Don’t Overlook Infection Control In Community Clinics

By Marcus A. Banks

Originally published by our sister publication, Gastroenterology & Endoscopy News

Health systems are increasingly relying on community-based clinics that perform many of the procedures offered in hospitals, but infection prevention efforts at those clinics may be less rigorous than hospital-based infection prevention programs due to a lack of oversight, training and supplies, according to a presentation at the 2021 virtual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC).

Some community clinics do not even have a formal infection prevention program, said Fozia Steinkuller, MPH, CIC, an infection preventionist at UT Physicians, in Houston, noting that such programs are not always required before a clinic opens its doors.

However, in most states, ambulatory surgery centers need to be available for on-site inspections that would include evaluation of infection control practices, and all health entities must adhere to infection prevention standards from governing and accrediting bodies, such as the CDC and the Joint Commission.

Active Training Program

At the APIC meeting, Ms. Steinkuller offered strategies for ensuring that infection prevention programs at non-hospital facilities are as rigorous as those in hospitals. She said a key ingredient for success of such programs is active, participatory training for anyone involved in infection prevention at community clinics.

When Ms. Steinkuller trains staff, she ensures that they hear information about infection control practices, repeat the information back to her, see the practices being done and take a quiz on the information.

She covers the distinction between low-level disinfection, high-level disinfection and sterilization, noting that only sterilization removes all forms of microbial life from a surgical instrument. High-level disinfection, she said, might leave small numbers of bacterial spores. “Sterilization is the best—it obliterates everything,” Ms. Steinkuller said.

But not every medical device or instrument needs to undergo the lengthier and more rigorous process behind full sterilization, she said. Pointing to the Spaulding Classification for determining which level of disinfection is appropriate (https://bit.ly/3BXYYuB), Ms. Steinkuller said a blood pressure cuff requires low-level disinfection because its only contact is with intact human skin that is less vulnerable to infection. In contrast, an endoscope that will touch a mucous membrane always requires high-level disinfection or better, Ms. Steinkuller said, whereas any surgical instrument requires complete sterilization between each use.

Ms. Steinkuller said she covers this information at every training because the medical assistants who attend her training sessions generally receive only a cursory overview of infection prevention principles during their schooling.

Knowing that steps frequently are missed in reprocessing (bit.ly/2ZYkNwo), Ms. Steinkuller developed a training program that includes an overview of infection prevention concepts along with an extensive demonstration of how to properly clean and reprocess medical equipment. She tailors specific examples to different devices used in different clinics.

After the demonstrations, Ms. Steinkuller asks students to take a quiz and reviews questions they answered incorrectly. Next, she has the new students apprentice with experienced staff at various clinics. After two months, she observes and assesses the students as they demonstrate different levels of disinfection and sterilization, using the CDC’s “Guide to Infection Prevention for Outpatient Settings” for the assessments (bit.ly/3BP4uj0). After completion of the program, the students receive certificates of competence they can present to potential employers.

Systemwide Approach Needed

Ms. Steinkuller’s efforts are one way to address the reality that, even if institutions do not prioritize training in infection prevention, they are still accountable to regulatory bodies for ensuring a sanitary and safe environment for patients. This is particularly true when reprocessing endoscopes, given well-publicized instances of endoscopic cross-contamination (bit.ly/3GVq9d6).

“The Joint Commission educates our surveyors on the appropriate cleaning process and reprocessing of endoscopes. Then when they are on survey, they are required to go to any area where they are reprocessing endoscopes, as part of the survey process,” said Sylvia Garcia-Houchins, MBA, RN, CIC, the Joint Commission’s director of infection prevention and control.

Beyond the details for managing endoscopes, Ms. Garcia-Houchins pointed out that infection control is an organization-wide responsibility that encompasses all personnel, hospitals and clinics within a health system.

“The expectations of the Joint Commission are that a health care organization has an infection control program—not an employee, not a department, but a program—that everyone in the organization participates in based on their role, be it a secretary, a physician, a contractor, a patient or a visitor,” Ms. Garcia-Houchins said. She stressed that this infection control program is binding on any facility within a health system, whether a flagship hospital or an ambulatory care clinic hundreds of miles away.

If any practice in a clinic or hospital presents an infection risk, there must be strategies in place to mitigate those risks. In the most egregious cases, Ms. Garcia-Houchins said, the Joint Commission could deem a medical facility to be an “immediate threat to health and safety” and require mitigation plans to be produced on the spot. Ms. Steinkuller’s efforts describe one strategy to help ward off such a result.