Doc offices, ambulatory care still under the IC radar
Little has changed since highly publicized outbreaks
The number of medical procedures performed in physician offices, clinics and other ambulatory care settings continues to increase, but these settings still operate with little regulatory oversight and there are few "drivers" to improve infection control and patient safety, experts warn.
The issue has drawn much attention and discussion in recent years after egregious infection control lapses led to highly publicized outbreaks of hepatitis. "I would venture to say that the infractions are still going on," says Nancy B. Bjerke, BSN, RN, MPH, CIC, an infection control consultant with Infection Control Associates in San Antonio. "They just haven't had an identified cluster or outbreak or a complaint. It is false security to think we have had one scare so we won't have any more."
Indeed, in recent years, four large outbreaks of hepatitis B and C virus infections occurred in the United States among patients in ambulatory care facilities that included a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic.1,2
A 2002 pain clinic outbreak in Oklahoma reached staggering proportions, resulting in 31 clinic-associated HBV infections and 71 clinic-associated HCV infections. An endoscopy clinic outbreak of HCV infection in 19 patients was linked to reinserting needles into contaminated multiple-dose anesthetic vials. In a hematology/oncology clinic outbreak, syringe reuse apparently led to the contamination of saline bags used to flush out implanted catheters, resulting in 99 identified HCV infections. All four outbreaks could have been prevented by adherence to basic principles of aseptic technique for needle use and the preparation and administration of parental medications, investigators emphasized.
Of course, such problems are not confined to bloodborne pathogens, but they are much easier to pick up than bacterial infections, epidemiologists advise. Hepatitis infections are required to be reported by public health officials, but there is no formal surveillance system for a lot of bacterial infections. Historically prevention of bacterial infections in ambulatory care has focused on appropriate use of multidose vials, intravenous administration sets and line flushing preparations. In addition, proper storage, aseptic technique and care, and maintenance of preparation areas — including separating infective materials from materials to be injected — are required to limit bacterial infections.
After outbreaks, a call to action
The hepatitis outbreaks resulted in calls for action and public health discussions that included both the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee (HICPAC) and The Joint Commission.
HICPAC formed a working group to look into the issue, but ultimately no guidelines or recommendations resulted. One issue cited in early discussions was that the problem that led to the outbreaks was not so much a lack of guidance but a lack of compliance. Indeed — in terms of guidance — in 1999, a panel of infection control experts issued a consensus document calling in part for nonhospital health care settings to seek the advice and consultation of hospital-based ICPs or infection control consultants.3 The general perception is that cost disincentives and other factors have left that recommendation largely unfulfilled.
"You go into hospitals, and the people who are skilled in infection control are still reasonably scarce," says Robert Wise, MD, vice president for standards in The Joint Commission's division of research. "The chances you are going to find ICPs and people who have skills in epidemiology in ambulatory settings are much smaller. You are certainly not going to find anybody who is dedicated to that particular issue. So you deal with the same problem [faced by ICPs in hospitals]. Someone who works in infection control is a straight cost center. There is no revenue being generated. It's not going to be one of the [positions] you are going to be finding ambulatory centers hiring."
For its part, HICPAC emphasizes with the issue of each new guideline that its recommendations apply to all health care settings, including ambulatory care. For example, the committee's recently issued guidelines on multidrug-resistant organisms (MDROs) defines ambulatory care settings as "facilities that provide health care to patients who do not remain overnight (e.g., hospital-based outpatient clinics, nonhospital-based clinics and physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, and dental practices."4 Still, the committee's infection control guidance is not tailored to those facilities, putting the onus on the individual physician or clinic operator to consider and adopt measures appropriate for their setting.
Community staph strains and ambulatory care
On the other hand, HICPAC does offer some specific guidance addressing the rising tide of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), which may become more frequently seen in clinics and physician offices if it continues to increase in prevalence. "Infections with these strains have most commonly presented as skin disease in community settings," the CDC states. "However, intrinsic virulence characteristics of the organisms can result in clinical manifestations similar to or potentially more severe than traditional health care-associated MRSA infections among hospitalized patients. The prevalence of MRSA colonization and infection in the surrounding community may therefore affect the selection of strategies for MRSA control in healthcare settings."
The guidelines recommend that ambulatory settings use standard precautions for patients known to be infected or colonized with target MDROs, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. In addition, the HICPAC guidelines emphasize that ambulatory settings that outsource microbiology laboratory services should "specify by contract that the laboratory provide either facility-specific susceptibility data or local or regional aggregate susceptibility data in order to identify prevalent MDROs and trends in the geographic area served."
Physician offices and clinics are likely seeing more CA-MRSA, but for the most part are probably treating the infections empirically with broad-spectrum antibiotics rather than working up or sending out cultures, Bjerke says. "There is a higher incident [of CA-MRSA] in the community and it is much more virulent than the hospital bugs," she says. "Some [physicians] may be actually culturing and some may not. Which means that they are 'shotgunning' with inappropriate antibiotics that heighten resistance patterns. They are not going to consult with an ID doc to keep savvy on what is going on. They have a patient in there, [time] is money, and they go ahead and treat them with something."
An irreversible trend
Indeed, epidemiologists have noted that ambulatory settings are often under fiscal pressure to handle a high patient census in a rapid fashion, which may lead to reliance on "flash" sterilization and other shortcuts that contribute to infection control lapses. Yet there appears to be no stopping the patient flow in that direction, as cost incentives push medical care out of the hospital even as advancing medical technology makes more complex procedures possible beyond the acute care setting.
"Think about it," Wise says. "People are being discharged sooner and sooner from hospitals with the expectation that they are being followed up in some sort of ambulatory setting. You are getting a sicker patient out into the community, but the [JCAHO] accreditation generally stops at the hospital. You are going then from a system that has a lot of quality improvement incentives to systems that don't have a whole lot of 'drivers.' This stuff tends to be expensive and they are not seeking it. Therefore, they are not building the infrastructure that would allow them to achieve it."
In the absence of that infrastructure, surveillance data are scarce, making it extremely difficult to uncover and record intermittent infections that may be occurring in such settings.
"It is hard to track infections in the ambulatory environment," say Patrick Brennan, MD, chairman of HICPAC. "It is a brief encounter and any follow-up would have to be through additional personal contact. So I think a lot of places began to focus on process measures that could be related to infections in the ambulatory setting — whether things are being cleaned properly and so on. There hasn't been as much science developed in this area."
Yet it doesn't take an infection control expert to see the hazards of infectious patients coming in for treatment and sharing the same crowded waiting room. Pediatric offices may be more likely to separate symptomatic patients into other waiting areas, but in general ambulatory settings may deploy minimally trained personnel and inadequate triage systems.
"We are finding that people who are assisting in doctors' offices have little or no health care training — even as a certified nursing assistant or things of that sort," Bjerke says. "The bottom line is how much profit can they make in a short amount of time, so if the physician is doing on the job training it is going to be very cursory. Not all of [the physicians] have the best infection control and prevention strategies themselves, i.e., hand washing. [Certainly not] exemplary enough for them to be instructing other people how to do it correctly."
As a result, the aforementioned outbreaks have probably led to little substantive changes in the ambulatory setting, she warns. Even the regulatory teeth of the federal bloodborne pathogen standard does not come into effect because clinics with fewer than 15 employees are exempt, she adds.
"It has become a community standard now and they should comply [regardless]," she says. "Any facilitate that delivers health care to patients indirectly or directly needs routine re-education on basic infection prevention and control principles and practices. It probably needs to be addressed and re-familiarized on an annual basis."
Few seeking JCAHO accreditation
However, many physicians only seek infection control consultation for their offices if they are trying to resolve a possible outbreak or they are seeking Joint Commission accreditation, she notes.
"The Joint Commission is trying to push that this is a competitive edge that they may want to seek, particularly in light of any procedures that they may be doing in their doctors' office," she says. "But it is still costly for them and many of them don't see it as that advantageous."
The Joint Commission has been offering accreditation — with its attendant emphasis on infection control and other quality standards — to physician offices and clinics for years, but is finding few takers, Wise laments.
"Accreditation does exist in ambulatory settings, but there are a huge number of ambulatory settings out there that are not seeking accreditation," he says. "Probably the only pressure [for accreditation] that I am aware of right now is the ones who are delivering anesthesia. There are a number of states right now that do require some sort of accreditation. Last time I checked, it was about five states. But other than that — certainly in a doctor's office — I am not aware that there are any significant drivers for that type of setting to seek accreditation."
Indeed, medical and moral principles aside, the bottom-line question to the whole situation is where are the drivers — the incentives — to improve infection control and patient safety in ambulatory care?
"Generally, the two drivers have been that there are either a requirement of some sort by the state or the feds or that accreditation is seen as giving them some kind of substantial competitive advantage," Wise says. "Those have generally been the two. I think at this point, in the ambulatory setting, neither of those two exists."
With the previous calls for action now largely silent, it appears nothing short of another highly publicized outbreak will force the issue back on the public health agenda.
- Williams IT, Perz JF, Beel BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1,592-1,598.
- Green ES. Hepatitis C Outbreak: More than 50 infected by reused needles and syringes. ASA Newsletter 2002; 66(12). Web: www.asahq.org.
- Friedman C, Barnett M, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: A consensus panel report. Infect Control Hosp Epidemiol 1999; 20:695-705.
- Siegal JD, Rhinehart E, Jackson, M, et al. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Published on the web at: http://www.cdc.gov/ncidod/dhqp/.