Infection Control Today - 05/2004: Clean Slate

Clean Slate
Keeping Outpatient Departments Safe

By Kathy Dix

Hospital outpatient departments straddle an uncomfortable position, teetering between inpatient departments and freestanding ambulatory centers. Because they are more open to the community, they may find it more of a challenge to meet cleaning, disinfection and sterilization standards.

That is not to say that these departments are deficient in any way simply that due to their high traffic and their rapid turnover, more people (and therefore pathogens) make their way into the facility.

Preventing disease transmission in a hospital setting is hard enough. But filling the space with the sick and allowing them to return to the community after just enough time to be exposed to whatevers in the air and on the doorknobs can create challenges for outpatient departments (OPDs).

There are many challenges for these departments community-acquired antibiotic-resistant pathogens, a large number of reusable instruments that require sterilization or high-level disinfection, and a sterilization department that may be located miles away. Many OPDs have decided to reprocess their instruments in-house, as they simply cant afford the time (or expense) to send items to the main hospital building or a third-party processor.

Do outpatient departments have it harder or easier when it comes to cleaning, disinfection or sterilization? Its not a black-and-white answer, says Terri Rearick, RN, BS, CIC, administrator of safety services at Childrens Memorial Hospital in Chicago. I really feel its facility dependent. Its dependent on the inner communications and mechanisms that an individual hospital with associated ambulatory areas has.

At some places, the ambulatory places sort of feel like the stepchild, she quips. Nobody knows they exist; theyre trying to get products and answers and find out what the policies are. But if you have good communication, and youre establishing a systems approach, it should be the same policies across the system, the same contact people and the same products. If you have those things aligned that way, it shouldnt make a difference whether its inpatient or outpatient.

The difference between outpatient and inpatient services, Rearick says, is that in ambulatory areas, whether thats an emergency room attached to a hospital or a freestanding clinic a block away or several miles away, that they have a different issue as far as high traffic and quick turnover. The patients not being admitted; theyre not going to stay there for multiple days. Its in-and-out, because the faster the better, the more revenue youre going to generate by using those rooms efficiently and quickly. So I really think the high traffic and quick turnover is the biggest challenge in ambulatory areas.

Cleaning is a very different beast in outpatient centers, she says, simply because the hours are more conducive to thorough cleaning. You might be cranking from 8 a.m. to 5 or 6 p.m., but then when the clinic closes, you can say everybody out, and have the cleaning service come in and clean, Rearick explains. In inpatient areas where youre a 24-hour-aday service, thats a challenge. What a lot of places have done is come to an agreement: if Im the patient and going in that exam room, and Im going to take off my clothes, youre going to give me that over gown and theyre going to pull that piece of paper on the exam surface. If I have not soiled or contaminated that surface, they can just change the paper between patients. If its actually soiled, the question is, whos going to clean it? The practical way to do it is to have the med tech or the nurse before the next patient comes looking at that exam room, at what condition it is in, [seeing something soiled] and having a product readily available to use right there. And you get a lot of people saying, Thats not really my job, but it is, because youre preparing that room for the next patient. There are nice products now that are easy to use. You dont have to have rags and mop heads. The trick becomes the contact time. Depending on the product choice the organizations making, they should look for something that needs a minimum contact time, not 10 minutes before the next patient is going into the room.

When reprocessing instruments in an outpatient facility, Rearick points out that Spauldings rankings of critical, semi-critical and non-critical instruments is the best approach.

When youre talking about instrument reprocessing, you would probably find as many different ways of doing that as there are systems. It depends on cost containment for that organization, what they see is the best bang for the buck, and also efficiencies. If you have a freestanding hospital with central supply where they do the instrument reprocessing, cleaning and packaging and sterilizing, some places will put in place a transport system. Ill bring it from Clinic X three miles away, transport it to our central supply and have it done there, and then I dont have to have staff in the clinic spending time cleaning, packaging and sterilizing instruments. I dont have to train them, worry about their competencies doing that, buying that equipment, doing preventive maintenance on that equipment and doing the biological indicators and other monitoring of equipment to make sure its working. My experience has been the more you can centralize your process, the better, because then you actually have control over the outcome of that instrument; you dont have 20 different people trying to figure it out, or fit it into the course of the day when they already have too much to do, or letting it sit until the end of the day and then having this pile of yuck that nobody wants to touch.

She continues, If you can centralize it, thats my preference; sometimes you cant. We have a surgery center that is 20 miles from our main campus. Well, theyre not going to want to drag everything back and forth, so we set up a separate on-site reprocessing center that is a duplicate of our reprocessing at the hospital. It follows the same policies, the same training, the same competency, the same products, the same methods so you can guarantee the patient at a 20-mile-away facility the same quality of product.

In outpatient facilities that use a great many endoscopes, for example, They dont have the luxury. If youre doing 20 scope procedures a day, you cant afford 20 scopes. Then you do need an on-site reprocessing area.

The advantage of outpatient as opposed to inpatient is sometimes theyre closed down to the patient population, agrees Gordon Bontrock, director of product development for environmental services for Aramark Healthcare Management Services. That gives us the ability to go into a non-occupied area for cleaning, so its actually easier to move through clinical areas. The surfaces are different. Spaces are usually clearer.

Bontrock adds, [In OPDs], your environmental services is not a part of that, so its your clinicians that are taking care of between-case cleaning.

However, Bontrock points out, We practice standard precautions whether its an outpatient service or whether its inpatient area. Were using the same cleaning agents. The process of cleaning, the very system concept of cleaning is the same. We consider a clinic still a patient area, and we would treat patient areas the same.

Our outpatient disinfection policies are exactly the same as the hospital setting, says Kathy Mathews, RN, CIC, a nurse epidemiologist at the University of California, San Francisco (UCSF) Medical Center. And we specifically set it up that way. One of the ways we monitor it is we developed competencies. The people on the ambulatory side who are doing sterilization and disinfection are trained, and they pass on these competencies, and its the same ones we use for the operating room staff.

High traffic and turnover does make cleaning and disinfection a challenge when theres a busy clinic, Mathews says. On the positive side, theres less blood and body fluids in the average clinic where people are coming in and checking their blood pressure. It really depends on the clinic. Some clinics may have a lot of procedures where it could be a greater risk.

Rene Santos, MD, an infectious disease specialist and chair of the infection control committee at South Suburban Hospital outside Chicago, adds, How do we cope with cleaning, disinfection and sterilization? For instance, are there any guidelines with respect to wheelchairs? I have done a literature search on that, and I have not seen any recommendations that deal specifically with wheelchairs. Wheelchairs are ubiquitous in the hospital; they are found all over the place. They travel from the entrance to radiology to outpatient to emergency room. I have not really found any research that has addressed the problem of are they transmitting diseases? Because we dont have any policies to clean them in between patients.

In terms of inside the outpatient setting, in the rooms where patients are placed, there are standard procedures that we do in terms of the examination table; there are procedures for cleaning all those inbetween patients, or the use of disposable linings to prevent any transmission. If there are endoscopes being used on that outpatient basis, we follow CDC guidelines as far as cleaning those. We have our policies and procedures in place in terms of cleaning, disinfection and sterilization, which have been in policy for several years. Im not sure if it has become easier or harder; its just one of those things that have to be done, Santos says. The problem is that whether [the outpatient department is] busy or not busy, you still have to follow the policies and procedures in terms of the isolation guidelines and the procedures in cleaning the physical environment where the patient has been and then in the disinfection and cleaning of equipment that has been used.

I think cleaning is different for outpatient departments in some instances because of the high traffic and high turnover, says Nancy Kupka, DNSc, MPH, RN, associate project director in the division of Standards and Survey Methodology for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). If they have good processes in place, it should not be more difficult for them. They should have planned to accommodate that.

Kupka observes, What I have seen (where organizations are struggling) is that there are sterilizers throughout the organization, and just keeping tabs on where those sterilizers are can be very difficult. Not to say its not done and done well by some, but that seems to be where some organizations have fallen down. I went to a lecture given by some infection control professional in a large hospital system. She said, We have five hospitals, and I decided to look at every sterilizer, and it took her several weeks to see every sterilizer. They found them in physicians offices, clinics, and its hard to keep track. If the organization has a good inventory of their equipment, it shouldnt be difficult. But if they dont have a good inventory, then it is.

Although hospitals and ambulatory facilities are accredited under different wings of JCAHO, the standards are the same, Kupka says. The standards are not different from center to center or from outpatient to inpatient.

JCAHO has just revamped its infection control standards for ambulatory and hospital care, among other programs, and has provided a prepublication of the revisions online; the standards will go into effect in January 2005. They can be viewed at

Resistant Bugs

Vancomycin-resistant enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) have become a concern for hospitals, but outpatient departments see so many patients that there may be more of an opportunity for these organisms to be introduced from the community.

Thats a very interesting subject these days, because all the literature is showing that MRSA is definitely there, Rearick says. Common practice is not to culture every patient, and theres not a rapid test. Before patients go into an exam room, you dont scan them like at the airport, to see whos colonized with what. You just dont know. Thats the beauty of consistent application of standard universal precautions. [Prevention of MRSA and VRE] is not so much to avoid needlestick injuries or blood exposure; its really good handwashing between patients and that surface wiping if theres reason to believe theres been actual soilage. You might hear some people say, We keep a list of our MRSA patients or VRE patients, and there are pros and cons to that. If you have a list, its important that the staff understands that list only identifies known individuals that for every person known to be colonized with MRSA, there may be X number of other patients that are also colonized; you just dont know it at the time.

Enforcing standard precautions across the board, Rearick says, empowers people to not be in a reactionary position. Im also practicing proactively to protect myself, so I dont have to wait for somebody to tell me that the patient has something. It really puts them in the drivers seat. The big challenge is that consistent behavior. Were all human, we all take shortcuts, we all get behind. Were all thinking, That patient looks like they dont have something, so Im going to skip it this time, and thats where people get caught in the crossfire.

Mathews says, Certainly everybody is concerned about MRSA and VRE. We clearly know that there is more MRSA in the community. If you look on the CDC Web site you can find that there have been community outbreaks associated with healthy young people who play sports. Theyre absolutely non-related to healthcare at all, so we do know that people can pick up these organisms on the outside as well. We teach people to treat all blood and body fluids or open draining wounds as if they are infectious, because youre not going to know whos got MRSA in that wound they acquired while out playing football.

Youre aware of the community-acquired MRSA, and also we always have the threat of SARS and respiratory illnesses that have global implications and also local implications, says Santos. The question is, how do we clean, sterilize and disinfect, and is it easier or harder? Those kinds of questions are difficult to address, because I have not really seen good studies in outpatients in terms of how the cleaning/disinfection/ sterilization actually contributes to transmission of illnesses in the outpatient setting.

Of course, MRSA and VRE are a concern. To me, its not clear how this has been acquired, Santos says. We know that community acquired MRSA is a different organism than the ones found in the institution. They have different antibiotic susceptibility. My suspicion is that community- acquired MRSA grew out of the community use of antibiotics, as compared with the hospital use of antibiotics. In an outpatient setting, it is difficult to know for sure who has it and who doesnt have community-acquired MRSA. VRE in our local area has not been so much of a problem in the outpatient setting; it remains a hospital, nursing home, long-term care facility kind of problem. Our rates are quite low.

I think in most infection control departments in all hospitals, their concentration has been in the inpatient side, and its true that the outpatient setting is lacking, Santos says. I do believe that the emphasis has really been more on the inpatient because the regulatory agencies that oversee our activities in infection control do put the greater emphasis on the inpatient side maybe because the patients are more critical. At least, the perception is that were not seeing huge transmissions of illnesses in the outpatient setting, probably because their visit is so transient. Inpatients are sick, their stays can be several days long, and more procedures are done to them, so then they have a much higher chance of acquiring nosocomial infection or colonization. In general, people who come through the outpatient setting are healthier, so theyre less prone to acquiring infections. Theyre not taking the broad-spectrum antibiotics that inpatients are. So then maybe the feeling is, We can relax our emphasis on that area, rather than on the inpatients. However, Santos cautions, Are there studies out there to back up these statements? Not that Im aware of.

Severe Acute Respiratory Syndrome (SARS) has changed the equation a lot in the outpatient setting, Santos observes. [One transmission] in Toronto occurred from a patient who came from China and transmitted it in the waiting room. Can we provide someone with respiratory illness a separate room from people otherwise visiting physicians? Thats very difficult to answer, because a lot of outpatient settings do not have the luxury of separate rooms, let alone a waiting room.

When asked whether community-acquired MRSA or VRE is a greater concern for outpatient departments, Kupka replies, I actually get asked this quite often, not specifically for MRSA or VRE, but people ask, Now is this a greater concern in physicians offices? It always has been a concern. Whether its a greater concern, I dont think anybody knows. You start out with the supposition that you can always transmit disease, so thats why they have standard precautions, universal precautions, etc.

Kupka continues, Now that weve gone through SARS, monkeypox, etc. ... many people said Outpatient centers poo-poo; everybodys going to run to the hospital. Well, thats just not true. People are going to see their physicians and people are going to outpatient clinics with the same kind of problems, so one cannot turn a blind eye to the kind of risk that entails.


At the UCSF Medical Center, some outpatient departments send out their reprocessing to the main hospital campus; several departments, however, have their own steam sterilizers. We have approximately 96 ambulatory practices associated with UCSF. Thats why we had to standardize things, so we dont have people off doing their own thing, Mathews explains. We make rounds once a year. Basically, its my job to visit all of them at least one time, and make sure they are following the procedures. Theres a checklist that includes looking at all the appropriate parameters to make sure their practice is correct. Theyre aware that theres an infection control practitioner available by pager, 24 hours a day, seven days a week, so they can always reach somebody if they have a question. The policies and procedures are also online. The terminals are all over. When we make rounds, we ask the healthcare workers, Show me the icon for the infection control manual and show me how to use it. So they have to demonstrate they know how to get into the Web site. Its no good if we put these great policies up there and nobody knows how to get to them.

The UCSF Medical Center first implemented these competencies for the ambulatory areas several years ago, when Mathews transferred from inpatient to outpatient services. Does everybody do that everywhere? I dont know. They dont let me out much, she says. I would suspect most people do something like that. I dont know that all hospitals have an infection control person dedicated to the outpatient practices for a portion of the time. Theres more and more focus on the importance of infection control in ambulatory services, because more and more procedures are going to ambulatory, so weve made it a focus within our department to look at infection control in our ambulatory practices because there are so many of them.

A hospital typically will have an infection control officer and a central sterile department, so typically, there is a better understanding of infection control sterilization issues. From an educational standpoint, its going to be better in a hospital, observes Philip Coles, president of PCI Medical. PCI Medical provides a range of fume hoods that are instrument- specific.

These instrument-specific hoods are found in outpatient departments, says Coles. Theyre also found in doctors offices, too, in some cases. This is really what makes them different; they are designed for single, small instruments. The smallest hood we make is 10 inches wide, for a transvaginal ultrasound probe. By definition, the probe is long and narrow, so what you need is a narrow machine.

Reprocessing off-site can be a tremendous financial investment, Coles points out. I am aware of some situations where they would take a scope or an internal ultrasound and have someone pick it up by courier in a bag, take it across to the hospital, where they would collect them and bring them back to central sterile. The cost of doing that is ridiculous, which is why we encourage people to have a machine at the point of use; then they dont need to have this ridiculous system of sending it off. Once that instruments out of your facility, you need to have another to replace it; you end up having to buy more instruments and some of those instruments are very expensive.

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