Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care
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Fundamental elements needed to prevent transmission of infectious agents in ambulatory care settings
Dedicate Resources to Infection Prevention (Administrative Measures)
Infection prevention must be made a priority in any setting where healthcare is delivered. Those with primary administrative oversight of the ambulatory care facility/setting must ensure that sufficient fiscal and human resources are available to develop and maintain infection prevention and occupational health programs. This includes the availability of sufficient and appropriate equipment and supplies necessary for the consistent observation of Standard Precautions, including hand hygiene products, injection equipment, and personal protective equipment (e.g., gloves, gowns, face and eye protection).
Infection prevention programs must extend beyond Occupational Safety and Health Administration (OSHA) bloodborne pathogen training to address patient protection. Facilities should assure that at least one individual with training in infection prevention is employed by or regularly available to the facility. This individual should be involved in the development of written infection prevention policies and have regular communication with HCP to address specific issues or concerns related to infection prevention. The development and ongoing refinement of infection prevention policies and procedures should be based on evidence-based guidelines, regulations, or standards. These policies and procedures should be tailored to the facility and re-assessed on a regular basis (e.g., annually), taking into consideration the types of services provided by the facility and the patient population that is served. This process (referred to as risk assessment by the Infection Prevention profession) will allow facilities to better prioritize resources and focus extra attention on those areas that are determined to pose greater risk to their patients. For example, an ambulatory surgical center, which performs on-site sterilization of surgical equipment, would be expected to have more detailed policies regarding equipment reprocessing than a substance abuse clinic, where on-site sterilization is unlikely to be performed. However, both facilities should have policies and procedures addressing handling of reusable medical equipment. Similarly, a clinic primarily serving patients infected with tuberculosis will have infection prevention needs beyond those of a general pediatric office.
Facility administrators should also assure that facility policies and procedures address occupational health needs including vaccination of HCP, management of exposures or infections in personnel requiring post-exposure prophylaxis and/or work restrictions, and compliance with OSHA bloodborne pathogen standards. Recommendations for prevention of infections in HCP can be found in the following documents: Guideline for infection control in healthcare personnel [PDF - 1.05 MB], Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization, and OSHA Bloodborne Pathogens and Needlestick Prevention.
Key administrative recommendations for ambulatory care settings:
- Develop and maintain infection prevention and occupational health programs
- Assure sufficient and appropriate supplies necessary for adherence to Standard Precautions (e.g., hand hygiene products, personal protective equipment, injection equipment)
- Assure at least one individual with training in infection prevention is employed by or regularly available to the facility
- Develop written infection prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations, or standards
Educate and Train Healthcare Personnel
Ongoing education and training of HCP are critical for ensuring that infection prevention policies and procedures are understood and followed. Education on the basic principles and practices for preventing the spread of infections should be provided to all HCP. Training should include both HCP safety (e.g., OSHA bloodborne pathogen training) and patient safety, emphasizing job- or task-specific needs. Education and training should be provided upon orientation to the facility and should be repeated regularly (e.g., annually) to maintain competency, including anytime policies or procedures are updated/revised. Competencies should be documented initially and as appropriate for the specific HCP positions.
Key recommendations for education and training of healthcare personnel in ambulatory care settings:
- Provide job- or task-specific infection prevention education and training to all HCP
- This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility
- Training should focus on principles of both HCP safety and patient safety
- Training should be provided upon orientation and repeated regularly (e.g., annually)
- Competencies should be documented initially and repeatedly, as appropriate for the specific HCP positions
Monitor and Report Healthcare-associated Infections
Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. Surveillance typically refers to tracking of outcome measures (e.g., HAIs) but can also refer to tracking of adherence to specific process measures (e.g., hand hygiene, environmental cleaning) as a means to reduce infection transmission. Surveillance for outcome measures in ambulatory care settings is challenging because patient encounters may be brief or sporadic and evaluation and treatment of consequent infections may involve different healthcare settings (e.g., hospitals).
At a minimum, ambulatory care facilities need to adhere to local, state, and federal requirements regarding reportable disease and outbreak reporting. Certain types of facilities (e.g., ambulatory surgical centers) may also be subject to additional HAI surveillance or process measure reporting requirements, for example as part of accreditation, Medicare certification, or state/local statutes. Facilities should check the requirements for their state/region to assure that they are compliant with all regulations and should have contact information for their local and/or state health department available to ensure required reporting is done in a timely manner. (A list of state reportable disease websites is available at the CSTE website.
Regular focused practice surveys or audits (e.g., audits of infection prevention practices including hand hygiene, medication handling and preparation, reprocessing of patient equipment, environmental cleaning) offer a means to assess competencies of HCP as recommended under Education and Training. One example of an audit tool being used by federal surveyors to assess adherence to elements of Standard Precautions in ambulatory surgical centers is available at: Infection Control Surveyor Worksheet [PDF - 667 KB]. An example of an electronic application used to monitor compliance with hand hygiene is available at the Hand Hygiene in Healthcare Settings website.
Key recommendations for HAI surveillance and reporting in ambulatory care settings:
- Adhere to local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting
- Perform regular audits and competency evaluations of HCP adherence to infection prevention practices