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North Carolina SPICE is model for other states
Ambulatory outbreaks draw attention to education
(Editor's note: In this first of a two-part series on infection control issues in ambulatory surgery, we tell you about a model program in North Carolina, as well as recent incidents as a hospital and surgery center. In next month's issue, we'll give you information about how infection rates actually have been reduced dramatically in an outpatient surgery setting.)
As recurrent hepatitis outbreaks continue to be reported in ambulatory care nationally, there are increasing calls for more oversight and training for health care workers in this setting. 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. Ambulatory facilities, physician's offices, and 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 Occupational Safety and Health Administration (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' 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 members 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." (See outline of outpatient training, above. For more information on the SPICE program, including an outline of the hospital program, go to www.unc.edu/depts/spice/courses.html.)
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 (CDC), 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.
"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 (APIC) is urging patients to look out for their own safety when receiving ambulatory care. [For more information, see "APIC Warns: Patient, Protect Thyself in Ambulatory Care," Same-Day Surgery Weekly Alert, March 20, 2009, below. To sign up for this free weekly ezine, contact customer service at email@example.com or (800) 688-2421.] It also would appear that training programs such as the one in North Carolina could 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.
|APIC Warns: Patient, Protect Thyself in Ambulatory Care
The Association for Professionals in Infection Control and Epidemiology (APIC) is urging patients to heighten awareness and become inquisitive before undergoing outpatient care.
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Outline of SPICE Training —
Infection Control in Outpatient Settings
Source: Statewide Program for Infection Control and Epidemiol-ogy (SPICE), University of North Carolina at Chapel Hill School of Medicine.
Hospital, ASC report improper sterilization
Two health care facilities recently have reported that their improper infection control techniques could have put patients at risk.
In Georgia, a surgery center exposed more than 1,000 people with improperly sanitization of endoscopes, according to a news report.1
The center sent a letter to 1,300 patients who had surgery between Sept. 10, 2007, and Feb. 9, 2009, according to the report. The letter said the center isn't aware of any related infections and the risk of infection is near zero. (Editor's note: To access the letter, go to images.bimedia.net/documents.) The manufacturer's recommendations weren't followed in one step of a five-step cleaning process, the center said. The mistake left the instrument in heated disinfectant for less than the recommended five minutes, it said.
The center voluntarily contacted the Georgia Department of Human Resources as a proactive measure, the news report said. The center underwent a full inspection and had no violations, it said. The center offered patient testing for diseases including HIV and hepatitis and provided a toll-free number for them to call, according to the report.
In other news, a Florida veterans' hospital has temporarily suspended performing colonoscopies after equipment was improperly cleaned, according to a news report.2
Water tubes and reservoirs used in colonoscopies and endoscopies were being rinsed between procedures, but not disinfected as required by manufacturer's specifications, an earlier report said.3
About 3,260 veterans had medical procedures since May 2004 on the improperly disinfected equipment, the report said.
The chance that the veterans could have been expected to infectious disease was described as "very small, but more-than-negligible chance'' by the chief of staff in the news article.
According to one of the reports2, Olympus America, the manufacturer, notified facilities earlier this year that some providers were not assembling the equipment correctly or were not cleaning it properly. Two months before that notice, Olympus America issued a safety warning when company representatives found that some veterans' hospitals were using the wrong connectors on tubing, the report said.
Infection control problems found at NV centers
More than half of 49 surgery centers inspected by the state in Nevada had "infection control-type deficiencies," according to a recent news report.1
The investigation by the state health division investigation began after 50,000 patients were advised in 2008 to be tested for potential exposure to hepatitis C at two Las Vegas surgery centers. Nine cases have been linked to two centers, and state health officials have listed an additional 105 cases from those centers as "possibly related."
Problems with sterilization and disinfection led to almost half of the infection control deficiencies at 25 centers in fiscal year 2008, according to the draft report. Inappropriate use of items labeled as single use, such as syringes, amounted to nearly one-third of the deficiencies, the report said.
The report doesn't list the centers that had deficiencies, but they will be posted on a web site by summer, according to a spokeswoman for the Nevada Health Division.
The state will conduct more frequent inspections, the spokeswoman was quoted as saying. They will be conducted every 18 months, if the division's request for more surveyors is granted, she said. The money for surveyors would come from increased licensing fees charged to facilities, including ambulatory surgery centers, the report said.