Infection Control in Outpatient Settings: Old Challenges, New Realities

Picture a busy outpatient clinic: physical therapy, oncology, cardiac, dental, urgent care. Over the course of a day, dozens of people—even amid COVID-19—may pass through its rooms: staff, patients, parents, caregivers, delivery people. In the US, outpatient visits have climbed steadily, to nearly a million in 2019 alone. According to the CDC’s “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care,” the past several decades have seen a “significant shift” in health care delivery from the acute, inpatient hospital setting to a variety of outpatient and community-based settings. More than three-fourths of all operations in the US are performed in settings outside the hospital.

But although they have the same main players—health care providers, other staff, patients—outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Epidemiologist Joe Perz, DrPH, who works for the CDC’s Prevention and Response Branch, told Infection Control Today® (ICT®) that “compared with inpatient care in a hospital setting or congregate care in long-term care settings like nursing homes, the outpatient environment has a ton more variety, in terms of the types of care provided. While core practices like hand hygiene and environmental cleaning apply to all patient encounters, outpatient settings also provide more specialized forms of care that come with more specialized infection control requirements. Plus, the volume of patient encounters is staggering, and this is spread across an enormous number of individually operated facilities, many of which do not have clear lines of oversight for infection control. These distinctions present significant challenges.”

Top 3 Challenges

If Perz had to list the top 3 of those challenges, here’s what he would choose: “Broadly speaking, I’d cite awareness, attention, and consistency. Traditionally, many outpatient settings had infection control quite low on their list of priorities and concerns. Too often it was out of sight and out of mind. Not surprisingly, knowledge of even the basics of infection control was lacking and we saw many gaps in terms of things like hand hygiene, injection safety, cleaning, and even device reprocessing. There were attention deficits and a lot of inconsistencies in terms of how outpatient providers practiced infection control.”

The result? The CDC says data similar to those for hospital-acquired infections are lacking for most outpatient settings, but “numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses, and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures.”

Case in point: In 2015, a CDC research team reviewed investigations of health care-associated infection outbreaks in Los Angeles outpatient settings between 2000 and 2012. Of the 28 investigations, 79% revealed more than 1 infection control breach.

Lapses in infection control were suspected as the source for 16 (57%) of the investigations, such as using single-use medications multiple times or reusing fingerstick blood glucose meters. Bacterial agents were implicated in half of the identified outbreak investigations. Breaches were frequently associated with injection safety, equipment processing and sterilization, and environmental cleaning. An investigation of a urology office, for instance, revealed that the facility had been improperly cleaning and disinfecting cystoscopes for more than 10 years.

The investigators were perturbed by their findings. “The lack of change in 5 decades related to outbreak source and infections resulting from preventable unsafe behaviors is alarming,” they wrote in their report for Emerging Infectious Diseases, “Most outbreaks documented could have been prevented by using standard precautions and practicing basic infection control. These findings highlight a need for more infection control oversight of outpatient settings, as well as better reporting from outpatient settings.”

That was 6 years ago. Has time made a difference? Time that has included COVID-19? Things have changed, after all. A 2020 data analysis found visits to ambulatory practices declined nearly 60% by early April 2020. Even after a rebound (across all specialties), numbers were still roughly one-third lower than before the pandemic.

And in a 2021 study, investigators tallied outpatient visits between January 1, 2020, and June 15, 2020, among 16,740,365 patients across the US. They found in-person visits from January 1 to June 10 dropped from 102.7 to 76.3 (a decrease of 26.4 or –30.0% change). By the last 4 weeks, the percent change from baseline ranged from –73.2% in Hawaii to –16.0% in Alaska.

No matter how few the visits, though, the basic problems remain. Kelsey OYong, MPH, CIC, supervising epidemiologist at Los Angeles County Department of Public Health and lead author on the investigation review, tells ICT® that “other than COVID-19 in the past 2 years, lapses in infection control continue to be the most common source of outbreaks.”

Though this varies by outpatient setting type, says OYong, her department continues to see reuse of single-dose vials and equipment as outbreak sources. Culprits also include environmental contamination and improper cleaning and disinfection of equipment.

“In a way,” says OYong, “the COVID-19 pandemic has highlighted the importance of infection prevention generally, and specifically in the realms of respiratory hygiene, personal protective equipment, source control, and employee health. Many outpatient settings are improving infection control practices and knowledge as it relates to respiratory diseases. We hope that this knowledge translates to other diseases, spread by contact or procedures, as well.”

Wanted: Stronger Support

The ultimate goal in all this is not only good health care, but safe health care (take another look at the title of the CDC guide, however; it sets the bar for safe care with “minimum expectations”). Many vulnerable patient populations rely on “frequent and intensive use of outpatient care to maintain or improve their health,” the guide says. Each year, for instance, more than 1 million cancer patients receive outpatient chemotherapy, radiation therapy, or both. But according to CDC data, since 2002, at least 9 serious infectious disease outbreaks, including unsafe injection practices, have occurred in cancer clinics. Hundreds of patients were infected; thousands more required notification and testing for blood-borne pathogens.

Obviously, building—or reinforcing—a stronger foundation for infection control would help. Compared with inpatient acute care settings, the CDC says, outpatient settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. And, to restate more of the obvious, outpatient settings are not like inpatient settings.

“In the broader context of all the hardships we’ve experienced, on the provider and patient sides of ambulatory care, there is greater appreciation of infection risk,” says Perz. “And we are seeing this across the spectrum, from primary care to specialized outpatient settings.” But, he adds, “to maintain effective outpatient care, there needs to be a foundation of protections, for both patients and health care workers.

OYong agrees. “The pandemic has stretched health care workers to their professional and emotional limit. For many settings, the majority of staff time is now spent on COVID-19 response efforts, taking away especially from surveillance and adherence monitoring activities. Stress and burnout are serious concerns for the health care workforce.”

They’re not only worn out; they’re also being stretched intolerably thin.“For infection preventionists in the outpatient setting,” she says, “juggling many different roles is a big challenge. They often play the role of infection preventionist, employee health director, risk manager, health educator, and health care epidemiologist, plus their normal nursing and clinical roles.”

Moreover, she points out that “sometimes designated infection preventionists [Ips] in outpatient settings don’t have the same access to resources or community that inpatient IPs have. They often work independently if they’re not part of a larger health care system or network and may not have access to community best practices or policies.”

Project Firstline

That’s beginning to change, though, Perz says. “One very positive development I’d like to highlight is Project Firstline, CDC’s national infection control training collaborative. Project Firstline’s content is designed so that, regardless of a health care worker’s previous training or educational background, they can understand and apply the infection control principles and protocols needed to protect themselves, their facility, and their patients from all infectious disease threats, such as COVID-19.” (“The COVID-19 pandemic has underscored gaps in infection control knowledge and practice in healthcare settings nationwide,” the website says.)

Project Firstline teams up a coalition of academic, public health, and health care partners plus 64 state, local, and territorial health departments through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases Cooperative Agreement. One of the initiatives integrates “enhanced infection control content” into community college classrooms. The program designers say they chose community colleges because they educate a significant portion of the US nursing and allied health care workforce; know how to meet the unique training needs of a diverse, intergenerational health care workforce; and are equipped to tailor training and educational resources to fill critical gaps in underserved communities.

While those up-and-coming health care providers are being trained, what to do about the ones with boots already on the ground? OYong has some suggestions for how to handle the persistent challenges she and the other investigators identified in 2015. For instance: Make it a group effort. The pandemic naturally changed practice. It also may have changed attitudes about “my job” vs “their job”; we’re truly all in this together.

“Building an infection prevention team helps mitigate all of those responsibilities falling to a single person,” she says. “Creating a facility-wide culture of safety helps all staff take accountability for infection control. Empowering all staff to speak up when they see issues with PPE, injection safety, etc. helps stop lapses at their source.”

Perz says “thepandemic experience taught us a lot about keeping our guards up to keep infection risks down. This begins when patients enter—or even approach—an outpatient facility. We are now all much more sensitive to the needs for things like screening, triage, and source control. We have been forced to be more mindful of the needs for worker protections, which were often taken for granted. These needs were all present prior to the pandemic but were vastly underappreciated.”

In the meantime, here’s his best evidence- and experience-based advice: “Remember that your efforts to stem the spread of infections are making a real difference. As health care providers, your mission has always been to protect health and promote quality of life. More than ever, infection control is central to this mission.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.