Healthcare-Associated Infections: Infection Prevention in Ambulatory Settings

Bloodborne pathogen exposures

Outbreaks due to bloodborne pathogen exposure from unsafe injection practices happen most frequently in the ambulatory care setting. Unsafe injection practices can include:

• Reuse of needles, syringes, or IV tubing for more than one patient.
• Reuse of needles or syringes to access a medication container and then using the contents of that container for another patient.
• Reuse of fingerstick devices for more than one patient.
• Drug diversion.

Facilities should ensure staff are trained and competent on safe injection practices to reduce the risk of disease transmission associated with unsafe injection practices.

Respiratory exposures

Respiratory exposures to diseases, such as TB, measles, and whopping cough can also lead to disease transmission among health care personal and other patients or visitors. Facilities should perform a risk assessment to determine the types of respiratory hazards that may be encountered in their facility and the type of PPE that should be used.

Facilities that identify respiratory hazards should establish and maintain a respiratory protection program (RPP) per the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard (29CFR 1910.134).

Multidrug-resistant organisms

Multidrug-resistant organisms (MDROs) can be spread in ambulatory care settings. Targeted infection prevention measures should be implemented to prevent the spread whether a patient is infected or colonized with an MDRO.

Steps health care personnel can take to prevent infections

• At a minimum, all outpatient settings must follow basic infection control practices. These are outlined in the CDC's (Centers for Disease Control and Prevention) Core Infection Prevention and Control Practices and Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care (PDF). In Wisconsin, Medicare-certified ambulatory surgery centers (ASCs) have additional rules and regulations that must be met.
• Implement empiric transmission-based precautions in addition to standard precautions based on the clinical syndrome or condition that is present at the time of the visit to reduce the risk of disease transmission within ambulatory care settings.
• Prevent the spread of MDROs, P-42513 (PDF) In general, standard precautions with an emphasis on hand hygiene, PPE use for high-risk activities, and environmental and equipment cleaning is sufficient to prevent the spread of MDROs in the outpatient setting.
  • Use gown and gloves during extensive patient contact and contact with uncontrolled secretions, pressure ulcers, draining wounds, incontinence, and ostomy tubes and bags.
  • Wear masks during splash-generating procedures (for example, wound irrigation, oral suctioning, and intubation); when providing care for patients with open tracheostomies and the potential for projectile secretions; and in circumstances where there is evidence of transmission from heavily colonized sources, such as burn wounds.
  • Clean and disinfect any surfaces (such as chairs and exam tables) and reusable equipment, such as blood pressure cuffs, that came into contact with the patient, such as chairs and exam tables. Use disinfectants that have an Environmental Protection Agency (EPA) registered claim for the targeted organism(s).
  • Communicate a patient’s MDRO status. Have a system in place to flag the patient's chart with the MDRO status. Inform (PDF) the receiving facility of the patient's MDRO status if the patient needs to be admitted or referred.
  • Educate patients about their MDRO status and what they can do when visiting health care settings.
• Audit infection prevention practices within the facility. Auditing infection prevention practices is a key to gathering process data to drive an infection control program. Auditing gives a pulse on how well infection control processes are adhered to and what quality improvement projects should be worked on. Utilizing standard auditing tools (PDF) allows facilities to establish baseline data and maintain performance on basic infection prevention measures. Audits also allow for the quick identification of performance improvement needs and targeted or risk-based monitoring if HAIs occur or an unexpected increase is noted.

Steps you can take to prevent infections

• Wash your hands often or use an alcohol-based hand sanitizer.
• Speak up if you have any questions or worries about the care you are provided. Ask your health care provider what steps they are taking to prevent infections.
• Be antibiotics aware and use antibiotics safely. Antibiotics can save lives but it’s important that we use them safely and only when needed.
• Know the signs and symptoms of infection, such as redness, pain, or drainage. If you notice any of these signs, talk to a health care provider.
• Stay up to date with vaccinations.
• Cover your mouth and nose when you sneeze or cough. Use a tissue to avoid spreading germs to your hands.

National Healthcare Safety Network (NHSN)

In 2019, NHSN developed the Outpatient Procedure Component, specifically for ambulatory surgical centers (ASCs), to allow the use of epidemiologically sound infection definitions to assist in benchmarking ASC outcome data.

Collecting data through NHSN allows facilities to stratify surgical site infections (SSIs) rates according to risk factors associated with SSI development and allow data feedback.

There are currently 30 different Current Procedural Terminology (CPT®) code categories that can be included in surveillance. New codes are added each year as the procedure landscape continues to evolve in the outpatient setting.

Enrollment in NHSN is voluntary and allows facilities to use risk assessments to determine which operative procedure to monitor.

Learn more about NHSN

• CDC, Core Elements of Outpatient Antibiotic Stewardship 
• CDC guides for specific high risk settings:
  • Basic Infection Control and Prevention Plan for Outpatient Oncology Settings (PDF)
  • Guide to IP in Orthopedic and Pain Management Office Settings (PDF)
  • Guide to Infection Prevention for Outpatient Podiatry Settings (PDF)
  • Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care (PDF)
• Centers for Medicare and Medicaid Services (CMS) and the Department of Health Services (DHS), Emergency Preparedness Rule Toolkit, P-01948e (PDF) – ASCs
• DHS, Antimicrobial Stewardship website
• DHS, Healthcare-Associated Infections: Infection Prevention in Dialysis Settings website
• DHS, Trends in Outpatient Antibiotic Prescribing 2018- 2021, P-03383 (PDF)

• Association for Professionals in Infection Control and Epidemiology, Infection Prevention and You website
• CDC, Antibiotic Resistance: Protect Yourself and Your Family webpage
• DHS, Healthcare-Associated Infections: Information for Patients and Families webpage
• DHS, What Can I Do to Prevent an Infection After Surgery brochure, P-01228 (PDF)
• Wisconsin Hospital Association CheckPoint,® Consumer resources webpage
• CMS, Care Compare website