Practice of Medicine

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Reducing Infection in Outpatient Settings

Executive Summary 

Outpatient healthcare settings must make infection prevention a priority and be equipped to observe standard precautions. Adoption of the guidance provided by CDC recommendations will reduce the incidence of preventable infections acquired in ambulatory settings. 

Recommended Actions  

  • Provide ongoing education and infection control training to staff to ensure that they understand infection prevention policies and procedures. 
  • Conduct surveillance to track outcome measures and adherence to specific process measures as a means to reduce infection transmission. 
  • Ensure that your healthcare organization is following CDC recommendations and taking standard precautions for infection control in the ambulatory care setting. 

The transition of healthcare delivery from acute care hospitals to outpatient (ambulatory) settings has revealed the need for greater understanding and implementation of basic infection prevention guidance. In 2011, this increased need resulted in the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee to release recommendations for infection control in the ambulatory care setting. 

All healthcare settings, regardless of the level of care provided, must make infection prevention a priority and must be equipped to observe “standard precautions.” The CDC advisory committee recommendations should guide healthcare providers in ongoing infection control training and prevention of acquired infections to the various ambulatory settings such as outpatient clinics, physician offices, surgery centers and procedural centers such as gastroenterology and cardiology. 

Ambulatory settings have unique considerations given the level of care provided and the differing requirements for infection control. Here we provide a brief summary of the published recommendations. 

The CDC recommendations suggest that those with primary administrative oversight of the ambulatory care setting should ensure that sufficient fiscal and human resources are available to develop and maintain infection control practices. That includes the availability of equipment and supplies necessary for the consistent observation of standard precautions, including hand hygiene products, injection equipment and personal protective equipment (e.g., gloves, gowns, face and eye protection). 

Ongoing education and infection control training of healthcare personnel is critical for ensuring that they understand infection prevention policies and procedures. Education on the basic principles and practices for preventing the spread of infections should be provided to all personnel. Infection control training should include both Occupational Safety and Health Administration (OSHA) bloodborne pathogen training and patient safety, emphasizing job- or task-specific needs. Education and training should be provided upon orientation to the facility and should be repeated annually to maintain competency. 

Another aspect that must be considered is surveillance, which is defined as the ongoing, systematic collection, analysis and interpretation of data regarding health-related events to reduce morbidity and mortality and to improve health. Surveillance typically refers to tracking of outcome measures but can also refer to tracking of adherence to specific process measures as a means to reduce infection transmission (e.g., hand hygiene). Surveillance for outcome measures in ambulatory care settings is challenging because patient encounters may be brief or sporadic and evaluation and treatment of consequent infections may involve different healthcare settings (e.g., if a patient seeks care for infection in the hospital). 

Standard Infection Control Practices 

Good hand hygiene, including use of alcohol-based hand rubs and hand washing with soap and water, is critical to reduce the risk of spreading infections in ambulatory care settings. 

Personal protective equipment (PPE) refers to wearable equipment intended to protect personnel from exposure to or contact with infectious agents. Examples include gloves, gowns, face masks, respirators, goggles and face shields. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents. In addition to protection of personnel, face masks are also effective in limiting the dispersal of oropharyngeal droplets and are recommended when placing a catheter or injecting materials into epidural or subdural spaces, as during myelography or spinal or epidural anesthesia. 

Implementation of the OSHA Bloodborne Pathogens Standard has helped increase the protection of personnel from blood exposure and sharps injuries, but there is room for improvement in ambulatory care settings. 

Further attention to patient protection also is needed as evidenced by continued outbreaks in ambulatory settings resulting from unsafe injection practices. Unsafe practices that have led to patient harm include: 

  • Use of a single syringe with or without the same needle, to administer medication to multiple patients 
  • Reinsertion of a used syringe with or without the same needle, into a medication vial or solution container (e.g., saline bag) to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients 
  • Preparation of medications in close proximity to contaminated supplies or equipment 

Ambulatory care facilities should establish infection control policies and procedures for routine cleaning and disinfection of environmental surfaces as part of their infection prevention plan. 

Reusable medical equipment (e.g., endoscopes) should be accompanied by instructions for cleaning and disinfection or sterilization as appropriate. Single-use devices (SUDs) are labeled by the manufacturer for only a single use and do not have reprocessing instructions. 

Respiratory hygiene/cough etiquette is an element of standard precaution that highlights the need for prompt implementation of infection prevention measures at the first point of encounter with the facility/ambulatory settings, such as reception and triage areas. This strategy is targeted primarily at patients and accompanying family members or friends. 

Facilities should develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to the facility. The majority of ambulatory care settings likely will not have the resources to implement all of the isolation practices and other transmission-based precautions (e.g., airborne precautions for patients with suspected tuberculosis, measles or chicken pox) recommended for hospital settings. Nonetheless, specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile respiratory illness, febrile rash) are routinely encountered in ambulatory settings and deserve appropriate triage.  

Hopefully, adoption of the guidance provided by the CDC recommendations will reduce the incidence of infections in all care settings. Facilities and healthcare providers are encouraged to refer to the CDC website, which provides detailed guidance and references for the information included in this article. 

Lessons Learned 

  • Establish infection control policies and procedures for routine cleaning and disinfecting of environmental surfaces. 
  • Ensure that sufficient supplies are readily available in all patient evaluation spaces, including hand hygiene products, injection equipment and personal protective equipment. 
  • Develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to your healthcare facility. 

Potential Damages 

Healthcare organizations run the risk of negligence lawsuits if a patient is injured as a result of failing to follow necessary infection prevention procedures. While lawsuits for infections acquired in outpatient settings are relatively infrequent, hospital-acquired patient infection litigation is known to be extremely costly. As ambulatory settings becomes more common, it is imperative to continue safe practices to avoid outpatient-acquired patient infections and subsequent litigation. Additionally, failing to adhere to local, state and federal requirements regarding reporting diseases and outbreaks can lead to costly fines. 

Quiz 

Answers are provided below 

True or false?  

Question 1: Providers should wear PPE to prevent exposure or contact with infectious agents. 

Question 2: Both reusable medical equipment and single use devices can be properly cleaned and disinfected before reuse. 

Question 3: Ambulatory care facilities should routinely clean and disinfect environmental surfaces as part of their infection prevention plan. 

Answers 

Question 1: True. Providers should wear PPE to prevent exposure or contact with infectious agents, including gloves, gowns, face masks, respirators, goggles and face shields. The necessary PPE is based on the nature of the patient interaction. 

Question 2: False. Reusable medical equipment should be accompanied by instructions for cleaning and sterilization before reuse; however, single-use devices are labeled by the manufacturer and should be properly discarded after use. 

Question 3: True. Ambulatory care facilities should establish policies and procedures that require routine cleaning and disinfection of environmental surfaces. 

01/23

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Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.