Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
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An estimated 1.5 million new cases of cancer were diagnosed in the United States in 2010 . With improvements in survivorship and the growth and aging of the U.S. population, the total number of persons living with cancer will continue to increase . Despite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients [3-5]. Increased risks for infection are attributed, in part, to immunosuppression caused by the underlying malignancy and chemotherapy. In addition patients with cancer come into frequent contact with healthcare settings and can be exposed to other patients in these settings with transmissible infections. Likewise, patients with cancer often require the placement of indwelling intravascular access devices or undergo surgical procedures that increase their risk for infectious complications. Given their vulnerable condition, great attention to infection prevention is warranted in the care of these patients.
In recent decades, the vast majority of oncology services have shifted to outpatient settings, such as physician offices, hospital-based outpatient clinics, and nonhospital-based cancer centers. Currently, more than one million cancer patients receive outpatient chemotherapy or radiation therapy each year . Acute care hospitals continue to specialize in the treatment of many patients with cancer who are at increased risk for infection (e.g., hematopoietic stem cell transplant recipients, patients with febrile neutropenia), with programs and policies that promote adherence to infection control standards. In contrast, outpatient oncology facilities vary greatly in their attention to and oversight of infection control and prevention. This is reflected in a number of outbreaks of viral hepatitis and bacterial bloodstream infections that resulted from breaches in basic infection prevention practices (e.g., syringe reuse, mishandling of intravenous administration sets) [7-10]. In some of these incidents, the implicated facility did not have written infection control policies and procedures for patient protection or regular access to infection prevention expertise.
A. Intent and Implementation
This document has been developed for outpatient oncology facilities to serve as a model for a basic infection control and prevention plan. It contains policies and procedures tailored to these settings to meet minimal expectations of patient protections as described in the CDC Guide to Infection Prevention in Outpatient Settings. The elements in this document are based on CDC’s evidence-based guidelines and guidelines from professional societies (e.g., Oncology Nursing Society).
This plan is intended to be used by all outpatient oncology facilities. Those facilities that do not have an existing plan should use this plan as a starting point to develop a facility-specific plan that will be updated and further supplemented as needed based on the types of services provided. Facilities that have a plan should ensure that their current infection prevention policies and procedures include the elements outlined in this document. While this plan may essentially be used exactly “as is,” facilities are encouraged to personalize the plan to make it more relevant to their setting (e.g., adding facility name and names of specific rooms/locations; inserting titles/positions of designated personnel; and providing detailed instructions where applicable).
This plan does not replace the need for an outpatient oncology facility to have regular access to an individual with training in infection prevention and for that individual to perform on-site evaluation and to directly observe and interact regularly with staff. Facilities may wish to consult with an individual with training and expertise in infection prevention early on to assist with their infection control plan development and implementation and to ensure that facility design and work flow is conducive to optimal infection prevention practices.
B. Aspects of Care That Are Beyond the Scope of This Plan
This model plan focuses on the core measures to prevent the spread of infectious diseases in outpatient oncology settings. It is not intended to address facility-specific issues or other aspects of patient care such as:
- Infection prevention issues that are unique to blood and marrow transplant centers (a.k.a. bone marrow transplant or stem cell transplant centers)
- Occupational health requirements, including recommended personal protective equipment for handling antineoplastic and hazardous drugs as outlined by the Occupational Safety and Health Administration and the National Institute for Occupational Safety
- Appropriate preparation and handling (e.g., reconstituting, mixing, diluting, compounding) of sterile medications, including antineoplastic agents
- Clinical recommendations and guidance on appropriate antimicrobial prescribing practices and the assessment of neutropenia risk in patients undergoing chemotherapy
For more information on these topics, refer to the list of resources provided in Appendix D of the plan.
- American Cancer Society. Cancer Facts & Figures 2010 Tables & Figures.
- Warren JL, Mariotto AB, Meekins A, Topor M, Brown ML. Current and future utilization of services from medical oncologists. J Clin Oncol 2008;26:3242−7.
- Kamboj M, Sepkowitz KA. Nosocomial infections in patients with cancer. Lancet Oncol 2009;10:589−97.
- Maschmeyer G, Haas A. The epidemiology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008;31:193−7.
- Guinan JL, McGuckin M, Nowell PC. Management of health-care−associated infections in the oncology patient. Oncology 2003;17:415−20.
- Halpern MT, Yabroff KR. Prevalence of outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest 2008;26:647−51.
- Macedo de Oliveria A, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. Ann Intern Med 2005;142:898−902.
- Watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck E, et al. Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. Arch Intern Med 2005;165:2639−43.
- Greeley RD, Semple S, Thompson ND, High P, Rudowski E, Handschur E et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control 2011 Jun 8. Epub ahead of print.
- Herndon E. Rose Cancer Center shut down; patients advised to get screening. Enterprise-Journal. July 31, 2011. Accessed September 9, 2011