Ambulatory Care: The Challenges for Infection Prevention

Ambulatory care centers and outpatient surgery facilities all seem like ideal settings to receive healthcare. A patient can be seen, treated and sent back home in half the time of a hospital visit. Therefore, it might appear that the risk of infection would be lower because the patient is only there briefly. So why has there been so much concern over these facilities recently? There are many reasons.

Because many outpatient clinics are not accredited, they may not have extensive quality improvement monitoring, infection surveillance or patient follow-up procedures. These facilities are usually small, and are therefore allowed to combine several services in one area – a practice that hospitals do not allow.

Recent investigations have exposed many of these issues. More than 60,000 patients in the United States were advised to get tested for hepatitis B and C because healthcare personnel failed to follow basic infection prevention practices, according to a January 2009 Centers for Disease Control and Prevention (CDC) report which described 33 infection outbreaks outside of the hospital setting in 15 states from 1998 to 2008. Reuse of syringes and blood-contamination of medications, fluids, equipment and devices caused these infections.

In reality, such errors have occurred for many years without discovery for two main reasons. First, there is a time lapse between exposure and development of symptoms for hepatitis B and C. For hepatitis B, it can be as short as two weeks or as long as six to nine months before the antigen testing is positive for HBsAg. While most patients become symptomatic, a small percent may have no symptoms at all and therefore may not suspect that they are infected.

The incubation period for hepatitis C ranges from two weeks to six months. However, hepatitis C may remain dormant for 20 years before symptoms appear. By the time one is diagnosed with hepatitis C, it is too late to identify the source of the infection. While the initial infection may be asymptomatic, a high percentage (50 percent to 80 percent) will develop a chronic infection.

A March 2009 report published in the CDC’s Morbidity and Mortality Weekly Report identified hepatitis C transmission in an outpatient hemodialysis unit in New York from 2001 to 2008. Of 162 patients, 18 percent were hepatitis C positive on admission, but 10 percent more acquired hepatitis C during their treatment. The report cited a number of clinic problems, including inadequate cleaning, failure to wear or change gloves between patients, failure to perform hand hygiene after contact with patients, no clean area for medication preparation and short turnover periods between patient treatments.

The second major factor relating to these outbreaks is the misunderstanding among staff that blood cells and bacteria do not have the ability to move up IV tubing. Blood cells, viral particles and bacterial growth have been found in IV ports not even near a patient’s IV site. These blood cells and bacterial material contaminate the needle used in an injection. When a needle and syringe are withdrawn from tubing, they are contaminated.

A further complication is that patients do not return to the clinic or outpatient setting if they develop an infection. They usually go to a physician’s office or a nearby hospital. The hospital infection preventionists may not report back to the clinic or outpatient setting because they frequently do not have time to investigate infections that are not caused in their facility. The outpatient physician may not be aware that the patient has gone to an emergency department or has been admitted to a hospital if hospital staff do not contact him or her.

The outbreaks in Las Vegas placed more than 63,000 people at risk for hepatitis C. These events involved contaminated syringes and improper use of multi-dose medication vials. More than 115 patients were infected, but the investigations are still continuing, so these numbers may rise. There continue to be reports of infection control flaws in other outpatient settings throughout the country. Errors such as this are preventable and should never occur in any healthcare setting. Infection prevention oversight in the ambulatory care setting is critical. Each facility should employ an infection preventionist either on staff or as a consultant to oversee their infection prevention program.

As more healthcare is delivered in the outpatient setting, it is imperative that healthcare workers become adequately trained in infection prevention measures.

In keeping with APIC’s core mission to educate our healthcare colleagues in methods of prevention, APIC provides extensive educational tools to support the ambulatory care community. For more information about our Ambulatory Care Section, educational courses, newsletters, textbooks, and chapter networking, visit http://www.apic.org/.

Christine J. Nutty, RN, MSN, CIC, is the APIC 2009 president.

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