Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
■ Daily air exchanges did not meet the ASHRAE standard of at least 20 per hour. They were noted for OR1 at 17.5 positive exchanges per hour and for OR2 at 17.6.
Compliance tips for:
ASCs must ensure that each individual patient has recovered adequately to be discharged home or transferred for additional care. The decision is the responsibility of the physician who performed the surgery.
Nerd Newbies (understand the requirement)
Compliance tips for:
Temperature, humidity and air exchange rates support infection prevention in surgical environments. Daily readings when ORs are intended for use provides an opportunity for proactive mitigation anytime these readings are out of appropriate range. ■ Log temperature, humidity, and air exchange rates for each OR on each day of use and prior to the beginning of each case. ■ Take immediate action to correct an environment that does not meet the required conditions. ٝ Reversed air pressure relationships can often be Immediately corrected but not if they are unknown. ■ If you use contracted services for HVAC, educate your vendors on the requirements of your surgical facility so that they can take quick action to avoid case cancellations.
■ Audit patient records for inclusion of discharge orders.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
ٝ Check for date, time, and signature of the physician who provided the surgical services. ■ It is acceptable for an operating physician to write an order for “discharge when stable” but the criteria applied must be documented along with a time.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 15: PHYSICAL ENVIRONMENT 15.01.02 Temperature, humidity and air-flow requirements Frequency of the citation: 35% Overview of the requirement: Ranges for OR temperature, humidity, and air exchange rates comply with American Society for Heating, Refrigerating, and Air Conditioning (ASHRAE) requirements and ASCs must maintain logs that demonstrate these are maintained. Comment on deficiencies: Compliance is evaluated through document review and direct observation. Most deficiencies noted a failure to document airflow/exchange rate for each day that the OR is used. Additional deficiencies noted that no corrective action was taken when readings were out of the required range (temperature or air exchange). Examples of ACHC Surveyor findings: ■ The ASC monitored and recorded the daily temperature and humidity of the ORs and sterile areas, but it did not monitor positive and negative room air pressures. ■ Documentation of air pressure in cardiac catheterization, decontamination, clean supply, and sterile supply, was logged monthly and must be logged daily when ORs are in use. ■ On two dates, the temperature was recorded as our of range (high) for the first case. The facility documented the temperature at the start of each case done on these days, and it remained above the acceptable range through 15 procedures performed. According to the policy, “Humidity and Temperature Control in the OR,” if the temperature goes outside the required range, the nursing supervisor will be notified, and procedures will be stopped until the issue is resolved.
Nerd Trailblazers (prepare the path for others)
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