Bennett & Brachman's Hospital Infections, 5th Edition

27

Ambulatory Care Settings

Candace Friedman

Kathleen H. Petersen

Background

Healthcare is increasingly provided in ambulatory care settings. These settings include a wide variety of primary and specialty offices and clinics, urgent care centers, dental offices, and physical medicine and rehabilitation centers. Treatments once provided only in a hospital are now offered in outpatient settings, including infusion therapy, dialysis, and endoscopy. In addition, many surgical procedures formerly performed only on inpatients are now routine practice in ambulatory surgery centers.

Ambulatory care settings present unique challenges for infection prevention and control. High volume, complexity of care, increasingly vulnerable patients, and brief visits influence the development and recognition of healthcare-associated infections (HAI).

Medical procedures performed in the ambulatory setting may put patients at risk of infections. Use of intravascular devices may lead to infections such as catheter site infection, bloodstream infection, septic thrombophlebitis, or endocarditis. Other invasive procedures, including surgical procedures, endoscopies, bronchoscopies, and cystoscopies, pose a risk of infection due to the disruption of normal host barriers. In addition, there have been reports of outbreaks due to inadequate sterilization or disinfection of equipment, absent or inappropriate use of barriers, inappropriate work restrictions for ill health care workers, and poor hand hygiene. However, despite increasingly complex ambulatory care, overall risks of HAI continue to remain low [1].

There also is the risk of exposure to communicable diseases in ambulatory settings. The potential for infection transmission, including the spread of measles and tuberculosis, to patients and staff in ambulatory care has long been recognized [1]. Additionally, there are concerns about transmission of antibiotic-resistant bacteria and the threat of biodisaster-related infections in these settings.

General Prevention

Several basic infection prevention [1,2,3] and control principles and practices to reduce the risk of infection are essential regardless of setting. These include hand hygiene, standard precautions, cleaning, disinfection, and sterilization of medical devices, management of infectious patients, and occupational health.

Hand Hygiene

Hands [4] must be cleaned as in any other healthcare setting. Plain or antimicrobial soap and an alcohol-based hand sanitizer should be readily available. Sinks must be conveniently located. Alcohol hand sanitizer containers should be placed in waiting areas, patient rooms, and support areas. For invasive procedures a surgical hand scrub is required. Staff should be offered a choice of antimicrobial scrub products. (See Chapter 3.)

An issue in ambulatory settings is how best to monitor appropriate hand hygiene. Observations are limited for areas where care is provided behind a door. Settings where observations are possible include surgery centers, infusion; dialysis, endoscopy, and physical medicine; and rehabilitation areas. A surrogate for observation can be an evaluation of the quantity of hand hygiene products used before and after any intervention designed to increase hand

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hygiene. The rate of use is then equal to the amount of product divided by the number of visits for a certain time period.

Standard Precautions

Use Standard Precautions for all patients. This includes the use of appropriate personal protective equipment (e.g., gloves, gowns, and face protection) as needed. The type of exposure expected will determine the specific barrier to use. Barriers should be readily available in examination and treatment rooms. Gloves must be worn for drawing blood, handling contaminated items, performing invasive procedures, and using certain chemicals. In addition, safety devices, especially intravenous catheters and blood drawing needles, must be accessible. Training regarding specific practices involved in standard precautions must be provided to staff.

Infectious Patients

Some method of isolation and barrier precautions must be used in any setting. Contact, droplet or airborne precautions may be implemented depending on the patient population and complexity of patient care [5].

A respiratory hygiene campaign should be routinely used instructing visitors, patients, and staff to “cover their cough.” Signs providing instructions should be prominently displayed, and tissues, hand sanitizer, and masks made readily available.

There should be a method to identify potentially infectious patients. Early identification can assist with the use of appropriate isolation/precautions. A screening tool may be useful for assessing diseases such as tuberculosis, chickenpox, measles, and pertussis. Screening can be performed on the telephone. Patients meeting screening criteria should be provided a mask if appropriate and separated from others as much as possible—not remaining in waiting areas. Patients with rash or fever should be seen at times when there are the fewest patients.

Cleaning/Disinfection/Sterilization

Cleaning the environment [6,7] and equipment is important in any setting. Room furniture, floors, countertops, examination tables, and other equipment should be cleaned routinely using a low-level disinfectant. Disposable, single-use items must not be reprocessed unless Food and Drug Administration (FDA) requirements are met [8]. Any reusable instrument or equipment that enters sterile tissue or cavities must be sterilized before use. High-level disinfection may be used for items that contact mucous membranes or non-intact skin. (SeeChapter 20.)

Written procedures should note how each instrument or piece of equipment will be processed. Outlining the barriers staff need to use, how to clean the item, the proper disinfection or sterilization method, and storage parameters makes the procedure a useful educational tool (see Table 27-1).

TABLE 27-1 DEVELOPING PROCEDURES FOR DISINFECTION/STERILIZATION OF EQUIPMENT

· Meet with clinic managers, nurse, or medical assistant educators · Develop procedures: use same procedures throughout institution · Develop training and competency · Implement procedures · Perform site surveys to assess practice: process surveillance · Evaluate assessment · Implement changes · Document and share with relevant staff

Steam autoclaves often are available in ambulatory care settings. Peel pouches may be used to package small items. There also may be items (e.g., vaginal specula) that can be steam sterilized unwrapped in place of high-level disinfection. Preventive maintenance is critical to ensure a safe, functional sterilizer.

Staff members must be educated on the practices required for safe and effective processing of items and how to properly use chemicals and sterilizers.

Storage

Store all clean or sterile items in a manner to prevent contamination. Sterile supplies should be kept in closed drawers or cupboards if not in a designated clean supply room. All supplies should be stored in a first-in, first-out manner to ensure the use of the oldest items first.

Occupational Health

Occupational health programs are important in ambulatory care settings. There should be a comprehensive vaccination program for employees including hepatitis B vaccine and influenza vaccine. A tuberculosis screening program also is important. There should be a system of follow-up for any body substance or chemical exposure. In addition, a program for prevention must include use of safety devices when applicable to prevent needlestick injuries. (See Chapter 4.)

Settings, Risks and Prevention

Each of the following sections summarizes the application of infection prevention and control principles in various ambulatory care settings. Prevention of infections due to

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infusion therapy and dialysis is covered elsewhere. (See Chapters 23 and 37.)

Primary and Specialty Care Medical Offices and Clinics

Services in these areas range from non-invasive health maintenance examinations to procedures such as endoscopies, biopsies, and minor surgeries. Overall risk of infection in this setting is very low. Potential risks to staff include sharps injuries and exposure to communicable infections. Risks to patients include exposure to infectious agents in the waiting room and other common areas and ineffective reprocessing of medical devices. The role of computer keyboards, stethoscopes, and other environmental sources in the spread of communicable diseases is generally low in the medical office and clinic setting [1].

Reportable diseases diagnosed by the medical office or clinic must be reported to the local health department. Primary care can also play a major role in promoting community health (e.g., providing immunizations and teaching patients about hand hygiene, appropriate use of antibiotics, and prevention of sexually transmitted diseases).

Specific measures to prevent infections include the following:

• Triaging patients with possible airborne illness (e.g., chicken pox) to enter an alternate door when available and avoid time in the waiting room.
• Practicing aseptic technique for minor procedures including proper patient skin antisepsis, and no preset up of sterile trays.
• Cleaning surfaces (e.g., examination tables, examination lights, and blood pressure cuffs) on a regular basis.
• Disinfecting and sterilizing instruments safely, effectively, and reliably after each patient use and consistent with policies and procedures of the organization. Staff with expertise in infection prevention and control should assist in the evaluation of reprocessing practices before placing new equipment or devices into use. This is especially important in specialty clinics, such as ophthalmology, infertility, and urology, where technology is advancing rapidly and new devices are often introduced.
• Immunizing patients: appropriate vaccine storage, preparation, and record keeping.
• Cleaning toys after contamination (e.g., “mouthing”) and on a regular basis [9].

Dental Offices

Dental and oral surgical procedures are among the most frequently performed procedures. Procedures vary from routine teeth cleaning to dental implants to temporomandibular joint surgery.

Risks of infection due to dental procedures include contaminated instruments and equipment (e.g., ultrasonic scaling, high-speed hand pieces, and waterlines). In addition, there is a risk of postsurgical infection after procedures due to microbes in the oral cavity (e.g., tooth extraction and dental implants). Dental healthcare workers may be exposed to infection due to contact with blood and oral/respiratory secretions, especially aerosols, and contaminated equipment and surfaces.

Specific measures to prevent infections include the following [1,10,11,12]:

• Performing a surgical scrub for oral surgical procedures.
• Using safety dental syringes/injectors and work practices to prevent body substance exposures.
• Decreasing aerosols generated during treatments through the use of rubber dams, high-velocity air evacuation, and proper patient positioning.
• Using water that meets Environmental Protection Agency standards for drinking.
• Sterilizing instruments that penetrate soft tissue, including reusable prophylaxis angles, high-speed dental hand pieces, and low-speed hand-piece components used intraorally.
• High-level disinfecting of instruments that contact oral tissues or heat-sensitive instruments.
• Cleaning hand pieces thoroughly both internally and externally. They must be run to discharge water and air after each patient.
• Flushing ultrasonic scalers and air/water syringes for 20–30 seconds after each patient.
• Cleaning the following areas with disinfectant cleaner after each patient: countertops, chair switches, light handles, dental unit surfaces, aspirator tube, edge of spittoon, and ultrasonic scaler hand piece.

Emergency Department

Services provided in an emergency or urgent care department (ED) [1,13,14,15,16,17] focus on the care of critically ill or injured individuals who are having various procedures performed. Some of these patients come to the ED with communicable diseases. In addition, individuals seeking treatment after a biological or chemical attack will be advised to go to an ED.

Risk of infection to patients arises primarily from invasive procedures performed (e.g., bloodstream infections related to intravascular catheter placement). Waiting and other common areas pose a risk of exposure to communicable diseases for patients, visitors, and staff. Staff are also at risk from aerosols and blood and body fluid exposure. ED staff are at a greater risk of exposure to bloodborne pathogens than other healthcare workers due to their frequent contact with blood.

Specific measures to prevent infections include the following:

• Using aseptic practices as in any healthcare setting for intravascular devices, ventilators, urinary catheterization, and any other procedure.

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• Assessing patients for signs and symptoms of communicable diseases. A triage screening tool can be used to identify potentially contagious patients (see Figure 27-1). Mask identified patients promptly and separate them from others.
• Having a system of isolation/precautions for management of potentially infectious patients.
• Having an emergency response plan that includes biological threats.

Figure 27-1 Sample triage policy for infection prevention in ambulatory care.

Outpatient Surgery

Outpatient surgery is performed in traditional hospital settings or in stand-alone surgery centers that may or may not be affiliated with larger medical institutions. Surgical procedures commonly performed on outpatients include removal of cataracts, muscle/tendon procedures, reduction of fractures, laparoscopic cholecystectomies, tubal ligation, hernia repairs, knee arthroscopies, and many types of plastic and oral surgery.

The risk of surgical site infection (SSI) varies according to procedure; however, it is reported to be <1% overall and certainly less than for inpatient surgery [18]. Outpatient procedures are generally shorter and not as invasive or complicated as those performed in hospitals. Prevention of postsurgical infections is covered in Chapter 35; however, there are special standards for office-based surgery outlined by the Joint Commission [19]. Surgical team members are also at risk for infection due to the potential for blood and body fluid contamination and injuries from sharp items.

The strategy for surveillance of surgical site infections differs slightly from inpatient surveillance; however, it is necessary to evaluate infection trends, develop rates for new or more complex surgeries, and monitor changes in

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rates following interventions. Surveillance should include the following:

• Determining procedures to follow: Perform a risk assessment for high-volume, high-risk, problem-prone, and historically problematic procedures. Perform a medical literature search for articles on the procedures that will be followed to determine a benchmark. Once enough data have been collected, an internal baseline rate can be determined.
• Developing case findings of effective data sources, such as medical records, letters to surgeons, and contact with the medical offices where patients receive postsurgery care.
• Performing data analysis and follow-up: Determine who will collect the data, develop reports, receive reports, and the frequency of reports; outline who will be responsible for follow-up of recommendations or changes in practice.
• Reassessing rates after changes in practice.

Diagnostic and Treatment

Endoscopy

Endoscopy procedures are among the most common of outpatient procedures. Infection risk related to endoscopy has been demonstrated to be very low [20]. Cross-infection has been traced to a failure to practice recommended cleaning and disinfection procedures of the endoscopes or ancillary equipment. These include Mycobacterium tuberculosis related to bronchoscopy, Hepatitis C related to colonoscopy, Pseudomonas aeruginosa related to endoscopic retrograde cholangiopancreatography, and Staphylococcal infections related to arthroscopy [1]. Patients also may develop infections from endogenous flora as the endoscopes are passed through the gastrointestinal, urinary, or respiratory tracts [21]. In addition, there have been reports of mucous membrane damage (i.e., colitis) linked to inadequate rinsing of disinfectant, specifically glutaraldehyde from sigmoidoscope channels [1]. Endoscopy staff members are at risk of exposure to body fluids during procedures and to chemicals during disinfecting procedures.

Endoscopes are inherently heat-sensitive, complex, and fragile instruments. This makes management of these devices critical. However, adhering to specific infection prevention and control activities reduces the risk of infection to a minimal level:

• Ensuring that all staff responsible for using and reprocessing the endoscopes are trained and competent.
• Reprocessing endoscopes consistently after each patient use. Most endoscopes are high-level disinfected. (See Chapter 20.)
• Following detailed procedures provided by each endoscope manufacturer and by professional organizations [20,21].
• In addition, because of the potential for tuberculosis related to bronchoscopies, performing these procedures using guidelines from the Centers for Disease Control and Prevention (CDC) [22].

Radiology

Radiology departments provide a number of services, including diagnostic radiography, computed tomography, fluoroscopy, ultrasound, and interventional procedures. Risks of infection are primarily related to intravascular catheter use, equipment (e.g., ultrasound probes and fluids, contrast medium). Because patients suspected of having tuberculosis or other communicable respiratory illness often are evaluated with diagnostic radiography, there is a risk of transmission to both patients and staff. Staff members also are at risk of bloodborne pathogen exposure due to their contact with blood during invasive procedures.

Specific measures to prevent infections include the following [1,23,24,25,26,27]:

• Using safety devices, especially intravenous catheters and needle holders/pads, and passing instruments safely.
• Using aseptic practices for intravascular devices and other procedures.
• Avoiding hair removal unless it interferes with the procedure. Clip the site, if necessary.
• Using appropriate techniques during invasive procedures, e.g., insertion of tunneled catheters, surgical scrub, and use of a sterile field system. Nonporous drapes must cover the area surrounding the wound; cover the patient and any hardware on the table that might come in contact with a long catheter/wire [28]. Operators should wear cap, mask, gown, and gloves [29]. Circulators should wear a scrub suit.
• High-level disinfecting endocavitary and vaginal ultrasound probes after each use, even when probe covers are used [27]. Reuse catheters in angiography only per FDA regulations [8].
• Implementing a protocol on how to manage patients suspected of having an airborne communicable disease, e.g., use of a mask on the patient when an identified patient is seen for chest radiography.

Cardiology: Cardiac Catheterization and Electrophysiology

Increasingly complex diagnostic and interventional procedures are performed on outpatients in the cardiac catheterization laboratory [28,30], including placement of pacemakers, stents and other implantable devices, angioplasty, and cardiac catheterizations.

Infections are rare after invasive cardiovascular procedures and usually are associated with the procedural site or the device. However, risks for infection have been linked to contaminated instruments and solutions or breaks in technique. When infection occurs, it is presumed that

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bacteria are introduced at the time of vascular puncture or incision. Infectious complications include bloodstream infection, endarteritis, pacemaker and defibrillator infections, coronary stent, and puncture site infections. Patients with implants also may develop late-onset infections. Skin microorganisms usually cause these infections. Endotoxin reactions after catheterization have also been reported. Risks for staff are mainly through exposure to blood from sharps injuries or splashing of blood.

Specific measures to prevent infections include the following:

• Preparing the patient: Follow standard vascular access and surgery site preparation. Do not remove hair unless it will interfere with the operation.
• Performing standard surgical hand antisepsis and avoid artificial nails, as described in Chapters 3 and 35.
• Using aseptic technique, as described in Chapter 3.
• Preparing staff [28]:
• The cardiologist should wear mask, eye protection, cap, sterile gloves, and sterile gown.
• Staff assisting within the sterile field should wear scrub suit, cap, mask, and gloves, adding eye protection if there is a splash potential during the specific procedure.
• Circulators should wear scrub suits.
• Inserting intravascular catheters and maintenance: follow CDC guidelines on prevention of catheter-related infections [31].
• Controlling intravenous solutions (e.g., dyes, flush solutions). Ensure sterility; cold infusates need to be cooled without contact with tap water that might contaminate the infusate and then be inadvertently injected into vessels.
• Processing equipment: Most supplies used in the unit are disposable. However, single-use device (SUD) catheters can be reprocessed for reuse, following stringent requirements of the FDA. Most electrophysiology units use third-party reprocessors for these devices [8].
• Ensuring sterility of implants: any implant removed for infection must be reported to the FDA. Work with the institution's risk management department on appropriate protocols.
• Controlling the environment: Air handling is similar to that in operating rooms. This includes ensuring that the room is set at positive pressure with a minimum of 15 air exchanges per hour; make sure construction/renovation plans follow health department specifications [32].
• Cleaning procedure rooms after each case [32,33].
• Using safety devices and disposing of sharp instruments and needles safely.
• Using prophylactic antibiotics per recommendations [28].
• Developing written policies and procedures for infection prevention and control.

Surveillance for bloodstream infections (BSI) and SSIs is difficult unless patients return to the clinic affiliated with the cardiac area. However, there should be a system in place for follow-up of patients. Because reported rates of infection are low, any evidence of an outbreak or cluster should be carefully evaluated.

Physical Medicine and Rehabilitation

Rehabilitation services provide a multidisciplinary team approach to treat patients with often complex medical and physical conditions. Rehabilitation specialties include physical, occupational, and speech and language therapy; orthotics and prosthetics; recreational, art, and music therapy; and rehabilitation engineering. Programs often target special needs, such as sports or spinal injuries, traumatic brain injuries, or strokes.

Although services are wide ranging, few involve invasive procedures, and infections related to these services are rarely reported. Some exceptions include electromyography (EMG), wound irrigation [34], and hydrotherapy for patients with open wounds [1]. Speech therapists or others working with the mouth or items that contact oral secretions, such as during swallowing studies, may be exposed to respiratory infections of the patient. Rehabilitation patients at increased risk of infection include cystic fibrosis (CF) patients who may develop and/or spread Pseudomonas spp. or Burkholderia spp. to other CF patients, arthritis patients on high-dose steroids, patients with large wounds coming for irrigation or hydrotherapy, diabetic patients being fitted for orthotics or prosthetics, and spinal cord injury or other rehabilitation patients with indwelling urinary catheters.

Specific measures to prevent infections include the following:

• Practicing standard precautions: Evaluate the need for barriers during treatment of patients who may be incontinent, have open wounds, or have increased respiratory secretions.
• Applying precautions consistently for all patients who may have antibiotic-resistant microorganisms (e.g., treating CF patients colonized with Burkholderiaspp. at the end of the day and/or individually when no other CF patients are being treated). Clean all equipment after each of these patients.
• Restricting children receiving speech and language therapy who have upper respiratory infections.
• Cleaning mats, walkers, canes, wheelchairs, weights, transfer devices, occupational and speech therapy tools, toys, and other equipment after use or place barriers between patients and equipment. Evaluate whether equipment touches skin, mucous membrane or sterile tissue. Establish a frequency of cleaning and which disinfectants will be used [35]. (See Chapter 20.)
• Using aseptic technique during wound care and dressing changes. Follow local health department regulations for medical/regulated/biohazardous waste for dressing disposal. When irrigation of large wounds is performed

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(e.g., pulsatile lavage), follow specific recommendations to prevent aerosolization, including the use of barriers such as gloves, impervious gowns, and face protection [34].

• Draining and disinfecting hydrotherapy tank and agitator jets after each patient.
• Following state laws for treating (e.g., chlorinating) and testing the pool or whirlpool water in aquatic therapy. Develop consistent policies for restriction of patients due to open wounds or fecal incontinence.
• Disposing of electromyography needles and other sharp items carefully.

Home Care

Services provided in a home setting consist of skilled nursing care, respiratory therapy, infusion therapy, wound care, dialysis, nutrition therapy, physical and occupational therapy, and hospice care. Home healthcare is a growing segment of the healthcare delivery system. Many patients cared for at home are immunocompromised, are of advanced age, and/or have a chronic illness. In addition, they may have various types of devices, including intravascular and urinary catheters, and use equipment that require management (e.g., ventilators). Risks for infection are generally associated with these devices, for example, bloodstream infections due to intravascular devices (See Chapters 31, 37). Staff may be at risk during contact with patients who have communicable diseases.

Much of the care provided in the home is by someone other than a healthcare worker (e.g., family members). These individuals also play an important role in infection prevention. Education of caregivers in hand hygiene, aseptic practices, care of devices, use of barriers, disinfection practices, and other aspects of care are extremely important. Caregivers should also be informed of appropriate signs and symptoms of infection.

Surveillance for infections is a challenge for home care agencies due to the difficulty of obtaining information. Data should be collected for high-risk infections in the populations served; these may include urinary tract infections, BSI, pneumonia, and skin/soft tissue infections. Definitions on surveillance criteria have been published for home care [36].

Home care agencies should monitor for BSI and tunnel or exit site infections in their patients who receive home infusion. If patients are on ventilators, they should be monitored for the development of pneumonia. Clinical home care staff will need to help collect data by identifying patients with clinical signs and symptoms of infection. They can then report the information to a central individual responsible for infection prevention and control. That person will then apply the definitions and make recommendations for changes in practice when appropriate.

Specific measures to prevent infections include the following [37,38,39,40,41]:

• Using standard precautions with attention to hand hygiene. Alcohol-based hand sanitizers, soap, and clean paper or cloth towels should be brought to the home by the healthcare worker.
• Immunizing patients as necessary.
• Transporting clean and sterile supplies in a manner to prevent contamination (e.g., in a travel bag).
• Setting up a clean work surface.
• Using safety devices and carefully discarding sharp items; take a container to the home if necessary.
• Disinfecting urinary drainage bags per safe protocols.
• Handling fluids (e.g., sterile water) in a manner to prevent contamination. Use small bottles, carefully handle caps, and store properly.
• Providing enteral feedings safely: refrigerate, thoroughly clean blender parts, measuring utensils, and other reusable items after use. Allow to thoroughly dry. Hang for only recommended time limits. Use clean technique to prepare and administer enteral feedings.
• Following intravascular device guidelines and ensuring proper handling and storage of medications [31].
• Providing sterile solutions prepared for intravenous infusion.
• Developing procedures on frequency of ventilator tubing changes, tracheostomy care, use of gloves when suctioning and disinfecting suction catheters, canisters, and tracheostomy cannula. Suctioning is usually performed using clean rather than sterile technique.
• Developing procedures that outline maintenance requirements for respiratory care equipment. Room humidifiers should be dried between uses.
• Outlining aseptic practices related to urinary catheterization. Clean technique is appropriate (see Chapter 30).
• Using clean technique during wound care.
• Teaching caregivers methods to prevent pressure ulcers.
• Developing a system to manage equipment taken to/from the patient's home (e.g., clean items always placed in a clear bag and used items placed into a colored plastic bag). Separate clean and dirty areas and items.

Infection Prevention and Control Program

The infection prevention and control (IPC) program design must take into account factors that will influence its activities. These include the population served, demographics of the institution, clinical focus, volume of activity, and number of staff.

Infection Control Professional

Responsibility for IPC programs in ambulatory care settings may be designated to a staff member or an infection control

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professional (ICP) with specialized training. It should be clear who has the designated responsibility.

Specific activities include surveillance, data management, cluster investigations, quality improvement activities, patient and staff education, policy and procedure updates, product evaluation, and exposure investigations. A staff member may be assigned many of these responsibilities. However, if necessary, the services of a trained ICP should be obtained as a consultant.

Whoever is assigned responsibility for IPC must include both clinical and support teams in the program to ensure success. Specific information on designing an IPC program is outlined in Chapter 5.

Specific IPC Activities in Ambulatory Care [1,42,43,44,45,46,47]

Data Management

One of the major functions of an IPC program is data management. Chapter 6 discusses surveillance; therefore, this section focuses on issues pertinent in ambulatory care settings.

A surveillance plan should be developed. It should outline what types of infection will be monitored (outcome surveillance) [48,49,50] or what practices will be routinely evaluated (process surveillance) [51,52]. In addition, the plan should note the methods used to disseminate data to appropriate staff.

Healthcare-associated SSIs postambulatory care surgery or BSI after infusion therapy or dialysis are appropriate outcome measures for settings to perform these procedures. There are no specific definitions for HAIs in ambulatory settings. The general definition used for an HAI is the development of an infection not present or incubating at the time of the visit or intervention. Any definition must include a temporal association with the visit or care provided. For example, a BSI occurring within 48 hours of a visit to an infusion center may be considered an HAI.

Any surveillance measuring outcomes must consider how to obtain information. Patients in these settings may not return to the same provider for follow-up if an infection occurs. Systems to identify these patients may include coordination with hospitals, provider offices, and home care services. Methods to obtain information may consist of phone calls to patients or providers, patient mail-back questionnaires, or provider surveys; laboratory and radiology reports; risk management database; and communication with staff.

Surveillance of processes may be used to review the care and maintenance of instruments and equipment and practices at a site. This system focuses on observations using a survey tool to collect information. Table 27-2 is an example of questions that can be used on a survey tool. Process surveillance methods are used to measure compliance with policies and procedures; data can then be used to improve outcomes. Reports of findings should be sent to staff who can facilitate changes and monitor practices.

TABLE 27-2 EXAMPLE OF AN AMBULATORY CARE SURVEY TOOL

Safe, Effective High-Level Disinfectant Yes No Are containers Completely covered? Labeled with chemical name and safety or environmental hazard? Checked each day of use for effectiveness? Results recorded? Labeled with expiration date? Are devices thoroughly cleaned before soaking in disinfectant? Are devices completely immersed in disinfectant? Are items soaked at least 20 minutes? Are devices rinsed thoroughly after soaking? Are competencies in place for staff?

Patients and staff also are at risk of infection due to exposure to communicable diseases. If this is a potential risk in a setting, it should be part of the surveillance plan.

Reportable Diseases

Certain communicable diseases are reportable to state and local health departments. It is important to provide this information as appropriate to ensure communication with health departments and laboratories.

Construction/Renovation

All construction/renovation projects must have infection control input [53]. Specific concerns include the management of the project, especially minimizing dust generation, and review to ensure that basic infection prevention measures are included (e.g., sinks and proper air flow).

Biodisaster/Emerging Diseases

Patients with diseases suspected of being related to bioterrorism may be identified in ambulatory care sites. Each area should have a biological disaster plan that may be included in a general disaster plan. A method for early recognition of the illness is a key component of any plan [54,55].

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