Infection control in the outpatient setting

Journal of Family Practice, June, 2004 by Doug Campos-Outcalt

Microbial antibiotic resistance, emergence of infectious diseases against which there are no treatments or vaccines, and the persisting possibility of intentional release of infectious agents have made the prevention of infectious disease transmission a top public health concern.

It is easy to overlook the potential for spreading infectious diseases in the outpatient setting. Relying on healthcare workers to practice good hygiene is unlikely to be enough. This public health battle must employ a comprehensive plan for clinic design, involving staff in setting and enforcing policies, and repeatedly emphasizing the importance of good hygiene.

* REASONS FOR CONCERN

Outpatient clinical settings are a prime location for the spread of infectious diseases, to staff and patients. In the past, when measles was common, physician offices were the source of infection in a significant proportion of all cases. Last year, hospitals were a principal focus for the spread of serious acute respiratory syndrome (SARS). This year's influenza season was complicated by doubts about vaccine effectiveness and the possibility of a more virulent strain, making prevention of disease transmission a primary concern.

As the Centers for Disease Control and Prevention (CDC) and state and local health departments struggle to contain these and other infectious diseases, physicians should insure that their facilities and systems are designed to prevent disease spread and, in so doing, set an example for the community. Physicians and office managers can take 4 basic steps:

* Institute and enforce policies on respiratory hygiene

* Institute and enforce policies on hand hygiene

* Immunize all office staff

* Establish triage policies that separate potentially contagious patients from the rest.

* RESPIRATORY HYGIENE

The concept of respiratory hygiene is not new, but it has not been a visible part of American culture. This is changing. The CDC has published recommendations on respiratory hygiene and cough etiquette for healthcare settings (Table). (1) As the public becomes aware of the dangers of respiratory diseases, these recommendations may become the norm of common courtesy.

* HAND HYGIENE

Hand hygiene has also recently received more attention, and a variety of new products can assist healthcare professionals with this task. The CDC recommends physicians should use an alcohol-based hand rub or an antimicrobial soap for routinely decontaminating hands. (2) If hands are visibly dirty or soiled they should be washed with soap (either antimicrobial or non-antimicrobial) and water. Situations in which hands should be decontaminated:

* Before direct patient contact

* After contact with a patient's skin

* After gloved contact with body fluids, mucous membranes, and dressings

* After contact with contaminated medical equipment

* Before and after gloving for procedures. Alcohol-based products are preferred for decontamination; antimicrobial soaps are acceptable, but neither works well against bacterial spores. In the rare instance when exposure to anthrax spores is suspected from a suspicious powder, hand washing with soap and water is recommended. Consult CDC guidelines for hand hygiene for a description of antiseptic agents and their activity against different infectious agents. (2)

* IMMUNIZATION

Immunization of physicians and others on the healthcare team is important for the protection of staff and patients. The CDC strongly recommends3 that all healthcare workers, except with contraindications, receive the following:

* Influenza vaccine annually

* Measles, mumps, and rubella vaccine or proof of immunity, including birth before 1957, lab evidence of immunity, or proof of immunization with 2 doses of live measles separated by at least 28 days, 1 dose of live rubella, and 1 dose of live mumps vaccine, all on or after the first birthday

* Varicella vaccine, or proof of immunity including a reliable history of varicella infection, laboratory evidence of immunity, or proof of immunization. Adequate immunization is 1 dose of varicella vaccine, if administered before age 13, or 2 doses at least a month apart if administered after age 13.

In addition, CDC recommends hepatitis B vaccine for all healthcare workers who have contact with or exposure to blood and body fluids. Two months after the completion of a 3-dose series, those with risks of injury from needle sticks or sharp instruments should be tested for antibody to hepatitis B surface antigen. If they have not developed any antibody, they should be checked for hepatitis B surface antigen; if results are negative, they should receive a second 3-dose series.

Guidelines should also be in place for management of healthcare workers exposed to certain infectious diseases at work, including tuberculosis, blood-borne pathogens, varicella, and others.

* TRIAGE POLICIES

Physicians and clinic managers should consider implementing triage policies to separate infectious patients from others when they arrive at the facility. If respiratory hygiene measures are followed, asking those with common respiratory infections sit in common waiting areas and using common exam rooms is acceptable practice.