IC practitioner develops tool for ambulatory sites

Site surveys can last 15 minutes to 3 hours

Acute care settings have long had tools for use in improving infection control, but often these tools are not a good fit for ambulatory sites.

This is why infection control practitioners at Duke University Medical Center (DUMC) of Durham, NC, have developed an infection control tool that is tailored for nonacute ambulatory care facilities and clinics.

The tool is revised when needed, such as when new infection control guidelines are published by the Centers for Disease Control and Prevention (CDC) in Atlanta says Judie Bringhurst, RN, BSN, CIC, an infection control practitioner in the infection control and epidemiology department at DUMC. She also is an editorial advisory board member of Infection Control for Physician Practices.

Bringhurst oversees infection control practice and compliance at more than 75 ambulatory care facilities. These facilities house practices that include urology, gastroenterology, plastic surgery, pulmonary, cardiology, dermatology, infectious disease, ophthalmology, orthopedics, otolaryngology, oral surgery, OB/GYN, high-risk perinatal, fertility, transplant clinics, neurosciences, family practice, pediatrics, and internal medicine.

Called the "Infection Control Clinic Survey Tool," the seven-page tool contains eight sections: handwashing facilities; storage of supplies; medication areas; linens; disinfection/sterilization; isolation; housekeeping; and refrigerators.

The tool is separated into left and right columns, with the infection control standard in the left column and the element of performance in the right. (See tool.)

Besides being a scoring tool for compliance with infection control standards, the document is also an educational tool for clinic staff and management.

"This is the tool that all the clinics get," says Bringhurst.

For every separate element on the tool, an infection control practitioner can score a site as either meeting or not meeting the standard, or the item may not be applicable, Bringhurst says.

Scoring the survey is straight forward: the denominator is the total of all elements scored; the numerator is the total of all elements "met."

All elements are weighted equally on the tool, although Bringhurst is looking at revising the tool to assign more weight in sections such as high-level disinfection and sterilization. There is a higher risk to patients in clinics that perform high-level disinfection and sterilization.

For instance, pediatric or family practice clinics that have toys in the waiting areas or exam rooms use low-level disinfection when cleaning the toys, and only toys which can be cleaned with a low-level disinfection are allowed.

"Clinics that use critical devices, including those devices that enter sterile tissue or the vascular system, are required to maintain national standards for sterilization," Bringhurst says.

Sterilization of a medical device destroys all microorganisms, including bacterial spores. High-level disinfection of a medical device destroys all microorganisms except high numbers of bacterial spores, Bringhurst adds.

"Your infection control practitioner needs to know what he or she is looking at, what process is supposed to be used, and then must ask the staff how they're doing it," Bringhurst explains. "We make sure our clinics are using infection control-approved practices and products."

Listings of hospital-grade products and their effectiveness can be found at the Environmental Protection Agency's web site. Occupational Safety and Health Administration (OSHA) standards also should be reviewed to ensure the safety of staff, she notes.

When low-level disinfectants are required, DUMC requires clinics to use a disinfectant that meets OSHA requirements for effectiveness against hepatitis C, hepatitis B, HIV, and tuberculosis, Bringhurst says.

"TB is used as a benchmark for effectiveness," she says.

"It is one of the microbes that is more difficult to kill," Bringhurst adds. "The understanding is that if a disinfectant will kill TB, it is generally effective against all of the bloodborne pathogens, including hepatitis B, hepatitis C, and HIV."

Often, clinic staff will select products without taking time to read the label, Bringhurst says.

"If there were one thing I could change in clinics it would be that everyone reads labels and policies," she says.

In devising the tool, Bringhurst pulled together information from every important source, including OSHA, the Centers for Disease Control and Prevention (CDC), The Joint Commission, and all infection control guidelines promoted by independent and governmental bodies.

In the day-to-day exercise of meeting infection control standards, the Joint Commission standards do pretty much cover everything, Bringhurst notes.

"But we also need to include elements from the American Institute of Architecture, which has guidelines on the construction of health care facilities, if we have a clinic undergoing construction of any sort."

Infection control surveys could be done in 15 minutes for small cardiology practices that are highly infection control-compliant, or they could be as long as three hours for a large gastrointestinal or urology clinic, Bringhurst says.

"The length of time it takes to complete a survey depends on what I find," she adds.

"My theory of infection control is to bridge the gap between infection control and the health care professional who lays hands on patients," Bringhurst says. "Until we get our word out to that person, we will not reduce the incidence and risk of infections in our patients."