Infection control in the OPD setting (JA Lim) - PHICS 2019

Infection Control in the
Outpatient Setting
Jodor A. Lim MD
PHICS@ 25

OBJECTIVES
• At the end of the session, the participants
should be able
• To understand the problem of infections in the
out patient setting
• To review some of the outbreaks that have
been reported because of infection control
breaches
• To apply principles of infection control in the
outpatient setting

Outline
A. Administrative Recommendation
B. Education and training
C. Surveillance and Reporting
D. Hand hygiene
E. Use of PPE’s
F. Safe injection Practices
G. Contamination of Point of Care Devices
H. Ambulatory Surgical Centers
I. Reuse of dialyzers
J. Processing Endoscopes

The Outpatient Setting
• Shift of services from acute, in patient hospital setting
based to a variety of out patient and community based
setting
• Provided by hospital based out patient clinics, non
hospital based clinics and physician offices, ambulatory
surgical centers and many specialized settings
• US data – more than three fourths of surgery is done
outside hospitals
• Between 1995 to 2007, average person visited clinic
3x/year
• By 2007 – total physician office visit reached 1 billion

The Outpatient Setting
• Each year one million cancer patient receive
outpatient chemotherapy, radiation therapy or
both
• Lack infrastructure and resources to support IC
and surveillance activities
• Outbreaks associated with breakdown in basic
infection prevention
• All healthcare settings must make infection
prevention a priority; must be equipped to
observe Standard Precaution

Definition
• Outpatient care - care provided in facilities where patients do not
remain overnight
• Out patient clinics
– hospital
– free standing
– mall practice
• TB dots
• Dialysis centers
• Endoscopy clinics
• Ambulatory Surgery Centers
• Dental clinics
• Dermatology clinics
• Infusion centers

Definition
• Healthcare personnel (HCP) - all persons, paid
and unpaid, working in outpatient settings

Healthcare-Associated Hepatitis B and C Outbreaks (≥ 2
cases) Reported to the Centers for Disease Control and
Prevention (CDC) 2008-2016
• 61 outbreaks (two or more cases) of viral hepatitis related
to healthcare reported to CDC during 2008-2017; of these,
58 (95%) occurred in non-hospital settings.
• Hepatitis B (total 24 outbreaks including one of both HBV
and HCV, 179 outbreak-associated cases, >10,935 persons
notified for screening):
• 5 outbreaks occurred in other settings, one each at: a free
dental clinic in school gymnasium, an outpatient oncology
clinic, a hospital surgery service, and two at pain
remediation clinics (one outbreak of HBV and one with
both HBV and HCV), with 46 outbreak-associated cases of
HBV and > 8,500 persons at-risk persons notified for
screening

• Hepatitis C (38 total outbreaks including one of both
HBV and HCV , >295 outbreak-associated cases,
>105,632 at-risk persons notified for screening):
• 14 outbreaks occurred in outpatient facilities (including
the above mentioned outbreak of both HBV and HCV),
with 116 outbreak-associated cases of HCV and
>74,457 persons notified for screening
• 21 outbreaks occurred in hemodialysis settings, with
102 outbreak-associated cases of HCV and 3,026
persons notified for screening

A. Key Administrative
Recommendation
1. Develop and maintain infection prevention
and occupational health programs
2. Assure availability of sufficient and
appropriate supplies necessary for adherence
to Standard Precaution (HH products, PPEs,
Injection equipment)

A. Key Administrative
Recommendation
3. Assure at least one individual with training in
IP is employed by or regularly available (eg. by
contract) to manage the facility's IP program
4. Develop written IP policies and procedures
appropriate for the services provided by the
facility and based upon evidence-based
guidelines, regulation, or standards

B. Recommendations for Education
and Training of HCP in Outpatient
Settings:
1. Provide job- or task- specific and training to all
HCP (both contracted or volunteers)
2. Training should focus on principles of both
HCP safety and patient safety
3. Training should be provided upon hire and
repeated annually and when policies or
procedures are updated/revised
4. Competencies should be documented
following each training

C. Recommendation for HAI
Surveillance and Reporting in
Outpatient Settings
1. Educate patients who have undergone
procedures at the facility regarding signs and
symptoms of infection that may be associated
with the procedure and instruct them to notify
the facility if such signs and symptoms occur
2. Adhere to local, state and federal requirements
regarding HAI surveillance, reportable diseases
and outbreak reporting
3. Perform regular audits of HCP adherence to
infection prevention practices

D. Recommendations for Hand
Hygiene in Outpatient Settings
1. Key situations where HH should be
performed
a. before contact with a patient
b. before performing an aseptic task
(preparing an injection)
c. after contact with the patient or objects in
the immediate vicinity of the patient

1. Key situations where HH should be
performed
d. after contact with blood, body fluids or
contaminated surfaces
e. if hands will be moving from a
contaminated- body site to a clean- body site
during patient care
f. after removal of PPEs

2. Use soap and water when hands are visibly
soiled (eg. with blood, body fluids),
Otherwise , the preferred method of HH in
clinical situations is with an alcohol based
hand rub

E. Recommendations for Use of PPE in
Outpatient settings
1. Facilities should assure that sufficient and appropriate
PPE is available and readily accessible to HCP
2. Educate all HCP on proper selection and use of PPE
a. PPE, other than respirators should be removed and
discarded prior to leaving the patient’s room or care
area. If a respirator is used, it should be removed and
discarded (or reprocessed if reusable) after leaving
the patient room or care area and closing the door
b. HH should be performed immediately after
removal of the PPE

E. Recommendations for Use of PPE in
Outpatient settings
3. Wear gloves for potential contacts with blood, body fluids, mucus
membranes, non intact skin or contaminated equipment
a. Do not wear the same pair of gloves for the care of more
than one patient
b. Do not wash gloves for the purpose of reuse
4. Wear a gown to protect skin and clothing during procedures or
activities where contact with blood or body fluids is anticipated
a. Do not wear the same gown for the care of more than one
patient
5. Wear mouth, nose & eye protection during procedure that are
likely to generate splashes or sprays of blood or other
body fluids

F. Recommendations for Safe Injection
Practices in outpatient settings
1. Use aseptic technique when preparing and
administering medications
2. Cleanse the access diaphragms of medication
vials with alcohol before inserting a devise into
the vial
3. Never 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

4. Do not reuse a syringe to enter a medication
vial or solution
5. Do not administer medications from single
dose or
single use vials, ampoules or bags or bottles
of intravenous solution to more than one
patient

Outbreaks and Patient Notification in
Outpatient Settings (CDC)
2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Infection Control Breaches
Surgical
Center
(1)
2014 N/A N/A Yes
(1100)
1. Reuse of syringes to access
medication vials used for >1
patient
2. Failure to properly reprocess
reusable medical equipment
Fox 43. York County surgical center notifies patients of possible Hepatitis & HIV
riskexternal icon

2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Plastic
Surgery
Center
(3)
2014 N/A N/A Yes (415) 1. Reuse of syringes to access
medication vials that may have
been used for >1 patient
Washington State Department of Health. Unsafe Injection Practices at Spokane Clinic
Poses Exposure Risk for Patientsexternal icon

6. Do not use fluid infusion or administration
sets (eg Intravenous tubing) for more than
one patient
7. Dedicate multidose vials to a single patient
whenever possible. If multidose vials will be
used for more than one patient, this should
be restricted to a centralized medication area
and should not enter the immediate patient
treatment area (eg OR, patient cubicle)/

2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Oral
Surgery
(5)
2013 Hep C Hepatitis Yes
(5,810)
1Mishandiling of injectable
medications including reuse of
single dose vials of propofol
2. Improper reprocessing of
dental instruments
Oklahoma State Department of Health. Dental Healthcare-Associated Transmission of
Hepatitis C Final Report of Public Health Investigation and Response, 2013 pdf icon

Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy
clinic—Nevada, 2007. MMWR Morbid Mortal Weekly Rep 2008;57:513–7.)

Dr. Pegues: It is interesting, too, that large bags
of saline are being used for multiple patients to
flush central venous catheters. One of the
assumptions, perhaps, is that intravenous fluid
cannot support microbial growth. In fact,
bacteria can grow and multiply, albeit at
slightly slower rates, in saline solutions.

8. Dispose of used sharps at the point of use in a
sharps container that is closable, puncture
resistant and leak proof

9. Wear a facemask (eg surgical mask) when
placing a
catheter or injecting material into the
epidural or subdural space (eg during
myelogram, epidural or spinal anesthesia).

Cough Etiquette as Part of Standars
Precaution

2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Radiolo
gy
Clinic
(18)
2010 Strepto
coccus
salivarus
Meningit
is
No 1. Healthcare personnel did not
wear facemask when
performing spinal procedures
2. Contents from single dose
vials used for > 1 patient

2010 - 2014
Setting Year
Inves
tigat
ed
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Pain
Manage
ment
Clinic (9)
2012 MRSA Mediasti
nitis,
Meningit
is,
Epidural
Abscess,
Sepsis
No 1. 1. contents from single-dose
vials used for > 1 patient
2. HCPdid not wear facemask
when performing spinal
injetion
Centers for Disease Control and Prevention. Invasive Staphylococcus aureus Infections
Associated with Pain Injections and Reuse of Single-dose Vials – Arizona and Delaware, 2012.
MMWR Morb Mortal Wkly Rep. 2012; 61:501-4.

G. Contamination of equipment,
supplies, and the environment
(⑴)equipment designed for use by a single person (eg, spring-
loaded fingerstick devices; blood glucose meters) was
inappropriately used for multiple patients;
(⑵)equipment used for multiple patients (eg, blood glucose
meters) was not cleaned and disinfected between each use;
and
(⑶)staff failed to wear gloves, change gloves, or perform hand
hygiene for fingerstick procedures..28, 45
Thompson, N.D. and Perz, J.F. . J Diabetes Sci Technol. 2009;3: 283–288
Louie, R.F., Lau, M.J., Lee, J.H. et al. . Point Care. 2005;4: 158–163

2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Health
Fair
(17)
2010 N/A N/A Yes (-60) 1. Same finger stick device used
> 1 patient to obtain blood
samples for blood glucose
monitoring
Thompson ND, Schaefer MK. “Never events”: hepatitis B outbreaks and patient
notifications resulting from unsafe practices during assisted monitoring of blood glucose,
2009-2010external icon. Journal of Diabetes Science and Technology. 2011; 5:1396-1402.

2010 - 2014
Setting Year
Invest
igate
d
Pathogen
(s)
Infection
(s)
Patient
Notificati
on
Perform
ed (#
Notified)
Plastic
Surg
Center
(6)
2013 Non
tuberculo
us
mycobact
eria
Surgical
site
infection
No 1. Off label use of lubricating
gel directly on sterile tissues
2. Reuse of single-use breast
implants
Nguyen DB et al. A Cluster of Surgical Site Infections following Breast Augmentation and
Face Lift Surgeryexternal icon. Plast Reconstr Surg Glob Open. 2014; 2:e156.

Schaefer, et al JAMA. 2010; 303(22):22763-2279

Conclusion
• Of the 68 ASC’s assessed, 67.6% had at least one lapse in infection
control
• Common lapses include using single dose medication vials for more
than one patient (28.1%); failing to adhere to recommended
practices regarding reprocessing of equipment (28.4%); and lapses
in handling of blood glucose monitoring equipment (46.3%)
• More than half (57%) were ultimately cited for deficiencies in IC and
around 30% (29.4)% were cited for deficiencies related to
medication administration, including single dose medications for
multiple patients
• Serious deficiencies as determined by CMS, required a follow up
inspection to check on compliance. Failure to adequately address
and correct citations could result in termination of the ASC’s
participation in the Medicare program.
Schaefer, et al JAMA. 2010; 303(22):22763-2279

• 2017: Two single cases of HCV were identified in two
outpatient hemodialysis units in Philadelphia
(unpublished data, Philadelphia Department of Health)
• 2017: Two single cases of HCV case in two outpatient
hemodialysis units in unidentified single state
(unpublished data)
• 2016: a single HCV case in an outpatient hemodialysis
unit in California (unpublished data, California
Department of Health)
• 2015: 3 single HCV cases in 3 outpatient hemodialysis
units in New Jersey (unpublished data, New Jersey
Department of Health)

Dialysis Related Outbreaks
• Large Hepatitis C Virus Infection Outbreak at an
Outpatient Hemodialysis Facility— Philadelphia,
PA, 2008-2013. Annual CSTE Conference 2014;
June 22-26, 2014; Nashville, TN. Abstract
141Reactivation and
• Transmission of Hepatitis B Virus from an HIV-
Positive Hemodialysis Patient— North Carolina,
2013. 63rd Epidemic Intelligence Service (EIS)
Conference, April 28 – May 1, 2014; Atlanta, GA

Dialysis-Related Outbreaks
Outbreak of bloodstream infections associated with
multiuse dialyzers containing O-rings. Infect
Control Hosp Epidemiol. 2014 Jan;35(1):89-91.
Gram-Negative Bacteremia Outbreak and Dialyzer
Reuse – California, 2013-2014. NKF Spring Clinical
Meeting 2015; March 25-29, 2015; Dallas, TX.
Abstract 183.
Outbreak of Bloodstream Infections at an
Outpatient Dialysis Center— Ohio, 2008. Annual
SHEA Conference 2008; March 19-22, 2009; San
Diego, CA. Abstract 64.

Conclusion
• This outbreak was likely caused by contamination
during reprocessing of reused dialyzers
• Results of this and previous investigation
demonstrates that exposing patients to reused
dialyzers increases the risk for blood stream
infections.
• To reduce infection risks, provider should
consider implementing single dialyzer use
whenever possible

Steps in Dialyzer Reuse
1. The dialyzer is rinsed and cleaned, either by
hand or with a machine. Doing this by machine is
generally safer.
2. The dialyzer is tested to make sure there are no
broken fibers and it is still working.
3. The dialyzer is filled with a germicide (chemical
solution used to kill germs).
4. When the dialyzer is ready for use, the germicide
is rinsed out.
5. The dialyzer is tested to make sure no germicide
is left, and the dialyzer can be used safely.

Reuse of Dialyzers
• Most common germicides are formaldehyde
and peracetic acid
• Reuse is generally considered safe when it is
done properly. All dialysis centers that reuse
dialyzers follow the guidelines developed by
the Association for the Advancement of
Medical Instrumentation (AAMI)..

Reuse of Dialyzers
• Dialyzers should be labeled carefully and always
used for the same patient.
• Dialyzers should be tested after rinsing to make
sure all disinfectants have been removed.
• Patients should be checked for any bad reactions
caused by reuse.
• Dialyzers that are reused should be well-tested
after each use to make sure they are still working
well.

Contamination of equipment, supplies,
and the environment
Failure to adhere to endoscope reprocessing guidelines have been
associated with numerous outbreaks of bacterial infections.58, 59
Reprocessing failures can pose a number of other infectious disease
risks and resulting notifications can have widespread adverse
impacts on patients and their family members.
Recent examples have involved US Department of Veterans Affairs
medical facilities in which over 10,000 patients were notified and
offered bloodborne pathogen testing because they were exposed to
improperly reprocessed endoscopy equipment.63
Health care providers and institutions must ensure that their staff are
appropriately trained in and adhere to recommended endoscope
reprocessing procedures as part of their basic infection control and
patient safety program.57,58, 59, 64
58 ASGE Standards of Practice Committee, Banerjee, S., Shen, B. et al.
Gastrointest Endosc. 2008; 67: 781–790
59 Seoane-Vazquez, E., Rodriguez-Monguio, R., Visaria, J. et al. . Endoscopy. 2007; 39: 742–778
60 Patel, P.R., Srinivasan, A., and Perz, J.F. Am J Infect Control. 2008; 36: 685–690
61 Nelson, D.B. Gastrointest Endosc. 2007; 65: 589–591

Review
A. Administrative Recommendation
B. Education and training
C. Surveillance and Reporting
D. Hand hygiene
E. Use of PPE’s
F. Safe injection Practices
G. Contamination of Point of Care Devices
I. Reuse of dialyzers
J. Processing Endoscopes

INFECTION CONTROL OUTSIDE THE
HOSPITAL
• HAND HYGIENE
– REST ROOMS
– ELEVATORS
– COUNTERS
– GAS STATIONS
– SCHOOLS
– BANKS
– AIRPORTS

INFECTION CONTROL OUTSIDE THE
HOSPITAL
• PERSONAL PROTECTIVE EQUIPMENT
(SURGICAL MASKS IN PARTICULAR)
– HOMES
– AIRLINES
– AIRPORTS
– PUBLIC TRANSPORTATION
– SHOPPING CENTERS
– SCHOOLS
– CHURCHES

EVOLUTION
• PHILIPPINE
• HOSPITAL
• INFECTION
• CONTROL
• SOCIETY
• PHILIPPINE
• HOSPITAL
• INFECTION
• CONTROL
• SOCIETY

Infection control in the OPD setting (JA Lim) - PHICS 2019

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Infection control in the OPD setting (JA Lim) - PHICS 2019