Fighting infection in the doctor’s office – The Journal of Healthcare Contracting

Hospitals are improving in the fight against infection. How about those newly acquired physician practices?

Editor’s note: Healthcare-acquired infections are among the leading causes of death in the United States, according to the U.S. Department of Health and Human Services. At any given time, about one in 20 patients has an infection related to their hospital care. Healthcare-acquired infections alone are responsible for $28 billion to $33 billion in preventable healthcare expenditures annually. These infections are largely preventable and can be significantly reduced to save lives and avoid excess costs. This month, the Journal of Healthcare Contracting looks at infections that can be incurred in the physician’s office – their causes, preventive measures and the role of the supply chain executive.

A culture of infection prevention marks most hospitals. Yes, improvement is needed. But in most hospitals, infection prevention professionals, epidemiologists, central sterile professionals, the OR team and others work diligently to keep patients and healthcare workers safe and infection-free.

But who’s minding the store in the physician’s office? As more and more hospitals and IDNs acquire physician practices, it’s a question that hospital administrators, infection preventionists and even supply chain executives will be asking.

There’s little oversight of physicians’ offices, particularly when compared with other sites that are accredited by the Centers for Medicare & Medicaid Services, such as hospitals and ambulatory surgery centers, notes Gina Pugliese, RN MS, vice president, Safety Institute, Premier healthcare alliance. “Physician offices are not subject to CMS oversight, and thus, these facilities do not undergo onsite surveys.”

It’s rare for an independent medical practice to designate one person with responsibility for infection control, she continues. “It’s a job shared by many, and it includes monitoring for unsafe practices.”

“I think it’s sort of the last frontier,” says Ann Marie Pettis, RN, BSN, CIC, director of infection prevention for the University of Rochester Medical Center, Rochester, N.Y.

What’s the big deal?
Physicians offices present their own set of infection-prevention challenges, says Pettis, whose IDN has, like many others, acquired physician practices in recent years.

“A lot of times, they have environmental challenges,” she says. In some cases, old homes or buildings were converted to medical offices. So, space can be a challenge.

“They don’t always have adequate space to separate ‘clean’ and ‘dirty’ areas,” for low-level disinfection, high-level disinfection and sterilization. “You should really have two separate rooms, but in most practices, you don’t have that. So you need signage and dedicated sinks, and you need to be creative in how you separate these things.”

It’s important that healthcare workers sanitize equipment – e.g., stethoscopes, glucometers – between uses, continues Pettis. Outbreaks of hepatitis B and C have been linked to improper sanitization of instruments in the office.

“One of the things we try to emphasize is, ‘Does the practice have the right chemical for cleaning the environment or disinfecting equipment?’” continues Pettis. “Are they using it correctly? Are they adhering to proper application techniques and drying times? Extensive training is required for environmental service workers.”

Sterilization of instruments presents its own set of challenges, she says. “You find that physicians and nurses don’t get a lot of infection prevention concepts in their curriculum. Therefore, they don’t always know what they don’t know.” Are they testing their sterilizers regularly? Do they know how to properly store instruments and equipment after sterilization?

Unsafe injection practices
Unsafe injection practices present another potential hazard in the physician office, says Pettis. In fact, the federal government documented 68 cases of viral hepatitis being transmitted in outpatient settings from 2001 to 2011 in 18 facilities – all traced to unsafe practices with multidose vials and needles and syringes.

And in 2007, the Centers for Disease Control and Prevention reported that four large outbreaks of hepatitis B and hepatitis C – in a private medical practice, pain clinic, endoscopy clinic and hematology/oncology clinic – could be traced back to the following two infection-control breaches: reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag), and use of a single needle/syringe to administer intravenous medication to multiple patients. (See related article.)

“Injection safety is a potential risk in any setting where injections are performed,” says Pugliese. “Patients should be aware that it is one syringe, one patient, one time…and they should speak up to the provider if there is any question.”

The waiting areas of physicians’ offices present another potential challenge to infection prevention. Seats are often close together, so sick people are sitting almost on top of one another, says Pettis. Have patients been triaged on the phone, so that those who present with potentially serious respiratory issues, such as tuberculosis, are scheduled at the end of the day and are ushered immediately into an exam room? Does the waiting area have large, visible signs reminding visitors to cover their mouths when coughing and washing their hands? Are tissues, alcohol-based handrubs and masks readily available for visitors’ use?

Are the toys in pediatricians’ offices cleaned and disinfected regularly? And what are oncologists doing to protect their immunocompromised patients, who are particularly susceptible to infection. “There are certain populations who are at higher risk than others,” says Pettis. “Risk can be practice-specific.”

Change coming?
The state of the art in gathering data on physician-office-acquired infections is rudimentary, according to those with whom the Journal of Healthcare Contracting spoke. National attention on the potential infection-control hazards of outpatient centers, including physicians’ offices, ebbs and flows, peaking with occasional, highly publicized, outbreaks of disease.

CMS has instituted a voluntary program, the Physician Quality Reporting System, or PQRS, which offers incentives to physicians who report data on quality measures for covered professional services for Part B Medicare beneficiaries, points out Pugliese. CMS intends for the system to form the basis of a value-based purchasing program for physicians paid under the Medicare physician fee schedule. But the quality measures focus on diagnostic and treatment-related issues, not surveillance of healthcare-acquired infections.

But the winds of change are blowing.
“Increased awareness of injection safety lapses from large outbreaks has made us more vigilant, and likely has resulted in increased reporting of cases and outbreak investigations,” says Pugliese.

Another harbinger of change are discussions underway to address infection prevention and control in the physician’s office in the next phase of the U.S. Department of Health and Human Services’ “National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination.” Phase 1 dealt with acute-care hospitals; Phase 2 with ambulatory surgery centers, end-stage renal disease facilities, and increasing influenza vaccination among healthcare personnel; and Phase 3 with long-term-care facilities.

Value-based purchasing for physicians’ services may currently focus on diagnosis and treatment-related issues, but it should have a favorable impact on infection rates in the physician’s office, says Pugliese, who is a member of the National Quality Forum’s patient safety committee as well as the Department of Health and Human Services’ Healthcare Infection Control Practices Advisory Committee, or HICPAC. Several safety measures relate to antibiotic usage, specifically, correct prescribing habits for antibiotics. Ending the overprescribing of antibiotics is one way to attack infections and antibiotic-resistant organisms.

Today’s emphasis on treating the whole patient, rather than individual diseases, should help as well, she says. Proper diagnosis, monitoring and treatment of diabetic patients, for example, can help avoid infections and peripheral vascular disease, which can lead to infections. “Looking at the patient more completely in how you diagnose and treat them prevents complications,” including infections.

Hospital oversight
Physician office staff are growing more cognizant of the need to optimize their performance in infection prevention, says Pettis. Lacking resources and infection prevention expertise of their own, they are hiring infection prevention professionals, often from hospitals, to come in on a consulting basis to help them improve their practices. Hospitals or IDNs that have acquired physician practices typically send in their infection preventionists to offer support. “I think there’s a real need, and that there have been improvements to patient safety, because of the fact that so many physician offices are coming under the umbrella of the hospital,” she says.

Gathering data on infections in the physician office can be difficult, she adds. However, infection preventionists and office staff can focus on process measures – such as safe injection practices or handwashing protocols – in non-hospital sites.
One more thing to be monitored? Physician office culture. As physicians face a reimbursement squeeze, shortcuts can be taken. “Everybody has to be more vigilant,” says Pugliese. Just as important, the physician office must become a place where anyone on staff feels free to speak up if he or she detects practices that might compromise patient or worker safety.”

Sidebar:

One needle, one syringe, one time
Safe injection practices can reduce infection in the doctor’s office

Injected medicines are commonly used in healthcare settings for the prevention, diagnosis, and treatment of various illnesses. But unsafe injection practices put patients and healthcare providers at risk of infectious and non-infectious adverse events and have been associated with a wide variety of procedures and settings. This harm is preventable, according to experts.

The risk
In the last decade, more than 125,000 patients in the United States were advised to get tested for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV due to the reuse of syringes and misuse of medication vials.

A review of outbreaks by the Centers for Disease Control and Prevention (CDC), published in the January 2009 edition of the Annals of Internal Medicine, identified 33 hepatitis outbreaks between 1998 and 2008 resulting from deficient healthcare practices. The study focused on outbreaks that occurred in outpatient settings, such as doctors’ offices, outpatient clinics, dialysis centers, and nursing homes. Unsafe injection practices, such as reuse of syringes, accounted for most of the infections and exposures.

An investigation of four large outbreaks of HBV and HCV among patients in ambulatory care facilities in the United States identified two primary breaches in infection control practice that contributed to these outbreaks: reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag), and use of a single needle/syringe to administer intravenous medication to multiple patients. In one of these outbreaks, preparation of medications in the same workspace where used needle/syringes were dismantled also may have been a contributing factor.

Safe injection practices
Outbreaks related to unsafe injection practices indicate that some healthcare personnel are unaware of, do not understand, or do not adhere to basic principles of infection control and aseptic technique. For example, a survey of U.S. healthcare workers who provide medication through injection found that 1 percent to 3 percent reused the same needle and/or syringe on multiple patients.

To ensure that all healthcare workers understand and adhere to recommended practices, principles of infection control and aseptic technique need to be reinforced in training programs and incorporated into institutional polices that are monitored for adherence.

The following recommendations apply to the use of needles, cannulae that replace needles, and, where applicable, intravenous delivery systems:

Use aseptic technique to avoid contamination of sterile injection equipment.
Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.
Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only, and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
Do not keep multidose vials in the immediate patient treatment area, and store in accordance with the manufacturer’s recommendations. Discard if sterility is compromised or questionable.
Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.

Only when patients and providers both insist on “One Needle, One Syringe, Only One Time” for each and every injection will the risk of contracting infectious disease through injections be eliminated.

Sidebar 2:

Avoiding infections in the doctor’s office: Key recommendations
CDC provides guidance to doctors’ office staff in 2011 document

Compared to inpatient acute care settings, ambulatory care settings have traditionally lacked the infrastructure and resources to support infection prevention and surveillance activities, points out the Centers for Disease Control and Prevention in its 2011 publication, “Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care.” Yet incidents of outbreaks have demonstrated the need for greater understanding and implementation of basic infection prevention guidance in outpatient settings, including physician offices.

Administrative recommendations
All healthcare settings, regardless of the level of care provided, must be equipped to observe Standard Precautions, that is, the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. In addition, they should:

Develop and maintain infection prevention and occupational health programs.
Assure sufficient and appropriate supplies necessary for adherence to Standard Precautions (e.g., hand hygiene products, personal protective equipment, injection equipment).
Ensure that at least one individual with training in infection prevention is employed by or regularly available to the facility.
Develop written infection prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations, or standards.

Education and training of healthcare personnel

Provide job- or task-specific infection prevention education and training to all healthcare personnel, including those employed by outside agencies and available by contract or on a volunteer basis to the facility.
Training should focus on principles of both healthcare personnel safety and patient safety.
Training should be provided upon orientation and repeated regularly (e.g., annually).
Competencies should be documented initially and repeatedly, as appropriate for the specific healthcare personnel positions.

Surveillance and reporting of healthcare-acquired infections

Adhere to local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting. (A list of state reportable disease websites is available at: http://www.cste.org/dnn/ProgramsandActivities/PublicHealthInformatics/PHIStateReportableWebsites/tabid/136/Default.Aspx).
Perform regular audits and competency evaluations of healthcare personnel adherence to infection prevention practices.

Hand hygiene

Key situations where hand hygiene should be performed include:
1. Before touching a patient, even if gloves will be worn.
2. Before exiting the patient care area after touching the patient or the patient’s immediate environment.
3. After contact with blood, body fluids or excretions, or wound dressings.
4. Prior to performing an aseptic task (e.g., placing an IV, preparing an injection).
5. If hands will be moving from a contaminated-body site to a clean-body site during patient care.
6. After glove removal.
Use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus). Otherwise, the preferred method of hand decontamination is with an alcohol-based hand rub.

Personal protective equipment
Personal protective equipment (PPE) refers to wearable equipment that is intended to protect healthcare personnel from exposure to or contact with infectious agents. Examples include gloves, gowns, face masks, respirators, goggles and face shields. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents.

Facilities should ensure that sufficient and appropriate PPE is available and readily accessible to healthcare personnel.
Educate all personnel on proper selection and use of PPE.
Remove and discard PPE before leaving the patient’s room or area.
Wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment. (Do not wear the same pair of gloves for the care of more than one patient; do not wash gloves for the purpose of reuse; perform hand hygiene immediately after removing gloves.)\
Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated. Do not wear the same gown for the care of more than one patient.
Wear mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids.
Wear a surgical mask when placing a catheter or injecting material into epidural or subdural space.

Safe injection practices

Use aseptic technique when preparing and administering medications.
Cleanse the access diaphragms of medication vials with 70 percent alcohol before inserting a device into the vial.
Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing.
Do not reuse a syringe to enter a medication vial or solution.
Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient.
Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient.
Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle).
Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof.
Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens.

Cleaning and disinfection of environmental surfaces

Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in ambulatory care settings. Focus on those surfaces in proximity to the patient and those that are frequently touched.
Select EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare.
Follow manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use, and disposal).

Cleaning, disinfection, and/or sterilization of medical equipment

Facilities should ensure that reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately prior to use on another patient.
Reusable medical equipment must be cleaned and reprocessed (disinfected or sterilized) and maintained according to the manufacturer’s instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multipatient use.
Assign responsibilities for reprocessing of medical equipment to healthcare personnel with appropriate training. Maintain copies of the manufacturer’s instructions for reprocessing of equipment in use at the facility; post instructions at locations where reprocessing is performed. Observe procedures to document competencies of healthcare personnel responsible for equipment reprocessing upon assignment of those duties, whenever new equipment is introduced, and on an ongoing periodic basis (e.g., quarterly).
Assure healthcare personnel have access to and wear appropriate personal protective equipment when handling and reprocessing contaminated patient equipment.

Respiratory, hygiene/cough etiquette

Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the duration of the visit.
1. Post signs at entrances with instructions to patients with symptoms of respiratory infection to: 1) cover their mouths/noses when coughing or sneezing, 2) use and dispose of tissues, 3) perform hand hygiene after hands have been in contact with respiratory secretions.
2. Provide tissues and no-touch receptacles for disposal of tissues.
3. Provide resources for performing hand hygiene in or near waiting areas.
4. Offer masks to coughing patients and other symptomatic persons upon entry to the facility.
5. Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care.
Educate healthcare personnel on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.

Source:Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care, Centers for
Disease Control and Prevention, http://www.cdc.gov/hai/pdfs/guidelines/ambulatory-care-04-2011.pdf