Ambulatory Care Quarterly

IP oversight required: If NV leads, will nation follow?

'Half-dozen' clinic laws under discussion

Proposed state laws in Nevada in the wake of a highly publicized hepatitis C outbreak in Las Vegas include proposals to hire infection preventionists (IPs) as consultants to oversee practice in freestanding clinics.

"It's possible that we could have that sort of requirement within the state of Nevada," says Brian Labus, MPH, a lead investigator in the case for the Southern Nevada Health District in Las Vegas. "We have had those sorts of discussions with the [state] Legislative Committee on Healthcare. Our legislature meets every other year and they will be meeting again in the spring of 2009."

With another recent HCV outbreak reported in a North Carolina cardiology practice, there is growing sentiment that something must be done to beef up infection prevention oversight in ambulatory care. Whether it involves IPs or some other approach such as increased health department inspections, the aftermath of the Vegas outbreak is expected to set the tone — and, possibly, the legislative model — for the rest of the nation.

"Nevada must be in the forefront," says William Schaffner, MD, chairman of the department of preventive medicine at the Vanderbilt University School of Medicine in Nashville, TN. "They are grappling not only with what happened in the past, but dealing with this going forward. They might be in a position to instruct us all."

A "half-dozen" bills are being drafted in Nevada for consideration at the legislative session, but the specifics are still being hammered out, Labus notes. "Something needs to be done after our large outbreak here," he says. "We're hoping it could serve as a model for other communities. At this point, we will have to see how the legislature wants to move on it. There will be a lot of discussion. [The involvement of IPs] is something that was discussed, and it is a strong possibility for the upcoming session."

The outbreak resulted in the largest look-back investigation in medical history, with some 50,000 patients seen at two endoscopy clinics advised to be tested for HCV, HIV, and hepatitis B. The practices under investigation in Nevada include alleged reuse of syringes and re-entry into single-dose vials of pain medication for different patients undergoing colonoscopies. "We have nine HCV cases that we can link to the clinic, and we have 77 cases that are possibly linked," Labus says. "Of those nine, eight are at the main facility and one is at the other location."

Latest count

The latest count of confirmed HCV cases adds one from the previous reports of eight patients, he clarifies. Investigators have completed genetic testing and are confident in reporting the nine cases, but previous reports of HIV transmission are being dismissed. A reported 11 HIV cases that have been identified are being ascribed to prior infections rather than clinic treatment, he says. "We have no HIV or hepatitis B transmissions related to the clinic," he says.

IPs and public health officials have warned for years that ambulatory settings and physician offices were flying under the radar when it comes to infection prevention. Bolstering the claim, a series of incidents has occurred with disturbing regularity. Last year, a physician anesthesiologist in Long Island was investigated by the New York State Department of Health for allegedly reusing syringes to draw up medicine from multidose vials. The department contacted approximately 8,500 patients who had been treated by the physician prior to Jan. 15, 2005, urging them to be tested for hepatitis and HIV. In recent years, large outbreaks of HBV and HCV infections have occurred among patients in private medical practices, pain clinics, endoscopy clinics, and a hematology/oncology practice.1 Even as the number of medical procedures performed in physician offices and clinics continues to increase, many of these settings operate with strikingly little regulatory oversight and expert consultation.

"Speaking generally, the vast majority have not developed a consultative relationship with anyone in infection control to come in and give them periodic guidance and oversight," Schaffner says.

Could there be similar bills elsewhere?

The legislative activity in Nevada could result in similar bills elsewhere, possibly opening up new consulting opportunities for IPs. "How to provide the oversight is something that needs to be debated at the national and state level," he says. "They could require these institutions for licensure to demonstrate that they have an association with some sort of infection control activity. Something that would do immediately is create a new industry of infection prevention consultants."

Indeed, hospital systems have turned to IPs for oversight of rapidly expanding networks of affiliated clinics. "I have over 80 clinics now; and a year from now, I will have over 100," says Judie Bringhurst, RN, BSN, CIC, an IP who oversees infection control in ambulatory settings at Duke University Medical Center in Durham, NC. "We are building by leaps and bounds."

With health care delivery rapidly moving beyond the hospital, it goes without saying that infection prevention activities must follow. "Ambulatory care has to change," she says. "If we can't do our duty to take care of our patients properly, somebody is going to have to make us do it. Duke insists on Joint Commission accreditation. Look at what happened in Las Vegas — my gosh, 50,000 people [advised to be tested]. I would hope some kind of regulation would result. But it has happened before, and nothing changed."

Reference

  1. Williams IT, Perz JF, Beel BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1,592-1,598.