Hospital Infection Prevention-Patients are at risk in ambulatory settings

Rapid expansion outstrips infection control

The explosion of health care delivered in ambulatory settings is rapidly expanding in the absence of standardized infection control programs, creating a situation where outpatient infections may be going undetected in medical surveillance, an epidemiologist warned at the Centers for Disease Control and Prevention's 4th Decennial International Conference on Nosoco mial and Healthcare-Associated Infection, held in March in Atlanta.

"There is increased acuity of care. These are now [the patients] that used to be seen in acute care settings," said Trish Perl, MD, assistant professor of medicine at Johns Hopkins University in Baltimore. ". . . Infections are occurring out there, and if we don't have appropriate techniques to identify them, we don't know what's happening."

Cost incentives have forced the movement of medical care out of hospital settings, even as advancing medical technology has made more complex procedures possible beyond the acute care setting. Outpatient and ambulatory sites now include all manner of clinics, as well as surgical, endoscopy, radiology, infusion and dialysis centers. Citing the most recent CDC data available, Perl said there were 67 million outpatient visits and 31 million ambulatory surgical procedures in 1996. Barriers to infection control in such settings include fewer trained personnel and lack of engineering controls for airborne illnesses such as tuberculosis and measles.

"Persons congregate in waiting rooms," she said. "Infectious patients frequently come to ambulatory facilities to be evaluated and treated. These facilities commonly have inadequate triage systems, with personnel who aren't trained to triage."

In addition, computer systems in ambulatory settings are likely to be designed for billing rather than clinical data collection, she said. "Many of them lack protocols and procedures that would enhance infection control," she told attendees. "There are no systems developed that can be used to measure outcomes. So in terms of data, there is very little." Another factor is that ambulatory settings are often under fiscal pressure to handle a high census in a rapid fashion, which may lead to reliance on "flash" sterilization and create opportunities for infection control lapses. "These centers are under extreme pressure to see large volumes of patients," Perl said. "So they have to turn those over quickly."

Nevertheless, the challenge remains to expand infection control to ambulatory settings, anchoring health care epidemiology in a shifting health care delivery system, she noted. (See chart, above.) "Prevention and control of health care-associated infections is absolutely necessary," Perl said. "Health care delivery will continue to extend into these nontraditional settings. We've got to develop and expand our role to serve the new paradigm in health care."

Recent consensus panel recommendations for infection control in non-hospital settings were an important step, she said.1 (See Healthcare Infection Prevention supplement in Hospital Infection Control, February 2000.) Perl reiterated that the panel strongly recommended establishing surveillance, analyzing data to improve patient outcomes, developing an outbreak investigation policy, and evaluating exposed or infected health care workers.


1. 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.