CDC Releases New Outpatient Safety Checklist to Reduce Infections

July 14, 2011 - Just as airline pilots are required to use safety checklists before taking off, so should medical facilities who are treating people on an outpatient basis, said the Centers for Disease Control and Prevention on Wednesday.

The CDC issued a new set of safety checklist guidelines to reduce outpatient infections because it has found that multiple facilities aren’t adhering to standard infection prevention practices.

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“Patients deserve the same levels of protection in a hospital or any other health care setting,” said Michael Bell, deputy director of the CDC’s division of health care quality promotion.

“Repeated outbreaks resulting from unsafe practices, along with breaches of infection control noted in ambulatory surgical centers during inspections by the (Centers for Medicare and Medicaid Services) indicate the need for better infection prevention.”

The CDC estimates that more than 2 million hospital-acquired infections occur in U.S. hospitals each year, and as many as 99,000 patients who get these infections die as a result. That has spurred hospitals to adopt safety checklists for their patients, through programs such as the Comprehensive Unit-based Safety Program, a joint venture led by several non-profit groups and hospitals to improve patient safety, and the World Health Organization’s surgical safety list.

Now the CDC has a recommended checklist for outpatients facilities such as non-hospital based clinics, physician offices, urgent care centers, outpatient surgical centers, public health clinics, imaging centers, oncology clinics, as well as hospital-based outpatient departments. The agency said that more than 75 percent of all operations are performed in these outpatient centers.

Press Release from CDC (July 13, 2011)

CDC Releases Infection Prevention Guide to Promote Safe Outpatient Care

Guide details minimum expectations for safe care, recommends every practice identify an infection prevention leader

Medical care in outpatient settings has surged in recent years, yet in many cases, adherence to standard infection prevention practices in outpatient settings is lacking. To protect patients and help educate clinicians about minimum expectations of safe care, the Centers for Disease Control and Prevention today released a new, concise guide and checklist specifically for health care providers in outpatient care settings such as endoscopy clinics, surgery centers, primary care offices, and pain management clinics.

"Patients deserve the same basic levels of protection in a hospital or any other health care setting," said Michael Bell, M.D., deputy director of CDC's Division of Healthcare Quality Promotion. "Failure to follow standard precautions, such as correct injection practices, cannot be tolerated. Repeated outbreaks resulting from unsafe practices, along with breaches of infection control noted in ambulatory surgical centers during inspections by the Centers for Medicare and Medicaid , indicate the need for better infection prevention across our entire health care system, including outpatient settings."

The Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care is based on existing, evidence-based CDC guidelines that apply to a wide range of health care facilities but are mostly used by hospitals. The easy-to-reference guide is accompanied by an Infection Prevention Checklist for Outpatient Settings and supporting materials including a new, no-cost, certified continuing medical education course titled Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes and offered on Medscape.org for clinicians in all health care settings. The video course was developed in collaboration with the Safe Injection Practices Coalition, a partnership of health care-related organizations formed to promote safe injection practices in all U.S. health care settings.

Among other important recommendations, the guide states that all outpatient practices should ensure that at least one individual with specific training in infection control is on staff or regularly available. This individual should be involved in developing a written infection control policy and have regular communication with health care providers to address specific issues or concerns.

The guide and supporting materials can be used for internal assessment within a facility or practice. They complement ongoing work by CDC and CMS to integrate CDC guidelines into CMS surveys used during inspections of outpatient settings including ambulatory surgery centers.

Outpatient settings, facilities where patients do not stay overnight, include non-hospital based clinics and physician offices, urgent care centers, outpatient surgical centers, public health clinics, imaging centers, oncology clinics, outpatient behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, as well as hospital-based outpatient departments and clinics.

More than three-quarters of all operations in the United States are performed at outpatient facilities. In addition, between 1995 and 2007, the average person made three visits each year to physician offices. By 2007, the total number of physician office visits approached 1 billion. Vulnerable patient populations make up a significant portion of health care users, and it is critical that care be provided under conditions that minimize the risk of health care-associated infections (HAIs).

These new materials reinforce that health care personnel should always:

● Follow procedures for the safe handling of potentially contaminated medical equipment
● Ensure safe medical injection practices are followed

Outpatient facilities and practices should:

● Develop and maintain infection prevention and occupational health programs

● Ensure that at least one individual with training in infection control is employed by or regularly available to the facility. This person should be responsible for overseeing the facility's infection prevention program

● Develop written infection-prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations, or standards

● Provide job- or task-specific infection prevention education and training to all health care personnel

● Make sure sufficient and appropriate supplies necessary for adherence to standard precautions are available

● Perform regular audits and competency evaluations of staff's adherence to infection prevention practices

● Utilize CDC's infection prevention checklist for outpatient settings to assess infection control practices

● Adhere to local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting

To access the guide, checklist, and supporting materials including the CME course, CDC and external commentary about the guide, clinician and patient education materials, a CDC Safe Surgery feature, and additional information, please visit http://www.cdc.gov/HAI/settings/outpatient/outpatient-settings.html.

CDC Check List

Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care

Outpatient Care Checklist: Personnel and Patient-care Observations

The Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care [PDF 538 KB] is a companion to the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. The checklist should be used:

To ensure that the facility has appropriate infection prevention policies and procedures in place and supplies to allow healthcare personnel to provide safe care.
To systematically assess personnel adherence to correct infection prevention practices.
(Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties.)

Facilities using this checklist should identify all procedures performed in their ambulatory setting and refer to appropriate sections to conduct their evaluation. Certain sections may not apply (e.g., some settings may not perform sterilization or high-level disinfection).

If the answer to any of the listed questions is No, efforts should be made to correct the practice, appropriately educate healthcare personnel (if applicable), and determine why the correct practice was not being performed. Consideration should also be made for determining the risk posed to patients by the deficient practice.

Certain infection control lapses (e.g., re-use of syringes on more than one patient or to access a medication container that is used for subsequent patients; re-use of lancets) can result in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants immediate consultation with the state or local health department and appropriate notification and testing of potentially affected patients.

Infection Prevention Checklist
I. Administrative Policies and Facility Practices

1. Facility Policies	Practice Performed	If answer is No, document plan for remediation
Written infection prevention policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards (Note: Policies and procedures should be appropriate for the services provided by the facility and should extend beyond OSHA bloodborne pathogen training)	Yes No
Infection prevention policies and procedures are re-assessed at least annually or according to state or federal requirements	Yes No
At least one individual trained in infection prevention is employed by or regularly available to the facility	Yes No
Supplies necessary for adherence to Standard Precautions are readily available (Note: This includes hand hygiene products, personal protective equipment, and injection equipment.)	Yes No

2. General Infection Prevention Education and Training1.	Practice Performed	If answer is No, document plan for remediation
Healthcare Personnel (HCP) receive job-specific training on infection prevention policies and procedures upon hire and at least annually or according to state or federal requirements (Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility.)	Yes No
Competency and compliance with job-specific infection prevention policies and procedures are documented both upon hire and through annual evaluations/assessments	Yes No

3. Occupational Health	Practice Performed	If answer is No, document plan for remediation
HCP are trained on the OSHA bloodborne pathogen standard upon hire and at least annually	Yes No
The facility maintains a log of needlesticks, sharps injuries, and other employee exposure events	Yes No
Following an exposure event, post-exposure evaluation and follow-up, including prophylaxis as appropriate, are available at no cost to employee and are supervised by a licensed healthcare professional	Yes No
Hepatitis B vaccination is available at no cost to all employees who are at risk of occupational exposure	Yes No
Post-vaccination screening for protective levels of hepatitis B surface antibody is conducted after third vaccine dose is administered	Yes No
All HCP are offered annual influenza vaccination at no cost	Yes No
All HCP who have potential for exposure to tuberculosis (TB) are screened for TB upon hire and annually (if negative)	Yes No
The facility has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use	Yes No
Respiratory fit testing is provided at least annually to appropriate HCP	Yes No
Facility has written protocols for managing/preventing job-related and community-acquired infections or important exposures in HCP, including notification of appropriate Infection Prevention and Occupational Health personnel when applicable	Yes No
For additional guidance on occupational health recommendations consult the following resource(s): Guideline for Infection Control in Healthcare Personnel [PDF - 285 KB] Immunization of HealthCare Personnel Occupational Safety & Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention Standards

4. Surveillance and Disease Reporting	Practice Performed	If answer is No, document plan for remediation
An updated list of diseases reportable to the public health authority is readily available to all personnel	Yes No
The facility can demonstrate compliance with mandatory reporting requirements for notifiable diseases, healthcare associated infections, and for potential outbreaks.	Yes No

5. Hand Hygiene	Practice Performed	If answer is No, document plan for remediation
The facility provides supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) and ensures they are readily accessible to HCP in patient care areas	Yes No
HCP are educated regarding appropriate indications for hand washing with soap and water versus hand rubbing with alcohol-based hand rub (Note: Soap and water should be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected infectious diarrhea (e.g., Clostridium difficile or norovirus). In all other situations, alcohol-based hand rub may be used.)	Yes No
The facility periodically monitors and records adherence to hand hygiene and provides feedback to personnel regarding their performance Examples of tools used to record adherence to hand hygiene [PDF - 165 KB]	Yes No
For additional guidance on hand hygiene and resources for training and measurement of adherence, consult the following resource(s). Guideline for Hand Hygiene in Healthcare Settings [PDF - 298 KB] Hand Hygiene in Healthcare Settings List of tools that can be used to measure adherence to hand hygiene [PDF - 165 KB]

6. Personal Protective Equipment (PPE)	Practice Performed	If answer is No, document plan for remediation
The facility has sufficient and appropriate PPE available and readily accessible to HCP	Yes No
HCP receive training on proper selection and use of PPE	Yes No
For additional guidance on personal protective equipment consult the following resource(s): 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

7. Injection Safety	Practice Performed	If answer is No, document plan for remediation
Medication purchasing decisions at the facility reflect selection of vial sizes that most appropriately fit the procedure needs of the facility and limit need for sharing of multi-dose vials	Yes No
Injections are required to be prepared using aseptic technique in a clean area free from contamination or contact with blood, body fluids or contaminated equipment	Yes No
Facility has policies and procedures to track HCP access to controlled substances to prevent narcotics theft/diversion	Yes No
For additional guidance on injection safety consult the following resource(s): 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings CDC's Injection Safety Website Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections CDC training video and related Safe Injection Practices Campaign materials

8. Respiratory Hygiene/Cough Etiquette	Practice Performed	If answer is No, document plan for remediation
The facility has policies and procedures to contain respiratory secretions in persons who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing through the duration of the visit. Policies include:	Yes No
Posting signs at entrances (with instructions to patients with symptoms of respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions.)	Yes No
Providing tissues and no-touch receptacles for disposal of tissues	Yes No
Providing resources for performing hand hygiene in or near waiting areas	Yes No
Offering facemasks to coughing patients and other symptomatic persons upon entry to the facility	Yes No
Providing space and encouraging 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	Yes No
The facility educates HCP 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.	Yes No
For additional guidance on respiratory hygiene/cough etiquette consult the following resource(s): 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Recommendations for preventing the spread of influenza

9. Environmental Cleaning	Practice Performed	If answer is No, document plan for remediation
Facility has written policies and procedures for routine cleaning and disinfection of environmental services, including identification of responsible personnel	Yes No
Environmental services staff receive job-specific training and competency validation at hire and when procedures/policies change	Yes No
Training and equipment are available to ensure that HCP wear appropriate PPE to preclude exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection)	Yes No
Cleaning procedures are periodically monitored and assessed to ensure that they are consistently and correctly performed	Yes No
The facility has a policy/procedure for decontamination of spills of blood or other body fluids	Yes No
For additional guidance on environmental cleaning consult the following resource(s): Guidelines for Environmental Infection Control in Healthcare Facilities [PDF - 285 KB]

10. Reprocessing of Reusable Instruments and Devices	Practice Performed	If answer is No, document plan for remediation
Facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another patient (Note: This includes clear delineation of responsibility among HCP.)	Yes No
Policies, procedures, and manufacturer reprocessing instructions for reusable medical devices used in the facility are available in the reprocessing area(s)	Yes No
HCP responsible for reprocessing reusable medical devices are appropriately trained and competencies are regularly documented (at least annually and when new equipment is introduced)	Yes No
Training and equipment are available to ensure that HCP wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection). (Note: The exact type of PPE depends on infectious or chemical agent and anticipated type of exposure.)	Yes No
The above basic information allows for a general assessment of policies and procedures related to reprocessing of reusable medical devices. Ambulatory facilities that are providing on-site sterilization or high-level disinfection of reusable medical equipment should refer to the more detailed checklists related to sterilization and high-level disinfection in separate sections of this document devoted to those issues. Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use (see Sterilization Section). Semi-critical items (e.g. , endoscopes for upper endoscopy and colonoscopy, vaginal probes) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse (see High-level Disinfection Section). Non-critical items (e.g., blood pressure cuffs) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination. Single-use devices (SUDs) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reprocessed for reuse except by entities which have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs. Note: Pre-cleaning must always be performed prior to sterilization and/or disinfection For additional guidance on reprocessing of medical devices consult the manufacturer instructions for the device and the following resource(s): Guideline for Disinfection and Sterilization in Healthcare Facilities FDA regulations on reprocessing of single-use medical devices

11. Sterilization of Reusable Instruments and Devices	Practice Performed	If answer is No, document plan for remediation
All reusable critical instruments and devices are sterilized prior to reuse	Yes No
Routine maintenance for sterilization equipment is performed according to manufacturer instruction (confirm maintenance records are available)	Yes No
Policies and procedures are in place outlining facility response (i.e., recall of device and risk assessment) in the event of a reprocessing error/failure.	Yes No
For additional guidance on sterilization of medical devices consult the manufacturer instructions for the device and the following resource(s): Guideline for Disinfection and Sterilization in Healthcare Facilities

12. High-Level Disinfection of Reusable Instruments and Devices	Practice Performed	If answer is No, document plan for remediation
All reusable semi-critical items receive at least high-level disinfection prior to reuse	Yes No
The facility has a system in place to identify which instrument (e.g., endoscope) was used on a patient via a log for each procedure	Yes No
Routine maintenance for high-level disinfection equipment is performed according to manufacturer instruction; confirm maintenance records are available	Yes No
For additional guidance on reprocessing of high-level disinfection devices consult the manufacturer’s instructions for the device and the following resource(s): Guideline for Disinfection and Sterilization in Healthcare Facilities

Some of this information is reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.

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