Infection Control Today - 05/2004: Clean Slate


Clean Slate
Keeping Outpatient Departments Safe

ByKathy Dix

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

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

Preventing disease transmission in a hospital setting is hardenough. But filling the space with the sick and allowing them to return tothe community after just enough time to be exposed to whatevers in the airand 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 reusableinstruments that require sterilization or high-level disinfection, and asterilization department that may be located miles away. Many OPDs have decidedto 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-partyprocessor.

Do outpatient departments have it harder or easier when itcomes 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 Hospitalin Chicago. I really feel its facility dependent. Its dependent on the inner communications and mechanismsthat an individual hospital with associated ambulatory areas has.

At some places, the ambulatory places sort of feel like thestepchild, she quips. Nobody knows they exist; theyre trying to getproducts and answers and find out what the policies are. But if you have good communication, and youre establishinga systems approach, it should be the same policies across the system, the samecontact 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 roomattached to a hospital or a freestanding clinic a block away or several milesaway, that they have a different issue as far as high traffic and quickturnover. The patients not being admitted; theyre not going to stay there for multiple days. Its in-and-out, because the faster the better, the morerevenue youre going to generate by using those rooms efficiently and quickly.So I really think the high traffic and quick turnover is the biggest challengein ambulatory areas.

Cleaning is a very different beast in outpatient centers, shesays, 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 thenwhen the clinic closes, you can say everybody out, and have the cleaningservice 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: ifIm the patient and going in that exam room, and Im going to take off myclothes, youre going to give me that over gown and theyre going to pullthat piece of paper on the exam surface. If I have not soiled or contaminatedthat surface, they can just change the paper between patients. If itsactually soiled, the question is, whos going to clean it? The practical wayto 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 somethingsoiled] and having a product readily available to use right there. And you get alot of people saying, Thats not really my job, but it is, because yourepreparing that room for the next patient. There are nice products now that areeasy to use. You dont have to have rags and mop heads. The trick becomes thecontact time. Depending on the product choice the organizations making, theyshould look for something that needs a minimum contact time, not 10 minutesbefore 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 andnon-critical instruments is the best approach.

When youre talking about instrument reprocessing, youwould 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 havea freestanding hospital with central supply where they do the instrumentreprocessing, cleaning and packaging and sterilizing, some places will put inplace 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 donthave to have staff in the clinic spending time cleaning, packaging andsterilizing instruments. I dont have to train them, worry about theircompetencies doing that, buying that equipment, doing preventive maintenance onthat equipment and doing the biological indicators and other monitoring ofequipment to make sure its working. My experience has been the more you cancentralize your process, the better, because then you actually have control overthe outcome of that instrument; you dont have 20 different people trying tofigure it out, or fit it into the course of the day when they already have toomuch to do, or letting it sit until the end of the day and then having this pileof yuck that nobody wants to touch.

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

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

The advantage of outpatient as opposed to inpatient issometimes theyre closed down to the patient population, agrees GordonBontrock, director of product development for environmental services for AramarkHealthcare Management Services. That gives us the ability to go into anon-occupied area for cleaning, so its actually easier to move throughclinical areas. The surfaces are different. Spaces are usually clearer.

Bontrock adds, [In OPDs], your environmental services isnot a part of that, so its your clinicians that are taking care ofbetween-case cleaning.

However, Bontrock points out, We practice standardprecautions whether its an outpatient service or whether its inpatientarea. Were using the same cleaning agents. The process of cleaning, the verysystem concept of cleaning is the same. We consider a clinic still a patientarea, and we would treat patient areas the same.

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

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

Rene Santos, MD, an infectious disease specialist and chair ofthe infection control committee at South Suburban Hospital outside Chicago,adds, How do we cope with cleaning, disinfection and sterilization? Forinstance, are there any guidelines with respect to wheelchairs? I have done aliterature search on that, and I have not seen any recommendations that dealspecifically with wheelchairs. Wheelchairs are ubiquitous in the hospital; they are found allover the place. They travel from the entrance to radiology to outpatient toemergency room. I have not really found any research that has addressed theproblem of are they transmitting diseases? Because we dont have any policiesto clean them in between patients.

In terms of inside the outpatient setting, in the roomswhere patients are placed, there are standard procedures that we do in terms ofthe examination table; there are procedures for cleaning all those inbetweenpatients, 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 andprocedures in place in terms of cleaning, disinfection and sterilization, whichhave been in policy for several years. Im not sure if it has become easier orharder; its just one of those things that have to be done, Santos says. The problem is that whether [the outpatientdepartment is] busy or not busy, you still have to follow the policies andprocedures in terms of the isolation guidelines and the procedures in cleaningthe physical environment where the patient has been and then in the disinfectionand cleaning of equipment that has been used.

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

Kupka observes, What I have seen (where organizations arestruggling) is that there are sterilizers throughout the organization, and justkeeping tabs on where those sterilizers are can be very difficult. Not to say itsnot done and done well by some, but that seems to be where some organizationshave fallen down. I went to a lecture given by some infection controlprofessional 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 tosee every sterilizer. They found them in physicians offices, clinics, and itshard 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 itis.

Although hospitals and ambulatory facilities are accreditedunder different wings of JCAHO, the standards are the same, Kupkasays. The standards are not different from center to center or fromoutpatient to inpatient.

JCAHO has just revamped its infection control standards forambulatory and hospital care, among other programs, and has provided aprepublication of the revisions online; the standards will go into effect inJanuary 2005. They can be viewed at

Resistant Bugs

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

Thats a very interesting subject these days, because allthe literature is showing that MRSA is definitely there, Rearick says. Commonpractice is not to culture every patient, and theres not a rapid test. Beforepatients go into an exam room, you dont scan them like at the airport, to seewhos colonized with what. You just dont know. Thats the beauty ofconsistent application of standard universal precautions. [Prevention of MRSAand VRE] is not so much to avoid needlestick injuries or blood exposure; itsreally good handwashing between patients and that surface wiping if theresreason 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 prosand cons to that. If you have a list, its important that the staffunderstands that list only identifies known individuals that for everyperson known to be colonized with MRSA, there may be X number of otherpatients 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 practicingproactively to protect myself, so I dont have to wait for somebody to tell methat 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, soIm going to skip it this time, and thats where people get caught in thecrossfire.

Mathews says, Certainly everybody is concerned about MRSAand VRE. We clearly know that there is more MRSA in the community. If you lookon the CDC Web site you can find that there have been community outbreaksassociated with healthy young people who play sports. Theyre absolutelynon-related to healthcare at all, so we do know that people can pick up theseorganisms on the outside as well. We teach people to treat all blood and bodyfluids or open draining wounds as if they are infectious, because youre notgoing to know whos got MRSA in that wound they acquired while out playingfootball.

Youre aware of the community-acquired MRSA, and also wealways have the threat of SARS and respiratory illnesses that have globalimplications 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 Ihave not really seen good studies in outpatients in terms of how thecleaning/disinfection/ sterilization actually contributes to transmission ofillnesses in the outpatient setting.

Of course, MRSA and VRE are a concern. To me, its notclear how this has been acquired, Santos says. We know that community acquired MRSA is adifferent organism than the ones found in the institution. They have differentantibiotic susceptibility. My suspicion is that community- acquired MRSA grewout of the community use of antibiotics, as compared with the hospital use ofantibiotics. In an outpatient setting, it is difficult to know for sure who hasit and who doesnt have community-acquired MRSA. VRE in our local area has notbeen 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 allhospitals, their concentration has been in the inpatient side, and its truethat the outpatient setting is lacking, Santos says. I do believe that theemphasis has really been more on the inpatient because the regulatoryagencies that oversee our activities in infection control do put the greateremphasis on the inpatient side maybe because the patients are more critical.At least, the perception is that were not seeing huge transmissions ofillnesses in the outpatient setting, probably because their visit is sotransient. Inpatients are sick, their stays can be several days long, andmore procedures are done to them, so then they have a much higher chance ofacquiring nosocomial infection or colonization. In general, people who comethrough the outpatient setting are healthier, so theyre less prone toacquiring infections. Theyre not taking the broad-spectrum antibiotics thatinpatients are. So then maybe the feeling is, We can relax our emphasis onthat area, rather than on the inpatients. However, Santos cautions, Are there studies out there toback up these statements? Not that Im aware of.

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

When asked whether community-acquired MRSA or VRE is a greaterconcern for outpatient departments, Kupka replies, I actually get asked thisquite often, not specifically for MRSA or VRE, but people ask, Now is this agreater concern in physicians offices? It always has been a concern.Whether its a greater concern, I dont think anybody knows. You start outwith the supposition that you can always transmit disease, so thats why theyhave 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 outpatientclinics with the same kind of problems, so one cannot turn a blind eye to thekind of risk that entails.


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

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

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

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

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

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