a brush between each. Never do a joint replacement without full scrub. No double gloving, some do but not required.

When you first come in you wash hands and before everything you do you wash hands and between patients too.  Some surgeons double glove but not many. Required to wear gloves if touching the site or IV and a mask if the child is sick, many staff get sick from the children.

Isolation ability


Yes and have one OR and endoscopy room where can shut the air flow off for TB patients.


# ORs and patients

5 OR rooms/ 420 people a month

14 ORs run on daily basis, 70% out patient, 30% inpatient, 14,500 average cases a year

Average 130-140 cases a month. 5 pre-op bays, 4 bays in PACU, then 2 or 3 other for step down, have extra space in PACU not use so just store things there.

2600 procedures a year, two ORs, number a day varies, 22-17 etc, depends, most ever done in one day is 25.

# Staff

35 staff approximately

Current employees: 130 for OR and anesthesia, all departments 225 employees for both part and full time.  On a daily basis 100 on at a time, endoscopy has 5 but they are not daily, anesthesia has 5 and are daily. Every room has minimum 1 RN and scrub tech or 2 RN, many rooms have assistant as well. Roughly 3 staff in a room, not include PRA and anesthesiologist, so each room has some overlap since lunch relief. Coordinators: 6 during day, 7 at night, 2 charge nurse, 3 secretaries.

Average 40 people, with PRN people (as needed) can call in as substitutes. 4 in business office, rest are clinical.


Staff illness guidelines

If you have an open wound you can't scrub in, pink eye can't even come into work, not supposed to come into work if sick.


Medical record: type


CERNER project- ASC is going to electronic health records, but not yet. No electronic medical records so is all paper chart, they have electronic medication records and x-rays. Each patient have paper chart follows patient.


Charting is mostly all on computers in rooms, which are not moved and cleaned regularly. Still trying to go all paperless but not there yet.

Building temperature/air

Temperature controlled by building. Wall in hall is next to garage and can get cold, temp fluctuates.

OR corridor has own separate air exchange, outside areas is different exchange, 15 to 1 ratio of air exchange per hour, standard is 12 to 1, gigantic HEPA filters, facility never shut down, full all the time, even on weekends.


Very strict humidity at 30%, temperature 70 degrees, flow is 20. Special filter system. Changed once a month, circulator checked once every three months, follow same guidelines as hospital. But since it is a rental property they have some control but not on everything. Have some issues with air circulation in clinic, but are addressing. Building brought up to standard code every year, is long term rent, heating problems. One room 80 degree them another 65 degrees, has potential for infection control problem and have engineering staff come onsite and work with landlord and adjust but still not perfect setting.

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Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Appendix D, Table D1B. Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.