Updated policy offers guidance on infection prevention, control in ambulatory settings
Mobeen H.Rathore, M.D., CPE, FPIDS, FAAP
A pediatrician sends a 3-year-old with possible pertussis to a hospital laboratory
to have a specimen tested for Bordetella pertussis. Before leaving the office, however, the patient had played with several children
and interacted with staff in the waiting room. Once at the lab, the patient is given
a mask to wear, but only after staff realizes the reason for referral to the hospital.
Several other patients and staff members are exposed to the patient before he receives
This incident required a contact investigation of all who interacted with the patient,
along with appropriate counseling and follow-up. Fortunately, none of the exposed
contacts developed pertussis.
Appropriate ambulatory infection prevention and control (IPC) practices can prevent
incidents such as the one above. While hand hygiene remains the most important IPC
practice, other precautions — depending on the mode of transmission of the infectious
agent — are necessary when certain infections are suspected. IPC strategies are based
on the a, b c, d routes of transmission: airborne, body fluid, contact and droplet. However, standard precautions are critical for prevention of transmission
and should always be followed. Cough etiquette education also is recommended.
The policy includes guidance on caring for patients with cystic fibrosis who may be
harboring multidrug-resistant organisms. These patients require some special procedures.
More and more patients and their families are staying at short-term residential facilities
such as Ronald McDonald houses. The policy has a section addressing the IPC needs
of patients and other individuals and staff at these locations.
Responsibilities related to communications
Also addressed are practice responsibilities to communicate with families and public
health authorities in the event of an outbreak. This allows for identification of
new cases and ensures the public health department can do appropriate investigation.
Practicing pediatricians often identify the first cases of a potential contagious
infection such as measles. Strategies are suggested to minimize infectious exposure
to other patients, those accompanying the patient and practice staff. Also stressed
is the importance of triaging when appointments are scheduled and having clear signage
in the office to instruct accompanying people to inform the staff if a patient has
certain signs or symptoms, or travel or contact history.
Even if there is no outbreak, pediatricians can help ensure that a potentially contagious
patient they are referring to another facility for testing does not spread the infection
at the receiving facility. A new section in the policy provides critical guidance
on communicating with referral facilities such as imaging centers and laboratories.
It also stresses the importance of providing appropriate personal protective equipment,
such as face masks, for patients and family (when necessary) to don before leaving
Vaccines remain the most important and safest intervention for preventing infectious
diseases not only in children and their families but also health care personnel. The
policy emphasizes the importance of providing certain vaccines for employees, including
mandatory influenza vaccinations, which the Academy and many other professional organizations
recommend. Required vaccines should be provided free of cost to staff.
Good IPC practices and well-written policies can result in better outcomes for patients
and staff. Knowledge of and adherence to IPC policies in ambulatory practices are
as important as in the inpatient setting.
Written policies and procedures for IPC should be available to office staff and reviewed
at least every two years.
Staff education should be reinforced and evaluated regularly, with new staff required
to review the policies.
Annual influenza vaccination should be mandatory for staff, as well as immunization
or documentation of immunity against other vaccine-preventable infections that can
be transmitted in the office.
All health care personnel should perform hand hygiene before and after patient contact
or contact with the patient’s immediate environment.
In waiting rooms, encourage use of respiratory hygiene/cough etiquette.
Promptly triage patients with potentially contagious diseases and those who are immunocompromised.
Alcohol is preferred for skin antisepsis before immunization and routine venipuncture.
Know the requirements of government agencies such as the Occupational Safety and Health
Administration related to operation of ambulatory facilities.
Handle needles and sharps with great care as outlined in the policy.
Have a written bloodborne pathogens exposure control plan that includes policies for
managing contaminated sharp object injuries.
Follow standard guidelines for sterilization, disinfection and antisepsis.
Have policies for communicating with local and state health authorities on reportable
diseases and outbreaks; with other health care facilities when referring potentially
contagious patients; and with patients and families in case of outbreaks and other
Use antimicrobial agents appropriately.
Dr. Rathore, a lead author of the policy, is a member of the AAP Committee on Infectious