Background: The Centers for Medicare and Medicaid (CMS) has begun mandating infection surveillance at surgical sites, which started in hospitals and is now in ambulatory surgical centers (ASCs). We found a 0.1% increase in infection rate between 2005 and 2007, which prompted us to examine the issue further. The purpose of the current study was to summarize the results of an investigation after an outbreak of infection at our ASC, specifically attempting to identify a common pathogen, vector, or unknown lapses in infection prevention. Additionally, we relate our experience to current trends in infection prevention at ASCs by examining the most recent CMS infection surveillance requirements.

Methods: We performed a retrospective review of patients with infections after orthopaedic procedures at our ASC from 2005 to 2008. Infections were identified by the Centers for Disease Control and Prevention surveillance definitions, with a total of 17 patients included in the study. We also reviewed the site inspection and documented the resultant interventions.

Results: No common pathogen was found in the 17 patients. The results of the site review noted a contaminated tendon-stripper used in half of the cases, poor disassembly of instruments before cleaning, overuse of “flash” sterilization, and poor ventilation in the operating suites. In 2011, infection rates returned to 1.3%.

Conclusions: An ongoing infection surveillance program, periodic site inspections, and process reviews are essential to prevent surgical site infections at ASCs.

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