Nina M. D’Amiano, MD. Candidate, Class of 2024 Johns Hopkins University School of Medicine. MPH Candidate, Class of 2024, Johns Hopkins Bloomberg School of Public Health.

Nina M. D'Amiano, MD

The side of a hospital that says "Outpatient"

In the outpatient setting, infection prevention and control measures (IPCM) are vital practices that ensure safety by preventing the transmission of infectious agents to patients, visitors, health care personnel, and other employees.

 Most standards for IPCM are the same in all health care delivery settings, whether inpatient or outpatient.

 Recommendations for IPCM in hospitals are well documented and are updated regularly.

In addition, health care–acquired conditions, especially those acquired in the inpatient setting, have undergone considerable research and received a good deal of policy attention.

 However, relatively little is known about the risks for infection transmission that might occur during office-based care.

 Ambulatory settings have traditionally lacked adequate infrastructure and resources to support infection prevention and monitoring compared with hospitals.

Because most patient encounters occur in the ambulatory setting, preventing infection transmission in the outpatient physical office setting is essential.

 Furthermore, during the COVID-19 pandemic, the potential for exposure to infection in office-based care settings has become a concern of the utmost importance.

Regarding the scope of the problem, one study conducted by Neprash et al attempted to quantify infection transmission rates in the outpatient setting. They found that among a national sample of primary care clinics studied before the pandemic, patients exposed to influenza-like illness in the outpatient office setting were more likely to revisit with a similar illness within 2 weeks than nonexposed patients.2 Exposure to urinary tract infection and back pain were used as noncontagious controls; similar patterns were not observed for these conditions.

Outbreaks of several infectious diseases, such as measles, tuberculosis, other airborne infections, and hepatitis B and C, have been traced to outpatient medical encounters.

 Most disease outbreaks reported in outpatient settings were associated with nonadherence to recommended IPCM.

Certain patient populations are particularly vulnerable to infection transmission in the outpatient setting. One such group includes young children on account of their developing immune systems and mouthing behaviors. Toys (such as those in waiting or exam rooms) have been implicated in transmitting some infections.

 Environmental audits conducted by infection control teams have demonstrated that toys kept in health care settings are frequently not subject to the recommended cleaning protocols.

 Another high-risk group includes patients undergoing dialysis, for whom infections remain a leading cause of death.

 The transmission of viral infections, including hepatitis B virus, hepatitis C virus, and HIV, from one patient to another can occur in dialysis units.

 Receiving hemodialysis in an outpatient dialysis facility significantly contributes to patients’ risks for infection due to their exposure to blood products and their compromised immune status.6 Patients with cancer who may be immunocompromised regularly receive chemotherapy and radiation therapy in the outpatient setting and represent another vulnerable population.

Overall, contaminated hands are the most common mode of infection transmission, highlighting the importance of appropriate hand hygiene (ie, using alcohol-based hand cleaner or hand washing with soap and water) before and after contact with each patient.

Knowledge about the modes of infection transmission is vital to understanding IPCM, which are based on the following 4 routes of pathogen transmission: (1) airborne, (2) droplets, (3) direct contact with body fluids, and (4) indirect contact through fomites or physical contact.

IPCM should begin when the medical visit is scheduled and they are critical to every patient encounter.1Time spent in reception areas and waiting rooms, and the medical encounter itself, present opportunities for transmitting pathogens among patients, visitors, providers, and staff.

CDC publishes the “Guide to Infection Prevention for Outpatient Settings” and a companion checklist.

 The guide covers various topics, including health care personnel training, hand hygiene, personal protective equipment (PPE), injection safety, respiratory hygiene/cough etiquette, point-of-care testing, and environmental cleaning.

Findings from recent studies on provider adherence to infection control measures have demonstrated varying levels of knowledge by provider, institution, and location.

A historical review conducted from 1946 to 1989 by Goodman et al revealed that high levels of disease transmission in the outpatient setting are likely associated with poor adherence to practices such as proper hand hygiene, use of PPE, instrument sterilization, and restriction of sick providers. This resulted in the proposition of infection prevention and control policies by Steinkuller et al, which, in addition to the above practices, focuses on injection safety, up-to-date vaccinations, and waiting-room practices that minimize the risk of airborne disease transmission.

 In the setting of the COVID-19 pandemic, routine surveillance of IPC compliance via clinic surveys and regular communication with an infection prevention specialist is
also recommended.

A more recent systematic review by Alhumaid et al reported gaps in health care worker knowledge, especially regarding occupational vaccines, modes of infectious disease transmission, and risk of infection from needlestick injuries.

These deficiencies have been linked to insufficient education on IPCM, especially for frontline health care workers. Evidence suggests that programs focused on IPCM training for health care workers significantly increase adherence to appropriate policies and reduce health care–associated infections: Data from several studies indicate a reduction of up to 30% of such infections.

 Specific application of the World Health Organization (WHO) multimodal hand hygiene strategy has resulted in increased hand hygiene compliance and decreased infection rates.

 The WHO strategy involves 5 components: (1) system change, (2) training and education, (3) monitoring and feedback, (4) reminders and communications, and (5) a culture of safety.

 It is evident that health care workers’ implementation and maintenance of proper IPCM depend on multiple factors.

Although there is ample literature on the effectiveness of IPCM programs in tertiary care settings, studies still need to be conducted in the outpatient setting. A systematic review by Lee et al on the IPC programs in long-term care facilities serves as the closest intermediate. This review found similar results to those from studies of tertiary care centers, thus demonstrating the effectiveness of a multidimensional approach toward IPCM adoption.

 However, compared with tertiary care hospitals and long-term care facilities, outpatient centers have fewer resources, including staff, infection control experts, diagnostic equipment, and environmental preventive measures (such as negative pressure rooms). These limitations may make it difficult for clinics to implement all the components of an IPC program. Further studies are necessary to evaluate the effectiveness and practicality of outpatient IPC program implementation.

In summary, although IPCM are traditionally better implemented, studied, and funded in the inpatient setting, outpatient physical offices must implement standardized IPC policies because most patient encounters occur in the ambulatory setting.

 Study data have demonstrated that infection transmission in the outpatient setting is indeed an issue that has led to disease outbreaks and disproportionately places vulnerable populations at higher risk.

Although the CDC has guidelines detailing infection prevention for outpatient settings, there is room for improvement concerning provider knowledge of and adherence to these preventive measures. In the wake of the COVID-19 pandemic, the adoption of existing IPCM by outpatient offices and increased use of telemedicine may help mitigate the risk of health care–related infections. Finally, after the programs are established, research on the effectiveness of IPCM in the outpatient setting is necessary for practice surveillance and approach refinement.

1. Rathore MH, Jackson MA; Committee on Infectious Diseases. Infection prevention and control in pediatric ambulatory settings. 

2017;140(5):e20172857. doi:10.1542/peds.20172857

2. Neprash HT, Sheridan B, Jena AB, Grad YH, Barnett ML. Evidence of respiratory infection transmission within physician offices could inform outpatient infection control. 

. 2021;40(8):1321-1327. doi:10.1377/hlthaff.2020.01594

3. Guide to infection prevention for outpatient settings: minimum expectations for safe care. CDC. Updated September 9, 2014. Accessed February 11, 2023. https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html

4. Little K, Cutcliffe S. The safe use of children’s toys within the healthcare setting. 

5. Waheed S, Philipneri M. Targeting zero infections in the outpatient dialysis unit: core curriculum 2020. 

 2020;76(1):130-140. doi:10.1053/j.ajkd.2020.02.441

6. Soi V, Soman S. Preventing hepatitis B in the dialysis unit. 

 2019;26(3):179-184. doi:10.1053/j.ackd.2019.03.003

7. Steinkuller F, Harris K, Vigil KJ, Ostrosky-Zeichner L. Outpatient infection prevention: a practical primer. 

 2018;5(5):ofy053. doi:10.1093/ofid/ofy053

8. Alhumaid S, Al Mutair A, Al Alawi Z, et al. Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review. 

 2021;10(1):86. doi:10.1186/s13756-021-00957-0

9. Ogoina D, Pondei K, Adetunji B, Chima G, Isichei C, Gidado S. Knowledge, attitude and practice of standard precautions of infection control by hospital workers in two tertiary hospitals in Nigeria. 

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10. Michel-Kabamba N, Ngatu NR, Leon-Kabamba N, et al. Occupational COVID-19 prevention among Congolese healthcare workers: knowledge, practices, PPE compliance, and safety imperatives. 

2020;6(1):6. doi:10.3390/tropicalmed6010006

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12. Raab M, Pfadenhauer LM, Millimouno TJ, Hoelscher M, Froeschl G. Knowledge, attitudes and practices towards viral haemorrhagic fevers amongst healthcare workers in urban and rural public healthcare facilities in the N’zérékoré prefecture, Guinea: a cross-sectional study. 

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Articles

Unlike hospitals, ambulatory settings have traditionally lacked adequate infrastructure and resources to support infection prevention and monitoring.

Nina M. D'Amiano, MD

Articles

Infection Control and Prevention in the Outpatient Physical Office Setting