Controlling Infections Outside the Hospital- A Challenging Task
ABSTRACT & COMMENTARY
Synopsis: Herwaldt and associates provide an interesting and comprehensive review of infection control in the ambulatory care setting. Their focus is on medical offices, clinics, and health care facilities outside the hospital. They do not deal with care in the home.
Source: Herwaldt LA, et al. Infection control in the out-patient setting. Inf Control Hosp Epidemiol 1998;19(1):41-74.
Herwaldt and colleagues point out the dramatic change in the location at which medical care is being provided, with a decline in patient hospital beds in the United States of 20% in the last 10 years and another 20-30% expected over the next 10 years. They note that 80-90% of cancer care is now delivered in an outpatient setting and that more than half of surgeries are performed in ambulatory care centers.1
Herwaldt et al note that resources devoted to infection control in ambulatory care are far less than in the hospital, yet there is an accumulating amount of information that the problems may be great and growing. With regard to bloodborne pathogens, the understanding of the problem among office staff appears to be clearly less than in the hospital-particularly in regard to needlestick injuries.2 They note the risks of congregating sick people in waiting rooms and long waits in emergency departments, even with triage systems. This is a problem with patients with airborne-spread viruses such as influenza and varicella. It is also true of tuberculosis.
Herwaldt et al suggest that a clear set of policies is needed for tuberculosis-not only for the office staff but also for the other patients in the waiting room who may have been exposed to the person with the infection. The spread of measles may also be facilitated by physician offices. Seventeen percent of the 266 cases of measles reported in Washington State in 1990 could be traced to exposures in medical settings. There is also good evidence of ambulatory care setting transmission of rubella, keratoconjunctivitis, and Bordatella pertussis.
Herwaldt et al provide a series of tables with reports of parenteral spread of infections in medical outpatient settings from articles dated 20 years. There are good references with documented outbreaks of hepatitis B in care settings ranging from acupuncture clinics to chiropractic clinics to dentistry clinics to weight loss clinics, and a dialysis center. There is also evidence of transmission of HIV in outpatient health care facilities involving dentistry, a dialysis center, and a physician's office.
Endoscopic devices are another potential vector for transmission of infections from one patient to another. There have been at least 291 reports of infections related to gastrointestinal endoscopy and 96 related to broncoscopy. The transmitted organisms range from salmonella to pseudomonas to helicobacter to hepatitis B to Strongyloides for gastrointestinal procedures. Broncoscopy appears to have caused outbreaks of Mycobacterium tuberculosis, Mycobacterium avium, pseudomonas species, rhodotorula, and blastomyces. Most of the outbreaks reported could have been prevented by basic infection control precautions with standard cleaning, disinfection, and maintenance of equipment using established procedures. There are also problems associated with flash sterilization and the use of multi-dose vials. The regulations and potential problems with medical waste disposal vary from city to city and state to state.
Herwaldt et al express particular concern about the spread of vancomycin-resistant enterococci (VRE) in the outpatient setting. The article contains a questionnaire they developed for clinic staff to test their knowledge of VRE and another information sheet for patients with VRE about what to do when they come to clinic visits. Both provide useful and practical information.
COMMENT BY ALAN D. TICE, MD, FACP
As increasing economic pressure and improved technology move the care of increasingly ill and complex patients from the hospital into the community, infection control becomes ever more important. The outpatient setting provides a fertile ground for exchange of organisms among patients and to develop infections with multi-drug resistant organisms. The problems are much the same as in the hospital, but patients are generally not in the clinic as long and are not as ill as those that are in the hospital. On the other hand, there are seldom the resources dedicated to infection control in ambulatory care than there are in the hospital, and the attention to procedures and protocols is often not as great.
Herwaldt et al provide a comprehensive review of problems in the outpatient setting, which will undoubtedly increase with early discharges and expanded outpatient therapy for what used to be considered hospital diseases.
Diseases such as tuberculosis, for example, present a major problem if not recognized before the person sits in the waiting room. A useful algorithm is presented in the article that may be helpful in approaching the screening of patients with possible tuberculosis and avoiding transmission of the disease.
It is apparent that there are patients with increasingly severe disease and immunocompromised states who are being treated as outpatients, but there is little knowledge of what the limitations are or what precautions should be taken. Infection control techniques should be as rigorous in offices and clinics as in the hospital, yet they are not. There are already particular risks with vancomycin-resistant enterococci and methicillin-resistant S. aureus, as well as the potential for vancomycin-intermediate S. aureus (VISA), in the community. For a patient treated in an office or clinic, it may seem almost silly to institute the gown and glove precautions in the office, yet this may be as appropriate as in the hospital.
Infection control in the outpatient setting is a growing problem and will take considerable resources to be effective.
The article also has an extensive review of references that should be quite helpful to the infection control practitioner.
References
1. Lamkin L. Outpatient oncology settings: A variety of services. Semin Oncol Nurs 1994;10:227,229-235.
2. Thurn J, et al. Needlestick injuries and needle disposal in Minnesota physicians' offices. Am J Med 1991;151: 2051-2056.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content