Infection Control in The Outpatient Clinic 6 th Borneo International Infection Control Congress 20-21th September 2018
Definition: Outpatient Facilities or Ambulatory Care • Facilities where patients do not remain overnight • Gain popularity in recent years – reduces admission, cost of healthcare • Poses unique challenges to infection control
Outpatient
Outpatient or Ambulatory Care DIAGNOSIS OBSERVATION CONSULTATION TREATMENT INTERVENTION REHABILITATION
Outpatient or Ambulatory Care • Comprises – Outpatient clinic : Hospital vs non-Hospital – Specialized clinic – Hemodialysis – Physiotherapy, Rehabilitation – Radiotherapy – Radiology – Day care center- oncology, Thalassaemia, surgery (endoscopy, day care surgery)
Definition • Healthcare personnel (HCP) • All persons (paid or unpaid) • Working in outpatient settings • Who has potential for exposure to patients and /or to infectious materials, including body substances, contaminated medical supplies, devices, contaminated environmental surfaces, or contaminated air • (includes clerical, house keeping, volunteers)
Definition – Healthcare personnel
Outbreaks reported
HONG KONG
Dedicat ed resourc es (admin) Fundamen Standar Educate tal d & Train Precautio HCP Elements n Monitor & Report HCAI
Dedicate resources (administrative) • Develop & maintain IP programs • Sufficient and appropriate equipment & supplies e.g. HH products, PPE, injection • At least one IP trained personnel (HR) • Written IP policies & procedures – Tailor according to services provided and patients populations – Prioritize & focus
Local Challenges • OPD IP policy still lacking • Lack of infection control trained HCP • ICN – multi-tasking e.g. administrative and nursing • Old building structure inadequate sink, ventilation, dedicated rooms for isolation • Lack awareness among HCW, Administrations • Lack of funding or administrative support
The administration • May not necessary to central government • Local head of unit eg Family medicine in- charge of unit, Matron or sister in-charge, head of radiology unit aware the importance of infection prevention
Education and Training in OPD • Job & Task-specific Education & Training • Focus on both HCP safety and patient safety • Provided upon hire & repeat, when policies revised • Competencies - documented
Local Scenario • Workshop on outpatient infection control • Head of unit to send relevant HCP to attend workshop OR post basic training • Retain trained HCW in IP
HAI Surveillance & Reporting Need National • Educate patients signs & symptoms of Policy Local audit infection, notify the facilities - local project • Local and National requirement of HAI - Understands local surveillance issue • Regular audit of HCP adherence
Standard precaution Cough & HH PPE Respiratory Etiquette Equipment Safe Injection sterilization & Practice disinfectant Linen and Environment Waste Cleaning Handling
$$$$ ?? STANDARD PRECAUTION
Prioritize is the KEY
Patient Triage - OPD • Experience or trained staffs – TRIAGE • Besides severity, potentially infectious patients identified. Examples: – Respiratory symptoms • Traveling : Middle East, Africa • TB • Pertussis (vaccination history) • Diarrhea – Fever + rash + 3 C = conjunctivitis, coryza, cough) measles
Triage
Registration Triage area • Visual alert – Banners, Poster, video, make announcement • HCP : Active Advice (BRIEF) / pamphlet – Cough etiquette/ Hand Hygiene • Equipment : Surgical mask , Alcohol hand rub at counter • Offer surgical mask, tissue to respi cases • Suspect – Measles ( fever, rash with 3 ”C” isolation ) – Chronic cough >3 weeks TB ( facilitate process)
Waiting Area • To provide reading material, pamphlets • To give a short CME or medical talk on relevant topics e.g. cough etiquette, hand hygiene, disease transmission eg TB • To provide educational video in waiting area • To provide alcohol hand rub (waiting & clinic)
Hand Hygiene
Personal Protective Equipment Prioritize - understand own usage
Cough & Respiratory Etiquette
Others • Separate : Diabetic clinic and TB clinic and OPD clinic • Well child clinic/ vaccination clinic screen and separate or expediate from sick children from vulnerable group eg severe premature, congenital heart disease, chronic lung disease
Environment Cleaning • One of the most important steps of infection control • Ensure Hospital Support Service Staffs (HSS) are being trained for environment cleaning & understand their important role • Emphasize on high touch area • Immediate Spillage control – eg vomitus, blood, stool
Equipment Sterilization and Disinfection • Equipment : common fomite, transmits disease • BP cuff thermometer, otoscopy, keyboard, ultrasound machine/ probes • Disposable set – dressing, suturing set, vaginal speculum • Nebulization, oxygen delivery apparatus • Digital thermometer • Laryngoscope • Emergency delivery set
Disinfection • NON– CRITICAL equipment – Eg BP cuff, pulse oximeter, nebulization set, auriscope nozzle, digital thermometer – Low level disinfection • Semi-critical Equipment – laryngoscope – high level disinfection
Safe Injection Practice • Aseptic, cleanse diaphragm • Single versus Multiple vial – vaccines • NO reuse syringe • NO same syringe for multiple patients • Sharps disposable bin – convenient area, not overfilled • NO RECAPPING • Regular audit
Transmission-based precaution
Tuberculosis - airborne • MDR & XDR TB – major public health threat • Lack of effective treatment of MDR & XDR infectious for longer period • HIV and TB infectious • Prevention of nosocomial TB to patients and HCW : paramount
HCW TB Infection Rate in Sabah Years HCW (number) Pulmonary TB Smear Smear Positive Negative 2013 31 29 2 2014 28 22 6 2015 24 17 7 2016 46 30 16 2017 29 22 7 Total 158 120 38 Unpublished data, JKNS Tb unit
Infection Control in Tuberculosis in OPD setting • Organisational Activities – Policy, Training, Research, Public Education, Surveillance, monitoring, Evaluation • Administration Activities • Environmental Control • Respiratory Protection – Respirator, HCW care & prevention
Which are the MOST feasible and important components?
Infection Control in Tuberculosis in OPD setting A. Organisational Activities A. Policy, Training, Research, Public Education, Surveillance, monitoring, Evaluation B. Administration Activities C. Environmental Control D. Respiratory Protection A. Respirator, HCW care & prevention
Administration Activities 1. Screen • Early recognition during Triage 2. Educate • Educate cough hygiene, safe distance • Provide mask 3. Separate • Separate from other patients • Waiting in well ventilated area 4. Provide HIV services 5. Investigate for TB • Prompt investigation for TB including CXR
Environmental control • After administrative controls • Reduce the concentration of infectious respiratory aerosols in the air – Mechanical ventilation – Enhancing natural ventilation – Filtration – Ultraviolet germicidal irradiation units
Ventilation • Simplest and least expensive technique – removes and dilutes the air from areas with TB patients – channeling it away from other patients and HCW without TB 1. Natural 2. Mechanical ventilation
TB infection control in Eastern Cape of South Africa • Training of HCW – TB infection prevention • Open-window stickers • Reminder HCW to screen for TB
Droplet precaution • Cough etiquette + respiratory hygiene + HH + Environmental Cleaning • Keep safe distance: 3 meters Examples: • Avian flu /H1N1 • MERS Cov • SARS • Adenovirus
Contact precaution • MRO ( bacteria) – MRSA – Carbapenemase resistant Enterobactericaeae – Vancomycin resistant enterococcus – Clostridium difficile with toxin • Virus – Rotavirus – Norovirus – Astrovirus – Hand foot mouth (enterovirus)
Summary • Infection Prevention is important in OPD • Feasible infection control activities despite limitation of resources and financial constraint • TB / Droplet – administrative activities can be done
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