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 the mask.
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.
The updated AAP policy statement Infection Prevention and Control in Pediatric Ambulatory Settings addresses scenarios like this one. The statement, from the Committee on Infectious Diseases, is available at http://pediatrics.aappublications.org/content/early/2017/10/19/peds.2017-2857 and will be published in the November issue of Pediatrics.
Know route of transmission
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 the office.
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.
Recommendations
- 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 emergencies.
- Use antimicrobial agents appropriately.
Dr. Rathore, a lead author of the policy, is a member of the AAP Committee on Infectious Diseases.
