5 Ways to Improve Infection Prevention in Outpatient Settings

In healthcare, acute care facilities receive a lot of attention for their risk of spreading healthcare-associated infections. However, outpatient settings pose just as significant of a risk. Outpatient facilities are frequented by millions of patients every year for a number of reasons. In fact, more than three-quarters of all operations in the United States are performed in settings outside of a hospital.1 In addition, vulnerable patient populations like cancer patients rely on frequent outpatient care to maintain or improve their health. These patients deserve an emphasis on the reduction of infection risk from their healthcare professionals in outpatient settings just as much as they do from an acute setting.

To ensure that outpatient facilities have efficient guidelines to build infection control plans, the Centers for Disease Control and Prevention (CDC) published the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care with the Healthcare Infection Control Practices Advisory Committee. In the document, the CDC outlines multiple standard precautions that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. Today, we’re going to cover all five of these standard precautions: hand hygiene, personal protective equipment, injection safety, environmental cleaning and respiratory hygiene/cough etiquette.

According to the World Health Organization (WHO), hands are the main pathways of germ transmission during healthcare; therefore, “hand hygiene is the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections.”2

Like other healthcare settings, those who work in outpatient environments have access to two forms of hand hygiene: alcohol-based hand rubs (ABHR) and soap and water. Based on the recommendations of the CDC and WHO, alcohol-based hand rubs should be utilized as the primary method of hand hygiene. Why?

ABHRs have elevated activity against a broad spectrum of pathogens, and compared to soap and water, the use of ABHR can increase compliance with recommended hand hygiene practices by requiring less time, facilitating hand hygiene at the patient bedside and less irritation of the hands.1 Skin irritation or damaged skin in healthcare settings has been known to be identified as loosely-packed skin cells that are void of lipids, commonly caused by the overuse of traditional handwashing. This is because soap is a rinse-off product, which can strip away the skin’s oils and lipids. ABHRs, on the other hand, are leave-on products and do not physically remove skin lipids. They can even contain conditioners and emollients which can benefit skin health.

There are, however, two cases in which soap and water are the preferred method of hand hygiene in an outpatient healthcare setting: when hands are visibly soiled (ex. blood, body fluids) or after caring for patients with known or suspected Clostridium difficile or norovirus during an outbreak. Otherwise, use an ABHR!1

Making hand hygiene a consistent routine is a staple in infection prevention and patient safety. Use the following recommendations from the CDC for where and when hand hygiene is essential, and learn more about how to properly perform hand hygiene and the 5 Moments for Hand Hygiene in Outpatient Settings from the WHO:1

• Before contact with a patient
• Before performing an aseptic task
• After contact with the patient or objects in the immediate vicinity
• After contact with blood, body fluids or contaminated surfaces
• If hands will be moving from a contaminated-body site to a clean-body site
• After removal of personal protective equipment

Complete guidance on hand hygiene can be found in the CDC’s Guideline for Hand Hygiene in HealthCare Settings.

The CDC defines personal protective equipment as “wearable equipment that is intended to protect healthcare professionals from exposure to or contact with infectious agents.”1 In outpatient settings, PPE can include gloves, gowns, face masks, goggles and more.

PPE protects healthcare professionals from coming in contact with potentially infectious hazards such as blood or body fluids, but it also protects the patient from contracting infections through mucous membranes, non-intact skin or other areas of the body. Because different facilities perform different procedures, PPE should be selected and stocked on an individual basis, and appropriate selection can be informed by the CDC’s Guideline for Isolation Precautions. Remember: hand hygiene should be performed immediately after removing any PPE!

The CDC recommends the use of PPE in outpatient settings in these cases:1

• Wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment.
• Do not wear the same pair of gloves for the care of more than one patient.
• Do not wash gloves for the purpose of reuse.
• Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.
• Do not wear the same gown for the care of more than one patient.
• Wear mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids.

“Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare provider during preparation and administration of parenteral medications.”1

Without diligence and patience from healthcare professionals, a simple shot can turn into a much larger problem for a patient. According to the CDC, instances of unsafe injection practices have been shown to lead to infections or outbreaks in outpatient settings, which include the use of a single syringe, with or without the same needle, to administer medication to multiple patients; reinsertion of a used syringe, with or without the same needle, into a medication vial or solution container to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients; preparation of medications in close proximity to contaminated supplies or equipment and failure to wear a face mask when placing a catheter or injecting material into the epidural or subdural space.1

The CDC has partnered with the Safe Injection Practices Coalition to create the One & Only Campaign, a movement aimed at eliminating unsafe medical injections and increasing infection prevention in healthcare settings. While you can find more best practices, in-depth training materials and other resources at their website, follow these do’s and don’ts as a good start to safer injections:1

DON’T

• Administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing
• Reuse a syringe to enter a medication vial or container.
• Administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient.
• Use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient

DO

• Use aseptic technique when preparing and administering medications.
• Cleanse the access diaphragms of medication vials with alcohol before inserting a device into the vial.
• Dedicate multidose vials to a single patient whenever possible
• Dispose of used sharps at the point of use in a sharps container that is closable, puncture-resistant and leak-proof.
• Wear a face mask when placing a catheter or injecting material into the epidural or subdural space

Think of environmental cleaning like an extension of hand hygiene. When you look at the chain of infection, you know that hands pick up germs from surfaces, and then those hands carry the germs to cross contaminate other surfaces or people. Therefore, if healthcare professionals are not cleaning surfaces and only washing hands, they won’t fix the root of the problem and will keep spreading pathogens.

Environmental surfaces in outpatient settings should be regularly disinfected as a part of an established infection prevention protocol. It’s important to note that, while it’s easy to identify and clean surfaces with visible soil, frequently touched surfaces that carry microorganisms should be emphasized for regular disinfection, like medical devices (blood pressure cuffs, stethoscopes, X-ray machines) and environmental surfaces (door knobs, beds and chairs, carts).

In an outpatient facility, surface disinfection is everyone’s responsibility. The CDC offers these five best practices, and also offers full guidance for the cleaning and disinfection of environmental surfaces, including for cleaning blood or body substance spills, in the Guidelines for Environmental Infection Control in Healthcare Facilities and the Guideline for Disinfection and Sterilization in Healthcare Facilities:1

• Responsibility for routine cleaning and disinfection of environmental surfaces should be assigned to appropriately trained healthcare professionals.
• Cleaning procedures should be periodically monitored or assessed to ensure that they are consistently and correctly performed.
• Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in the facility.
• Policies and procedures should also address prompt and appropriate cleaning and decontamination of spills of blood or other potentially infectious materials.
• Select EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare.
• Disinfectant products should not be used as cleaners unless the label indicates the product is suitable for such use.
• Follow manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (ex. amount, dilution, contact time, safe use and disposal).

Finally, reception and triage areas pose a risk for the spread of infection before patients even enter the clinical area of an outpatient facility. The act of coughing can quickly spread germs on a patient’s skin and the surfaces surrounding\ the patient, increasing the risk that another patient or healthcare professional contracts the germs. This can be contained through the education of proper respiratory hygiene and cough etiquette, and can be accomplished by following a few guidelines:1

• Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the duration of the visit.
• Post signs at entrances with instructions to patients with symptoms of respiratory infection to:
• Inform HCP of symptoms of a respiratory infection when they first register for care
• Cover their mouths/noses when coughing or sneezing
• Use and dispose of tissues
• Perform hand hygiene after hands have been in contact with respiratory secretions.
• Provide tissues and no-touch receptacles for disposal of tissues.
• Provide resources for performing hand hygiene in or near waiting areas.
• Offer masks to coughing patients and other symptomatic persons upon entry to the facility, at a minimum, during periods of increased respiratory infection activity in the community.
• Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care.
• Educate healthcare professionals on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens.

Standard precautions during patient care are the main line of defense against healthcare-associated infections, but there are a few other critical components of infection prevention that outpatient clinics can utilize to establish the structures in which healthcare professionals, administrative professionals and other staff members can control the transmission of germs.

• Dedicate Resources to Infection Prevention (Administrative Resources)

Develop and maintain infection prevention and occupational health programs. Assure the availability of sufficient and appropriate supplies necessary for adherence to standard precautions and make sure at least one individual with training in infection prevention is employed by or regularly available to manage the facility’s infection prevention program. Facilities should also develop written infection prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations or standards.1

• Educate and Train Healthcare Personnel

Ongoing education and competency-based training 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, healthcare professional safety and patient safety should be emphasized. Training should be provided upon orientation to the facility and should be repeated annually and anytime policies or procedures are updated/ revised to maintain competency.1

• Monitor and Report Healthcare-Associated Infections

Adhere to local, state and federal requirements regarding healthcare-associated infection surveillance, reportable diseases and outbreak reporting and perform regular audits of adherence to infection prevention practices by staff. You can also educate patients about the symptoms of infection and instruct them to notify the facility if such symptoms occur.1

• Perform a Risk Assessment

Appendix A in the Guide to Infection Prevention for Outpatient Settings is an Infection Prevention Checklist for Outpatient Settings that can be used by outpatient clinics to periodically assess practices in their facility and ensure they are meeting the minimum expectations for safe care.1

As if patient care wasn’t intricate enough, the principles of infection prevention can be time-consuming and easy to forgot or skip over. However, as healthcare professionals, your ultimate job is to protect your patients and save lives. Adhering to these standard precautions and other infection prevention fundamentals will help outpatient facilities reduce the risk of cross contamination and the spread of infection, and might even help improve patient satisfaction scores. For more information about infection prevention, visit the Infection Control Today, CDC Healthcare-Associated Infections and WHO Infection Prevention and Control websites.

Resources:

1. https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf
2. https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf?ua=1