News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
CME Author: Charles P. Vega, MD
Clinical Context
The
majority of medicine is practiced in ambulatory settings, and the authors of
the current recommendations provide a review of this care. They state that the
total number of office medical visits in the United States reached 1 billion in
2007. The average person makes approximately 3 visits to a clinician's office
per year. In addition, more than three quarters of all operations in the United
States are performed in settings outside of the hospital.
Ambulatory
care facilities may not always maintain the same rigor in infection control
practices as hospitals. The current recommendations by the US Centers for
Disease Control and Prevention (CDC) describe systemic and personal means to
implement effective infection control in ambulatory health centers.
Study Synopsis and Perspective
Each
outpatient practice should identify an infection prevention leader, according
to a new concise guide and checklist issued by the CDC and reported online July
13. The new recommendations, which aim to protect patients by informing
clinicians about minimal expectations of safe care, target healthcare providers
in outpatient care settings.
Despite
the recent dramatic rise in medical care in outpatient settings, compliance
with standard infection prevention practices is often poor in these facilities,
which include endoscopy clinics, surgery centers, primary care offices, pain
management clinics, urgent care centers, public health clinics, imaging centers,
oncology clinics, outpatient behavioral health and substance abuse clinics,
physical therapy and rehabilitation centers, and also hospital-based outpatient
departments and clinics.
"Patients
deserve the same basic levels of protection in a hospital or any other health
care setting," said Michael Bell, MD, deputy director of CDC's Division of
Healthcare Quality Promotion, in a news release. "Failure to follow
standard precautions, such as correct injection practices, cannot be tolerated.
Repeated outbreaks resulting from unsafe practices, along with breaches of
infection control noted in ambulatory surgical centers during inspections by
the Centers for Medicare and Medicaid, indicate the need for better infection
prevention across our entire health care system, including outpatient
settings."
In the
United States, clinicians at outpatient facilities currently perform more than
75% of all surgical procedures. Between 1995 and 2007, the average number of
outpatient visits to physician offices was 3 per person per year, resulting in
a total of nearly 1 billion physician office visits by 2007.
Because a
significant proportion of outpatients come from vulnerable patient populations,
it is essential that clinicians offer care under conditions that minimize the risk
for healthcare-associated infections (HAIs).
On the
basis of currently available, evidence-based CDC guidelines mostly used by
hospitals but applicable to a variety of healthcare settings, the
easy-reference guide uses Standard Precautions as the foundation to prevent
transmission of infectious agents during patient care in all healthcare
settings. Accompanying materials include an Infection Prevention Checklist for
Outpatient Settings and supporting materials.
Among the
supporting materials is a new, no-cost, certified continuing medical education
video course for clinicians in all healthcare settings, titled Unsafe Injection Practices: Outbreaks, Incidents, and Root
Causes . The video
course, which is offered on the Medscape Education Web site, was developed by
the CDC in collaboration with the Safe Injection Practices Coalition, a
partnership of healthcare-related organizations convened to facilitate safe
injection practices in all US healthcare settings.
For
internal evaluation, a facility or practice can use these materials, which
complement ongoing CDC and Centers for Medicare and Medicaid efforts to
integrate CDC recommendations into Centers for Medicare and Medicaid surveys
used while inspecting ambulatory surgery centers and other outpatient settings.
One of
the leading recommendations in the new guide is that all outpatient practices
should designate 1 or more persons specifically trained in infection control to
be on staff or regularly available. The infection control leader(s) should play
an important role in developing a written policy to prevent and contain
infection and should regularly communicate with the other healthcare providers
regarding specifically identified issues or concerns.
Other
Recommendations
Other
recommendations for outpatient facilities and practices include the following:
- Infection
prevention and occupational health programs should be developed,
implemented, and maintained.
- Written
infection prevention policies and procedures, based on evidence-based
guidelines, regulations, or standards, should be developed to address services
provided by each facility.
- All healthcare
personnel, including those employed by outside agencies and available by
contract or on a volunteer basis to the facility, should receive job- or
task-specific infection prevention education and training focusing on
principles of both healthcare provider safety and patient safety.
- Sufficient and
appropriate supplies needed to comply with standard precautions should
always be available. These precautions should include hand hygiene, use of
personal protective equipment, safe injection practices, respiratory
precautions, cough etiquette, and environmental cleaning and maintenance
of reusable medical equipment according to the maker's instructions.
- Staff's
compliance with infection prevention practices should be monitored
regularly with audits and competency evaluations.
- To evaluate infection
control practices, facilities should use CDC's infection prevention
checklist for outpatient settings.
- Facilities
should comply with local, state, and federal requirements regarding HAI
surveillance, reportable diseases, and outbreak reporting.
- Healthcare
personnel should always follow procedures to ensure safe handling of
medical equipment that may be contaminated.
- Healthcare
personnel should always follow safe medical injection practices.
Additional
resources, including the guide, checklist, continuing medical education course,
CDC and external commentary about the guide, clinician and patient education
materials, a CDC Safe Surgery feature, and other supporting materials are
available in the guidelines.
"The
majority of ambulatory care settings are not designed 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)
that are recommended for hospital settings," the guide states. "Nonetheless,
specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile
respiratory illness, febrile rash) are routinely encountered in ambulatory
settings and deserve appropriate triage. Facilities should develop and
implement systems for early detection and management of potentially infectious
patients at initial points of entry to the facility."
"To
the extent possible, this includes prompt placement of such patients into a
single-patient room and a systematic approach to transfer when
appropriate," the guide concludes. "When arranging for patient
transfer, facilities should inform the transporting agency and the accepting
facility of the suspected infection type."
CDC. Guide
to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe
Care. Published online July 13, 2011.
Study Highlights
- The ambulatory
facility should have access to at least 1 individual trained in infection
control practices. This person should establish and communicate standards
for infection control, which might vary based on the type of ambulatory
practice.
- The infection
control administrator should also ensure compliance with safety practices
such as vaccinations for healthcare workers and post-exposure prophylaxis
in case of unintended injuries.
- Finally, the
infection control expert should coordinate and evaluate efforts to train
healthcare personnel in habits to prevent the spread of infection, such as
hand hygiene.
- Infection
control training for healthcare personnel should focus on the safety of
both practitioners and patients.
- Training should
be repeated regularly, and all trainees should demonstrate competency in
the practice of infection control germane to their responsibilities.
- At a minimum,
ambulatory sites should adhere to established requirements for reporting
communicable diseases. Regular surveys may help to ensure compliance with
recommended protocols to prevent the spread of infection.
- Standard
practices in infection control expected of all healthcare facilities
include hand washing, use of personal protective equipment, safe injection
practices, safe handling of contaminated surfaces in a patient care
environment, and respiratory/cough hygiene.
- Alcohol-based
hand rubs should be the primary means of hand hygiene in practice, given
their ease of use and efficacy against most pathogens. Hand rubs are also
faster and less irritating to the hands vs hand washing with soap and
water.
- Nonetheless,
soap and water should be used when the provider's hands are visibly soiled
or after caring for a patient with a known communicable disease.
- The provider
should practice hand hygiene before touching a patient, even if wearing
gloves, and on leaving the patient care area. Hands should also be
cleansed after gloves are removed.
- Vials of
injected medications should ideally be assigned to only 1 patient.
Similarly, fluid and infusion equipment should be used for only 1 patient.
- A syringe should
never be reused to enter a medication vial or solution.
- The healthcare
facility should attempt to control the possible transmission of infections
via aerosol or droplets from the moment a patient enters that facility.
Signs should alert patients to cover their mouths and noses when coughing
and sneezing. Tissues should be provided, with no-touch receptacles to
discard them after use.
- Hand hygiene
should be available in patient waiting areas, and masks should be offered
to patients who cough or sneeze.
- The facility may
consider a separate waiting area for patients with possible infectious
respiratory tract illness.
Clinical Implications
- Alcohol-based
hand rubs should be the primary means of hand hygiene in practice. They
are faster and less irritating to the hands vs hand washing with soap and
water. The provider should practice hand hygiene before touching a
patient, even if wearing gloves, and on leaving the patient care area.
- Means to reduce
the spread of infectious respiratory tract illness in healthcare
facilities include the provision of tissues, hand hygiene available in
patient waiting areas, masks for patients who cough or sneeze, and a
separate waiting area for patients with possible infectious respiratory
tract illness.
regards, taniafdi ^_^
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