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Basic Infection Control And Prevention Plan for Outpatient ...

Basic Infection Control And Prevention Plan forOutpatient Oncology SettingsNational Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality PromotionDecember, 2011An estimated million new cases of cancer were diagnosed in the United States in 2010[1]. With im-provements in survivorship and the growth and ag-ing of the population, the total number of per-sons living with cancer will continue to increase [2]. Despite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients[3-5]. Increased risks for Infection are attributed, in part, to immunosuppression caused by the underlying malignancy and chemotherapy. In ad-dition patients with cancer come into frequent con-tact with healthcare settings and can be exposed to other patients in these settings with transmissible in-fections. Likewise, patients with cancer often require the placement of indwelling intravascular access de-vices or undergo surgical procedures that increase their risk for infectious complications.

Basic Infection Control . And Prevention Plan for. Outpatient. Oncology Settings. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

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1 Basic Infection Control And Prevention Plan forOutpatient Oncology SettingsNational Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality PromotionDecember, 2011An estimated million new cases of cancer were diagnosed in the United States in 2010[1]. With im-provements in survivorship and the growth and ag-ing of the population, the total number of per-sons living with cancer will continue to increase [2]. Despite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients[3-5]. Increased risks for Infection are attributed, in part, to immunosuppression caused by the underlying malignancy and chemotherapy. In ad-dition patients with cancer come into frequent con-tact with healthcare settings and can be exposed to other patients in these settings with transmissible in-fections. Likewise, patients with cancer often require the placement of indwelling intravascular access de-vices or undergo surgical procedures that increase their risk for infectious complications.

2 Given their vulnerable condition, great attention to Infection Prevention is warranted in the care of these recent decades, the vast majority of oncology services have shifted to Outpatient settings, such as physician offices, hospital-based Outpatient clinics, and nonhospital-based cancer centers. Currently, more than one million cancer patients receive outpa-tient chemotherapy or radiation therapy each year[6]. Acute care hospitals continue to specialize in the treatment of many patients with cancer who are at increased risk for Infection ( , hematopoietic stem cell transplant recipients, patients with febrile neu-tropenia), with programs and policies that promote adherence to Infection Control standards. In contrast, Outpatient oncology facilities vary greatly in their at-tention to and oversight of Infection Control and pre-vention.

3 This is reflected in a number of outbreaks of viral hepatitis and bacterial bloodstream infections that resulted from breaches in Basic Infection preven-tion practices ( , syringe reuse, mishandling of in-travenous administration sets)[7-10]. In some of these incidents, the implicated facility did not have written Infection Control policies and procedures for patient protection or regular access to Infection Prevention Intent and ImplementationThis document has been developed for Outpatient on-cology facilities to serve as a model for a Basic infec-tion Control and Prevention plan. It contains policies and procedures tailored to these settings to meet min-imal expectations of patient protections as described in the CDC Guide to Infection Prevention in Outpatient Settings (available: ). The ele-ments in this document are based on CDC s evidence-based guidelines and guidelines from professional so-cieties ( , Oncology Nursing Society).

4 This plan is intended to be used by all Outpatient oncology facilities. Those facilities that do not have an existing plan should use this plan as a starting point to develop a facility-specific plan that will be updated and further supplemented as needed based on the types of services provided. Facilities that have a plan should en-sure that their current Infection Prevention policies and procedures include the elements outlined in this docu-ment. While this plan may essentially be used exactly as is, facilities are encouraged to personalize the plan to make it more relevant to their setting ( , adding facility name and names of specific rooms/locations; inserting titles/positions of designated personnel; and providing detailed instructions where applicable). This plan does not replace the need for an Outpatient oncology facility to have regular access to an individual with training in Infection Prevention and for that individ-ual to perform on-site evaluation and to directly observe and interact regularly with staff.

5 Facilities may wish to consult with an individual with training and expertise in Infection Prevention early on to assist with their infec-tion Control plan development and implementation and to ensure that facility design and work flow is conducive to optimal Infection Prevention Aspects of Care That Are Beyond the Scope of This PlanThis model plan focuses on the core measures to pre-vent the spread of infectious diseases in Outpatient on-cology settings. It is not intended to address facility-specific issues or other aspects of patient care such as: Infection Prevention issues that are unique to blood and marrow transplant centers ( bone marrow transplant or stem cell transplant centers) Occupational health requirements, including recom-mended personal protective equipment for handling antineoplastic and hazardous drugs as outlined by the Occupational Safety and Health Administration and the National Institute for Occupational Safety Appropriate preparation and handling ( , recon-stituting, mixing, diluting, compounding) of sterile medications, including antineoplastic agents Clinical recommendations and guidance on appro-priate antimicrobial prescribing practices and the assessment of neutropenia risk in patients undergo-ing chemotherapyFor more information on these topics, refer to the list of resources provided in Appendix D of the , 2011 References1 American Cancer Society.

6 Can-cer Facts & Figures 2010 Tables & Figures. Warren JL, Mariotto AB, Meekins A, Topor M, Brown ML. Current and future utilization of services from medical oncologists. J Clin Oncol 2008;26:3242 Kamboj M, Sepkowitz KA. Nosocomi-al infections in patients with cancer. Lancet Oncol 2009;10:589 Maschmeyer G, Haas A. The epide-miology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008;31:193 Guinan JL, McGuckin M, Nowell PC. Management of health-care as-sociated infections in the oncology patient. Oncology 2003;17:415 Halpern MT, Yabroff KR. Prevalence of Outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest 2008;26:647 Macedo de Oliveria A, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL et al. An out-break of hepatitis C virus infections among outpatients at a hematol-ogy/oncology clinic.

7 Ann Intern Med 2005;142:898 Watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck E, et al. Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. Arch Intern Med 2005;165:2639 Greeley RD, Semple S, Thompson ND, High P, Rudowski E, Handschur E et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control 2011 Jun 8. Epub ahead of Herndon E. Rose Cancer Center shut down; patients advised to get screen-ing. Enterprise-Journal. July 31, 2011. Available at: Accessed September 9, of Abbreviations ..2I . Fundamental Principles of Infection Prevention ..2 A. Standard Precautions ..2 B. Transmission-Based Precautions ..2II . Education and Training ..2 III . Surveillance and Reporting ..3IV . Standard Precautions ..3 A. Hand Hygiene.

8 3 B. Personal Protective Equipment..4 C. Respiratory Hygiene and Cough Etiquette ..5 D. Injection Safety ..6 E. Medication Storage and Handling ..7 F. Cleaning and Disinfection of Devices and Environmental Surfaces..8V . Transmission-Based Precautions ..11 A. Identifying Potentially Infectious Patients ..11 B. Contact Precautions ..11 C. Droplet Precautions ..11 D. Airborne Precautions.. 12VI . Central Venous Catheters .. 12 A. General Maintenance and Access Procedures.. 12 B. Peripherally Inserted Central Catheters (PICCs) .. 13 C. Tunneled Catheters.. 14 D. Implanted Ports .. 14 Appendices .. 15 A. Example List of Contact Persons and Roles/Responsibilities.. 15 B. Reportable Diseases/Conditions .. 16 C. CDC Infection Prevention Checklist for Outpatient Settings.. 17 D. Additional Resources..28 Table of ContentsInfection Prevention PlanDecember, 20112 Ongoing education and training of facility staff are required to maintain competency and ensure that Infection Prevention policies and procedures are understood and followed.

9 A list of names of designated personnel and their specific roles and tasks and contact information is provided in Ap-pendix Education and Training All facility staff, including contract personnel ( , environmental services workers from an outside agency) are educated and trained by designated personnel regarding: Proper selection and use of PPE Job- or task-specific Infection Prevention practices Standard PrecautionsStandard Precautions represent the minimum infec-tion Prevention measures that apply to all patient care, regardless of suspected or confirmed Infection status of the patient, in any setting where healthcare is de-livered. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. Standard Precau-tions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation.

10 Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment ( , gloves, gowns, facemasks), depending on the anticipated exposure, 3) respiratory hygiene and cough etiquette, 4) safe injection prac-tices, and 5) safe handling of potentially contaminated equipment or surfaces in the patient PrecautionsTransmission-Based Precautions are intended to supplement Standard Precautions in patients with known or suspected colonization or Infection of highly transmissible or epidemiologically important patho-gens. These additional precautions are used when the route of transmission is not completely interrupted using Standard Precautions. The three categories of Transmission-Based Precautions include: 1) Contact Precautions, 2) Droplet Precautions, and 3) Airborne Precautions. For diseases that have multiple routes of transmission, a combination of Transmission-Based Precautions may be used.


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