2012 IC UpdateSeminar IC Ambulatory Setting

7/30/2019 2012 IC UpdateSeminar IC Ambulatory Setting

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Infection Control inAmbulatory Care Settings

Linda Henderson

Infection Control Nurse Advisor

Infection Control Service, CDCB


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Objectives

> Identify infection risks associated withproviding health care in ambulatory caresettings

> Identify general infection control principlesof management in hospital ambulatorydepartments


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Ambulatory Care definition

> Facilities that provide health care topatients who do not remain overnight (e.g.hospital-based outpatient clinics,

radiology/imaging clinics, medical officesetc.)

CDC Management of multidrug-resistant organisms in healthcaresettings. 2006


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Implication for Infection Control

Infection control & changing health care deliverysystems. Jarvis W.R. Emerging Infectious Diseases,vol.7, No.2, March-April 2001

> Instead of the acute-care facility being the centre ofthe infection control universe, the infection controldepartment has become the centre of the diversehealth-care delivery system.

> Infection control departments will need to expand

their surveillance of infections and adverse eventsand their prevention efforts to all settings in whichhealth care is delivered.


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What are the HAI risks?

2008 2009 2010 2011

Cardiac surgery 5.8 10.2 12.7 8.9

Cardiology 3.9 3.4 3.3 2.8

Gastroenterology 7.2 5.2 7.7 7.2

General medicine 2.2 2.9 3.4 3.1

General surgery 7.0 7.1 9.2 7.7

Gynae/Obstetrics 1.4 1.4 1.3 1.0

Haematology/oncology 21.5 21.7 27.9 29.8

Neonatology 7.6 7.3 10.3 7.0

Nephrology 2.8 8.6 7.1 6.8

Neurosurgery 4.3 6.8 4.2 4.8

Orthopaedic 2.0 2.5 2.1 2.4

Other specialties* 1.7 1.6 1.4 0.9Other surgical specialties 4.8 4.6 4.5 4.6

Paediatric Haematology/oncology 48.8 70.1 48.8 30.1

Paediatric medicine 7.9 10.9 11.1 1.6

Paediatric surgery 5.7 14.9 10.2 6.6

Vascular 7.5 6.8 3.2 8.7

CLINICAL UNITrate per 10,000 patient days

The highest rateof blood streaminfections (BSI)episodes occursin haematology/

oncologypatients (adultand paediatric),mainly due to theincreased risk ofinfection in thispatient group.

Source: ICS HCAI BSI report (2006-2011)


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Sources of bloodstream infection

Source: ICS HCAI BSI report (2006-2011)


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What is the relevance forambulatory care?

> How many patients are known to have acommunicable disease or multi-resistantorganism?

Known patients

Unknown patients


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What is the relevance forambulatory care?

> Risk-based approach

> What are the activities conducted in theambulatory setting?

Consult

Wound management

Insertion of invasive devices

Administration of medication (IV)

> What does the literature state?


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CDC Management of multidrug-resistantorganisms in healthcare settings. 2006

> In ambulatory settings, use standardprecautions for patients known to beinfected or colonised with target MDROs,making sure that gloves and gowns areused for contact with uncontrolledsecretions, pressure ulcers, drainingwounds, stool incontinence, and ostomytubes & bags (page 39)

Category II suggested for implementation and supported bysuggestive clinical or epidemiologic studies or a theoreticalrationale.


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Guide to infection prevention in outpatientsettings: minimum expectations for safe careCDC May 2011

> Surveillance for outcome measureschallenging

> Surveillance for adherence to specificprocess measures

> Adhere to local, state & federalrequirements

> Perform regular audits & competencyevaluations of HCW adherence to ICpractices


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Guide to infection prevention in outpatientsettings: minimum expectations for safe care(cont.)CDC May 2011

> Standard Precautions

Hand hygiene

PPE

Injection safety

Aseptic technique

Environmental cleaning

Equipment cleaning/sterilising

Reusable medical equipment e.g. glucometers &other point of care devices

Endoscopes, naso-endoscopes etc.

> Respiratory hygiene


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Guide to infection prevention in outpatientsettings: minimum expectations for safe careCDC May 2011 (cont.)

> Additional considerations:

Transmission-based precautions not easilyadapted in ambulatory settings, thereforeconsideration should be given to specific

syndromes of diagnostic uncertainty e.g.diarrhoea, febrile respiratory illness, febrile rash

Systems for early detection & management e.g.prompt placement into a room, PPE

> Risk assessment of patient & procedure

Patients symptoms

Invasiveness of procedure


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Infection: prevention & control of healthcare-associated infections in primary & communitycare. NICE 2012

> Primary care settings i.e. general practice,dental clinics, health centres & polyclinics.(as well as ambulance, and communityresidential care settings)

> Focuses on high riskprocedures i.e.insertion of invasive devices (urinarycatheters, vascular access devices, woundmanagement, administering IV

medications)> Education of patients & carers

National Institute for Health & ClinicalExcellence (NICE)


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Other studies / articles

> Limited studies relating tooutpatient/ambulatory setting

Italian study: Infection control in the outpatientsetting: Sanson D, Taurlli S et al, Igiene eSanita Pubblica[2007, 63(5):587-598]

> Associated with lack of, or insufficientadherence to, evidence-based preventivemeasures


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What are the risks summarisedfrom the literature?

> Risk-based approach

> Undiagnosed communicable diseases e.g.influenza, gastroenteritis

> SSI inadequate hand hygiene & aseptictechnique for post operative wound care

> BSI inadequate preparation & insertion(aseptic technique, hand hygiene) of intra-vascular devices (PICC)

> Inadequately reprocessed reusablemedical equipment


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Solutions as per CDC ambulatorycare document

> Standard precautions Hand hygiene

Staff adequate placement of ABHR & sinks

ABHR for patients on entry

Signage on entry for patients (for respiratorysymptoms) & family

> Ensure that one person with infectioncontrol training is available to the area

> Develop policies & procedures relevant tothe area & services

> Surveillance on process measures ratherthan outcome i.e. audit compliance withprocedures


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Solutions/suggestions as per ICS

> Infection control champion in theambulatory area

> Pay attention to general hygiene &respiratory signage on entry for all patients

> ABHR on entry patients & staff

> Focus interventions where high riskprocedures are conducted e.g.treatment/procedural rooms

Aseptic technique

Hand hygiene


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Solutions as per ICS (cont.)

> Process surveillance e.g. auditing staffcompliance with:

Hand hygiene

Aseptic technique

Cleaning of shared patient equipment Correct reprocessing of reusable medical

equipment

> Symptom-based infection control e.g.

identify patients with diarrhoea, vomiting,respiratory symptoms (fever, cough), fever& rash apply TBP


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References> Siegel J, Rhinehart E, Jackson M, et al. Management of

Multidrug-Resistant Organisms in Healthcare Settings:

Centers for Disease Control and Prevention. 2006.

> Centers for Disease Control & Prevention (CDC) & theHealthcare infection Control Practices Advisory Committee(HICPAC). Guide to infection prevention in outpatientsettings: minimum expectations for safe careCDC May

2011> Jarvis W.R. Infection control & changing health care

delivery systems. Emerging Infectious Diseases, vol.7,No.2, March-April 2001

> Friedman C, Peterson K. Infection control in AmbulatoryCare. 2004

> Sanson D, Taurlli S et al.Infection control in the outpatientsetting: Igiene e Sanita Pubblica. 2007, 63(5):587-598

> National Institute for Health & Clinical Excellence.Prevention & control of healthcare-associated infections inprimary & community care. 2012


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Other studies / articles/ books

Infection control in Ambulatory Care.Friedman C, Peterson K. 2004

> Detailed book

> Good tools and resources for surveillance


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Questions????

Documents

2012 IC UpdateSeminar IC Ambulatory Setting