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Preventing infections in physician practices
Physician practices respond to CA-MRSA
With community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) continuing to emerge nationally, infection control professionals and consultants are educating physician office staff — many of whom may not have extensive medical training — about the essential elements of infection prevention.
"When I do inservices, [CA-MRSA] always comes up," says Judie Bringhurst, RN, BSN, CIC, an infection control professional responsible for oversight and education in physician offices and clinics affiliated with Duke University Medical Center in Durham, NC. "Staph is always a concern, so I try to hit them from the angle that if they are protecting themselves they are going to protect their patients."
Though she doesn't go into too complicated of an explanation, Bringhurst tells the workers that the CA-MRSA being seen in patients in the Duke clinics is different from the typical MRSA acquired by hospitalized patients.
"I tell them it used to be only a hospital-acquired bug, but it is not anymore," she says. "In the clinics, we have [employees] that are not degreed health care workers. A lot of them are medical assistants, and I have some clinics that do not have a nurse [at all]. I have to meet them where they are at when I am talking to them. If they have a patient with a draining wound, we do expect them to gown and glove and we check to see if there are gowns in the clinics."
Of course, hand washing and other aspects of standard infection control precautions are emphasized, but physician offices and clinics may not have the ease of access to the alcohol gel dispensers that have become ubiquitous in hospitals.
"There are fire safety requirements," Bringhurst says. "I have lots of clinics without sprinklers and more than a few with carpets. They can't put them in egress halls but they still put them over a sink in the exam room."
Designate a procedure room
Another common sense infection control measure physician offices can take to protect staff and patients from transmission of pathogens such as CA-MRSA is designating certain rooms for "dirty" procedures such as incision and drainage of abscesses related to skin and soft-tissue infections.
Such recommendations are being emphasized by the Centers for Disease Control and Prevention in the wake of a fatal CA-MRSA infection that possibly was acquired on the job by a pediatric clinic worker in Nashville, TN.
"One thing that is hard in an outpatient setting is to try doing certain higher-risk or 'dirtier' procedures in designated locations," says Rand Carpenter, DVM, the CDC Epidemic Intelligence Service officer who is investigating the Nashville clinic case. "It is common in many clinics that once a person gets into a exam room, the tendency is to do everything that needs to be done with them in that room. [We discussed with clinic staff] designating certain exam rooms or procedure rooms that can be cleaned easier and that you know may need special cleaning."
Designating such rooms not only emphasizes environmental cleaning, but reminds workers entering them to perform procedures to don protective equipment. "There are advantages to that," Carpenter says. "It takes on special significance and it serves as a reminder to people that [this procedure] should be done in a special room while ingraining the notion in staff that they may need to take infection control precautions as well."
Follow infection control recommendations
In the aftermath of the fatal infection, Carpenter and colleagues have recommended that the clinic follow CDC infection control recommendations and those created for physician offices by the American Academy of Pediatrics.
The infection control issues go well beyond CA-MRSA of course, as the number of increasingly complex medical procedures performed in physician offices, clinics and other ambulatory care settings continues to increase. The general consensus among health care epidemiologists is that infection control and prevention have not been sufficiently emphasized in physician offices and outpatient clinics. The issue drew national attention a few years ago when 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
Investigators cited egregious infection control lapses in all of the outbreaks. 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.
Transmission probably occurred indirectly from patient to patient after exposure to injection equipment that was contaminated with the blood of one or more source patients. 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 many 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. The emergence of CA-MRSA is bringing a new emphasis on such infection prevention measures in physician offices and ambulatory settings.