North Carolina SPICE a model for other states
Ambulatory outbreaks draw attention to education
As recurrent hepatitis outbreaks continue in ambulatory care nationally, there are increasing calls for more oversight and training for health care workers in those settings.
A possible model that could be used by states is a North Carolina law that requires an individual in each health care organization in which invasive procedures are performed to complete an approved infection control course. Funded by the state, the Statewide Program for Infection Control and Epidemiology (SPICE) is located at the School of Medicine at the University of North Carolina at Chapel Hill.
"There is actually a law in our state, effective 1994, that all health care organizations that do invasive procedures — as defined by using a needle — [must receive training]," says Karen K. Hoffmann, RN, MS, CIC, associate director and clinical instructor at SPICE. "If you give an injection, you are covered under this rule and you have to have attended a state-approved course for your area of practice."
For hospitals, training lasts two weeks; long-term care, 2.5 days; and ambulatory settings, physician's offices, outpatient settings, dental practices must take a one-day program. "I do the training and actually developed the curriculum for these outpatient areas," Hoffmann says. "So dental has its own, home health and hospice has its unique curriculum, and outpatient settings have a unique curriculum."
The infection control curriculum is not a substitute for the training required by the OSHA Bloodborne Pathogen Final Rule.
"We focus on issues that OSHA does not address: disinfection, sterilization, housekeeping environmental issues, medical waste handling," Hoffmann says. "Then, while we have them there, we go over needle safety. We have broken that out and made it a whole focus because of the recent outbreaks."
Indeed, one of the outbreaks occurred in North Carolina last year where seven patients reportedly acquired hepatitis infection while undergoing stress tests at a cardiology practice. An epidemiological investigation pointed to patient-to-patient transmission due to unsafe injection practices, a common theme in the outbreaks. The outbreak occurred after the clinic started injecting a radioactive "tagging agent" used to identify potential heart problems via nuclear imaging.
"For any hepatitis B and C cases that are sent to the local health department, there is an exposure work-up [that includes] recent dental or medical procedures," Hoffmann says. "And they do have the health department follow each of those up as a possibility. I have helped with a couple of those investigations."
While the outbreak underscores that no training program will eliminate all outbreaks, Hoffmann contends that infection control in ambulatory settings is improving in the state. "I think it's getting much better," she says. "One of the reasons is that so many of these outpatient settings are coming under the umbrella of one of our five or six major medical facilities across the state."
Plans call for putting the training online in recorded modules. "I think that is going to make the doctors offices practices much more compliant," she says. "I think they are a weak area in terms of sending people. We don't have an easy way to [reach them]."
Settings that have had problems typically are those that have not sent any staff member in for the SPICE training, Hoffmann notes. "I think it does help to have someone — just like [IPs] in hospitals — to have enough basic knowledge to say, 'That doesn't look right,'" she says. "They may have been taught that in school, but that is so far removed from actual practice that they don't feel that they have the knowledge or authority."
Apparently, no one felt empowered enough to say anything at the site of one of the most recent national outbreaks, a dialysis center in New York City. Recently reported by the Centers for Disease Control and Prevention, the outbreak was uncovered last year when health officials found that three patients seroconverted for HCV after receiving treatment in a hemodialysis center that was subsequently shut down.1 State health officials conducted patient interviews and made multiple visits to the hemodialysis unit to observe hemodialysis treatments, assess infection control practices, evaluate HCV surveillance activities, review medical records, and conduct interviews with staff members. They found that six additional patients had HCV seroconversion between 2001 and 2008. The hemodialysis unit had numerous deficiencies in infection control policies, procedures, and training, the CDC reported.
Given the conditions described at the clinic, it would appear that anyone with a modicum of training would have recognized the risk to patients. "Visible blood remained on dialysis chairs, dialysis machine surfaces, and the surrounding floor between patient treatments," the CDC reported. "Moreover, direct care staff members failed to don gloves with every patient encounter, change gloves between patients, or perform hand hygiene after contact with patients and soiled surfaces. Supervisory staff members failed to address these breaches. Many of the direct care staff members were unaware of the hemodialysis unit's written infection control policies, including those pertaining to cleaning and disinfection."
Given such flagrant violations, the Association for Professionals in Infection Control and Epidemiology is urging patients to look out for their own safety when receiving ambulatory care. It also would appear that training programs such as the one in North Carolina could well serve as a model for other states to build on. "I think this is working well in our state, and one of the things we are trying to do is make it more accessible," Hoffmann says.
Reference
- Centers for Disease Control and Prevention. Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit — New York, 2001 — 2008. MMWR 2009; 58(08):189-194.
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