INFECTION PREVENTION AND CONTROL ESSENTIALS FOR AMBULATORY CARE A RESOURCE WORKBOOK Table of Contents Acknowledgements . 3 MODULE 1: Infection Preventionist’s Role in Ambulatory Care........ 4 MODULE 2: Infection Prevention & Control Plan/Risk Assessments... 11 MODULE 3: Infection Prevention & Control Basics................... 78 MODULE 4: Epidemiology & Infectious Diseases .................... 117 MODULE 5: Occupational-Employee Health ........................ 118 MODULE 6: Construction & Water Management .................... 127 MODULE 7: Environmental Cleaning ............................... 139 MODULE 8: Cleaning/Disinfection/Sterilization .................... 156 2 Acknowledgements Development of this Workbook required input and expertise from a team of subject matter experts who selected and organized the materials from a range of facilities and other resources . The Association for Professionals in Infection Control and Epidemiology acknowledges the valuable contributions from the following individuals: Contributors Judie Bringhurst, RN, MSN, CIC Infection Preventionist and Instrument Reprocessing Specialist University of North Carolina Hospitals Chapel Hill, NC Pamela S . Falk, MPH, CIC, FAPIC, FSHEA Epidemiologist Northside Hospital Sandy Springs, GA Carolyn Kiefer, BSN, RN, CIC Infection Preventionist Carilion Medical Center Roanoke, VA Carol McLay, DrPH, MPH, RN, CIC, FAPIC CEO Infection Control International Lexington, KY Sara Townsend, MS, HQS, CIC, FAPIC Infection Prevention Manager Children’s Hospital of Philadelphia Philadelphia, PA Project Management Elizabeth M .R . Hartke Director, Practice Resources Association for Professionals in Infection Control and Epidemiology Elizabeth Garman Vice President, Communications and Practice Resources Association for Professionals in Infection Control and Epidemiology Groff Creative Cover Design, Text Design and Layout Silver Spring, MD 3 Module 1 Infection Preventionist’s Role in Ambulatory Care Contents 1.1 Emerging Models of Ambulatory Care . 5 Constance Cutler, RN, MS, CIC, FSHEA, FAPIC; Jill Lindmair-Snell, MSN, RN, CIC, FAPIC, and Brian Dennen, MBA, AIA, NCARB Prevention Strategist, Winter 2018, p .56-60 https://apic org/publication_types/prevention-strategist/. 1.2 Infection Control Compliance Rounding Checklist . 10 Forms & Checklists for Infection Prevention, Volume 1 Resources Infection Preventionist Competency Model Association for Professionals in Infection Control and Epidemiology (APIC) https://apic org/professional-practice/infection-preventionist-ip-competency-model/. One and Only Campaign Centers for Disease Control and Prevention (CDC) https://www cdc. gov/injectionsafety/1anonly. .html Bloodborne Pathogen and Needlestick Prevention Occupational Safety and Health Administration (OSHA) https://www osha. gov/SLTC/bloodbornepathogens/gen_guidance. .html Healthcare-Associated Infections in Outpatient Settings CDC https://www cdc. gov/hai/settings/outpatient/outpatient-settings. .html 4 1.1FEATURE Emerging models of ambulatory care BY CONSTANCE CUTLER, RN, MS, CIC, FSHEA, FAPIC, Healthcare data show increasing shifts JILL LINDMAIR-SNELL, MSN, RN, CIC, FAPIC, AND from inpatient to outpatient care.1 Figure 1 BRIAN DENNEN, MBA, AIA, NCARB illustrates this trend, which is predicted to continue into at least the next 10 years. As t used to be that an infection preventionist (IP) was responsible healthcare facilities compete on value not for only one location, usually a hospital, but now they have more volume, there are six market forces driving than one outpatient venue because of acquisitions and mergers. this change (Figure 2):1 I 1. Compression Those days are coming to an end as healthcare evolves in new ways 2. Care management with many outpatient facilities now under the IP’s umbrella. If your 3. Contraction facility is similar to the authors’, you may have an outpatient pain 4. Consolidation clinic, cancer care center, immediate/urgent care facility(ies), owned 5. Consumerism 6. Connectivity physician offices, offsite endoscopy procedure site, and an ambula- There is also a change in all specialties for tory surgery center, as well as others. All provide new opportunities which patients will be treated as outpatients, and challenges, which this article will address to give you an idea ranging from a slight increase (5.6 per- how to start and what resources are able to assist you. cent) in colorectal patients to a substantial MARK WINFREY/SHUTTERSTOCK.COM MARK 56 | WINTER 2018 | Prevention 5 increase (44.4 percent) in hematology oncol- ogy patients.1 Studies show that revenue derived from outpatients is rising dramati- cally, as compared to inpatient revenue.2 Outpatient ophthalmology and colorec- tal surgeons’ offices have also been impli- cated in disease transmission, as shown in these headlines (Figure 3) that show some occurrences, including a shocking one where anal catheters were reused in 2018. Now that the stage is set for our shift- ing focus as IPs, we can prepare to take on these new arenas. To start, do your research on historic outbreaks when care Figure 1. Increasing shift to outpatient care. Adapted from Truven Market Expert. 2017-2027 Total US Market.1 was mostly provided to inpatients. PATIENT-TO-PATIENT TRANSMISSION As recently as the 1970s, outpatient hemodialysis centers saw clusters of cases of both hepatitis B and C occurring at their free-standing centers. These were addressed by recommendations from the Centers for Disease Control and Prevention (CDC) and other agencies to do blood testing and use separate cleaning protocols and machines on known positive patients. Thankfully, in recent years the numbers of these blood- Figure 2. Six types of market forces. Adapted from Truven Market Expert. 2017-2027 Total US Market.1 borne pathogens in dialysis patients have decreased with improved oversight by both dialysis personnel and IPs. Dialysis cen- ter issues haven’t completely disappeared, though. An article reviewing hepatitis B virus (HBV) in dialysis centers summarized several outbreaks that occurred from 1992 through 2014. There were 16 outbreaks that involved 118 patients on maintenance dialysis; 10 fatal cases occurred; multiple deficiencies in standard or hemodialysis- specific procedures was the most common route of patient-to-patient transmission Figure 3. Infection prevention headlines. Adapted from Truven Market Expert. 2017-2027 Total US Market.1 of HBV. 3 A survey of clinicians found that 12 percent of physicians and 3 percent of nurses indicated syringe reuse occurs in their workplace.4 This, along with other WHAT CAN AN IP DO? surprising and depressing results, led the • Review what kind of issues have occurred in the past and with what frequency. CDC to develop the “One Needle, One • Make the business case that it is “potentially” scary out there but that regular Syringe, One Time” Campaign. visits from a qualified IP can mitigate the real risks. • Go out and see for yourself what’s actually happening, focusing first on the AMBULATORY SURGICAL riskiest areas: CENTERS - Those performing sterilization of instruments. An assessment performed by the Centers - Those doing high-level disinfection. for Medicare & Medicaid Services (CMS) - The others “just” providing routine patient care such as using syringes. of ambulatory surgical centers (ASCs) www.apic.org | 57 6 FEATURE Figure 4. Summary of ASC pilot survey findings. Adapted from Truven Market Expert. 2017-2027 Total US Market.1 showed that practices in those increas- surveyor in evaluating healthcare practices make sure the ASC is prepared for a regula- ingly prevalent areas also pose infection during an onsite visit.10 The surveyor will tory visit any time. In addition to the work- prevention risks, leading to a specialization observe at least one surgical procedure and sheet, the IP should establish and maintain in ASCs for IPs.5 The actual pilot survey follow a patient from registration through an environmental rounding program. A is summarized in Figure 4. discharge.10 The ICSW will be used to multi-disciplinary team can examine the ASCs pose unique challenges and an obtain details about the facility includ- center for potential patient safety and IP may take on responsibility for them, ing the types of procedures performed, infection prevention concerns. The team specializing in them. The concept of hav- number of procedural rooms, types of should observe medication administra- ing surgery and going home on the same contracted or employed services, hand tion in all areas: aseptic technique, surgi- day started in 1970, when two physicians hygiene, medication practices, cleaning cal procedures, cleaning of patient care opened the first freestanding ASC in and reprocessing of reusable medical items, reprocessing of medical equipment Phoenix.6 Surgery in an ASC offers patients devices, environmental cleaning, point of including transporting, decontaminating, a cost-effective and convenient alternative care testing, and the infection prevention and sterilizing of surgical instruments. to surgery in a hospital setting. As of 2017, program.10 The surveyor will interview or Observing these practices can assist the there were approximately 5,500 Medicare- perform observations to acquire enough IP in creating a prioritized risk assessment certified ASCs in the United States.7 The information to complete the worksheet; to develop a successful IPC program plan. shift continues from inpatient to outpa- however, if a breach in IPC practices is tient as CMS adds to the 3,500 procedures