Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care
Note to Readers
The following document is a summary guide of infection prevention recommendations for outpatient (ambulatory care) settings. The recommendations included in this document are not new but rather reflect existing evidence-based guidelines produced by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. This summary guide is based primarily upon elements of Standard Precautions and represents the minimum infection prevention expectations for safe care in ambulatory care settings. Readers are urged to consult the full guidelines for additional background, rationale, and evidence behind each recommendation. All guidelines are available at: Guidelines and Recommendations
The transition of healthcare delivery from acute care hospitals to outpatient (ambulatory care) settings, along with ongoing outbreaks and patient notification events, have demonstrated the need for greater understanding and implementation of basic infection prevention guidance. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care (includes an Infection Prevention Checklist, Appendix A) [PDF - 680 KB] distills existing infection prevention guidance from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
Over the past several decades, we have witnessed a significant shift in healthcare delivery from the acute, inpatient hospital setting to a variety of ambulatory and community-based settings. Ambulatory care is provided in hospital-based outpatient clinics, nonhospital-based clinics and physician offices, ambulatory surgical centers, and many other specialized settings. Americans have frequent encounters with ambulatory care. For example, more than three-quarters of all operations in the United States are performed on an outpatient basis. In addition, between 1995 and 2007, the average person made three visits each year to physician offices. By 2007, the total number of physician offices visits approached one billion. Vulnerable patient populations rely on frequent and intensive use of ambulatory care to maintain or improve their health. For example, each year more than one million cancer patients receive outpatient chemotherapy, radiation therapy, or both. It is critical that all of this care be provided under conditions that minimize or eliminate risks of healthcare-associated infections (HAI).
Compared to inpatient acute care settings, ambulatory care settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities[5,6,7]. While data describing risks for HAI are lacking for most ambulatory settings, numerous outbreak reports have described transmission of Gram-negative and Gram-positive bacteria, mycobacteria, viruses, and parasites [8,9] . In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures (e.g., reuse of syringes leading to transmission of bloodborne viruses).
All healthcare settings, regardless of the level of care provided, must make infection prevention a priority and must be equipped to observe Standard Precautions. The 2007 CDC and HICPAC Guideline for Isolation Precautions was a first attempt to provide recommendations that can be applied in all healthcare settings. The Guide presented here is based primarily upon elements of Standard Precautions from that guideline and represents the minimum infection prevention expectations for safe care in ambulatory care settings. It is intended for use by anyone needing information about general infection prevention measures in ambulatory care settings.
For the purposes of this document, ambulatory care is defined as care provided in facilities where patients do not remain overnight (e.g., hospital-based outpatient clinics, non-hospital based clinics and physician offices, urgent care centers, ambulatory surgical centers, public health clinics, imaging centers, oncology clinics, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers). Healthcare personnel (HCP) are defined as all persons, paid and unpaid, working in ambulatory care settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. This includes persons not directly involved in patient care (e.g., clerical, house-keeping, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. This document does not replace existing, more-detailed guidance for hemodialysis centers or dental practices. Further, the reader is referred to other CDC and HICPAC guidelines and websites for more detailed information and for recommendations concerning specialized infection prevention issues (e.g., sterilization and disinfection of equipment, multi-drug resistant organisms).
By highlighting existing CDC and HICPAC recommendations, this summary guide: 1) provides basic infection prevention recommendations for outpatient (ambulatory care) settings; 2) reaffirms Standard Precautions as the foundation for preventing transmission of infectious agents during patient care in all healthcare settings; 3) provides links to full guidelines and source documents, which readers can reference for more detailed background and recommendations.