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Healthcare-Associated Infections: Infection Prevention in Ambulatory Settings

A waiting room, blurred.

Outpatient care, also known as ambulatory care, is any care provided in a setting where individuals do not remain overnight. This can include physician offices, urgent care settings, oncology clinics, hospital or non-hospital-based outpatient clinics, and ambulatory surgery centers (ASCs).

Outbreaks of healthcare-associated infections (HAIs) in ambulatory care settings are most often associated with lapses in basic infection control measures. These breaches can result in disease transmission, patient notification, and disciplinary or legal action.

This webpage features infection prevention and control practices and resources for ambulatory care settings.

Infection prevention consideration in ambulatory care settings

At a minimum, all outpatient settings must follow basic infection control practices. These are outlined in the CDC's (Centers for Disease Control and Prevention) Core Infection Prevention and Control Practices and Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care (PDF). In Wisconsin, Medicare-certified ambulatory surgery centers (ASCs) have additional rules and regulations that must be met. Accredited facilities must also be aware of any specific requirements set forth by their accrediting body.


You can find more information and resources on infection prevention in ambulatory settings sorted by topic in the following sections.

Regular cleaning and disinfection of environmental surfaces is important to help prevent the spread of infectious diseases within the health care setting. Best practices include:

  • Ensuring products used for cleaning and disinfection are Environmental Protection Agency (EPA) approved and cover targeted organisms.
  • Developing cleaning and disinfection checklists for high-touch surfaces such as light switches, handles, and computers as well as housekeeping surfaces such as floors and sinks.
  • Diluting any concentrated disinfection solutions properly, according to the manufacturer’s instructions for use (IFU). Wear appropriate personal protective equipment (PPE), and label the diluted solution appropriately, including the modified expiration date. Do not "top off" bottles of diluted solutions. The remaining product should be discarded and the container rinsed. The bottle can then be refilled with new diluted solution.
  • Following the required dwell time to ensure effective disinfection occurs.
  • Cleaning all medical equipment per the IFUs and ensure the IFUs are readily available for staff.
  • Ensuring contracted housekeeping services are trained on cleaning health care facilities and are meeting the facilities specific needs. This includes utilizing appropriate chemicals and cleaning tools.

Resources

Learn more about cleaning, disinfection, and sterilization by visiting the HAI Starter Kit webpage.

View the webpage here

Effective hand hygiene is essential for preventing the spread of infections in the healthcare setting. Alcohol-based hand rub (ABHR) can be used in most clinical situations. Soap and water should be prioritized when hands are visibly soiled or after taking care of a patient with suspected infectious diarrhea. Other hand hygiene best practices for ambulatory settings include:

  • Ensuring availability of hand washing sinks or ABHR in each exam and procedure room.
  • Dedicating sinks for hand washing only to prevent cross contamination.
  • Confirming that soap, paper towel, and lotion are readily available for staff.
  • Developing a system to verify that supplies are available, functioning properly, and not expired.

Resources

Refer to the HAI: Precautions webpage for additional information and resources on hand hygiene.

View the webpage here

Improperly sterilized instruments can lead to the transmission of illnesses, such as Hepatitis B, Hepatitis C, HIV and bacterial infections. Adequate sterilization requires a series of steps, all of which must be performed properly.

  • Follow the manufacturer’s instructions for use (IFUs) for proper cleaning, disinfection, and sterilization instructions. If an instrument does not have an IFU, it must be assumed that instrument is intended for single patient use and be disposed of after the procedure.
  • Choose nationally recognized evidence-based guidelines, such as CDC, the Association for the Advancement of Medical Instrumentation (AAMI), the Association of Perioperative Registered Nurses (AORN), or the Society of Gastroenterology Nurses and Associates (SGNA) to develop policy and procedures.
  • Ensure proper training and competency for individuals who are responsible for equipment and instrument reprocessing.
  • Create clear separation of dirty and clean steps while reprocessing equipment or instruments.
    Ideally there should be two rooms for reprocessing instruments. If this is not possible, ensure there is no cross contamination of the dirty and clean steps in the process.
  • Monitor the sterilization process including time, temperature, pressure, and biological and chemical indicators to ensure that instruments have been properly sterilized.
  • Properly store sterilized instruments in a clean space that does not compromise the integrity of the package by following the storage IFUs of the instruments and packages utilized.
  • Utilize instruments on a first in, first out basis to ensure adequate rotation of sterilized instruments.
  • Perform a risk assessment to determine if event-based sterility or a time-based expiration date will be used for sterilized instruments. Label all instruments appropriately based the process chosen.

Resources

Review the HAI Starter Kit webpage for more detail on cleaning, disinfection, and sterilization.

View the webpage here

Although linen use in the ambulatory setting is typically less than other health care settings, best practices should be followed to minimize contamination.

  • Protect clean linen by keeping it covered or enclosed in bins or cabinets.
  • Avoid storing supplies next to unprotected linen.
  • Handle contaminated linen with minimal agitation and bag at the point of use to transport to the soiled holding area.
  • Wear appropriate personal protective equipment (PPE) while handling soiled linen.
  • Follow best practices for on-site laundry processes, this includes:
    • Ensuring proper water temperature.
    • Using appropriate chemicals and detergents.
    • Cleaning and maintaining laundry machines.
    • Separating clean and dirty.
  • Monitor quality metrics for laundry that is sent off-site. There are no set standards for quality metrics, the facility should determine the measures that they will monitor and ensure off-site laundry processes are meeting them. It is recommended to tour the laundry facility on a regular basis.

Resources

Multidrug-resistant organisms (MDROs) can be spread in ambulatory care settings. Targeted infection prevention measures should be implemented to prevent the spread whether a patient is infected or colonized with an MDRO.

  • Use gown and gloves during extensive patient contact and contact with uncontrolled secretions, pressure ulcers, draining wounds, incontinence, and ostomy tubes and bags.
  • Wear a mask during splash-generating procedures, such as wound irrigation; oral suctioning and intubation; when providing care for patients with open tracheostomies and the potential for projectile secretions; and in circumstances where there is evidence of transmission from heavily colonized sources, such as burn wounds.
  • Clean and disinfect any surfaces, such as chairs and exam tables, and reusable equipment, such as blood pressure cuffs, that came into contact with the patient. Use disinfectants that have an EPA registered claim for the targeted organism(s).
  • Communicate a patient’s MDRO status. Have a system in place to flag the patient's chart with the MDRO status. Inform the receiving facility of the patient's MDRO status if the patient needs to be admitted or referred.
  • Educate patients about their MDRO status and what they can do when visiting health care settings.

Resources

Further education can be found on the HAI Reportable MDRO webpage.

View the webpage here

Health care providers should choose personal protective equipment (PPE) based on their risk of exposure to infectious agents or chemicals. Important considerations in ambulatory settings include:

  • Implementing empiric transmission-based precautions in addition to standard precautions based on the clinical syndrome or condition that is present at the time of the visit to reduce the risk of disease transmission.
  • Putting transmission-based precautions in place for known disease processes until the infectious period has passed.
  • Ensuring PPE is readily available at the point of use.
  • Verifying training and competency for donning and doffing PPE appropriately on a regular basis.

Resources

More information on different types of PPE and when to use them can be found on the HAI: PPE webpage.

View the webpage here

Implement respiratory hygiene (cough etiquette) practices as part of standard precautions in your facility. This includes:

  • Placing signage at the point of entrance to the facility asking patients and visitors to wear a mask if they are experiencing signs and symptoms of respiratory illness. Tissue, masks, ABHR, and a trash can should be readily available.
  • Screening patients for signs and symptoms of respiratory illness at the first point of contact or prior to entering the facility. Prioritize rooming patients with signs and symptoms of an infectious illness immediately.
  • Separating waiting rooms for ill and well patients or space seating at least 3 feet apart to minimize close contact.
  • Considering implementing the use of source control (everyone mask upon entry to the facility or targeted area) during periods of increased respiratory illnesses in the community.

Resources

Find elements of respiratory hygiene and cough etiquette on the HAI: Precautions webpage.

View the webpage here

Outbreaks due to bloodborne pathogen exposure from unsafe injection practices happen most frequently in the ambulatory care setting. Unsafe injection practices can include:

  • Reuse of needles, syringes, or IV tubing for more than one patient.
  • Reuse of needles or syringes to access a medication container and then using the contents of that container for another patient.
  • Reuse of fingerstick devices for more than one patient.
  • Drug diversion.

Facilities should ensure staff are trained and competent on safe injection practices to reduce the risk of disease transmission associated with unsafe injection practices. Best practices include:

  • Using aseptic technique.
  • Using needles and syringes only one time.
  • Using single-dose vials instead of multi-dose vials whenever possible.

Safe preparation and storage of injections and medications is imperative in decreasing the potential for contamination.

  • Dedicate a clean room or area with minimal traffic with all needed supplies readily available in the space.
  • Avoid sources of contamination such as a sink within 3 feet of preparation surface or point-of-care testing supplies on the same surface.
  • Prepare the medication as close as possible to the administration time.
  • Access multi-dose vials (MDV) in a centralized medication area. Dedicate MDV as single patient use if brought into the patient care area, like the exam or procedure room.
  • Label MDVs appropriately with a 28-day expiration date, unless directed otherwise.
  • Minimize the use of immediate use sterile compounds and follow best practices when preparing and administering.

Resources

The safe handling of needles and other sharp devices is included in standard precautions to help prevent injury and exposure to bloodborne pathogens for health care workers. Ambulatory care settings should implement practices that decrease the risk of sharps injuries including:

  • Disposing of sharps in appropriate containers.
  • Developing process to safety transport sharps of contaminated instruments from the procedure room to the reprocessing areas.
  • Implementing safety devices when possible.

Resources

Refer to the HAI: Precautions webpage for further details.

View the webpage here

Recommendations and administrative resources

Eighty to ninety percent of antibiotic use occurs in the outpatient setting, with nearly 30% being prescribed unnecessarily. Many infectious diseases in the outpatient setting are caused by viral infections. Antibiotic stewardship efforts are necessary to balance the need for effective treatment for bacterial infections while reducing unnecessary treatment for viral infections. Over prescribing antibiotics is the leading cause of antibiotic-resistant bacteria which is creating difficulties in treating many patient conditions leading to serious and life-threatening illnesses. Ambulatory care settings should establish a multidisciplinary team to implement antimicrobial stewardship initiatives in their facility.

Resources

Many resources for an effective antibiotic stewardship program and targeted measures are available on the HAI Antimicrobial Stewardship: Resources for Health Care Providers webpage.

View the webpage here

An effective infection prevention program considers the facilities specific infection risks, the population it serves, the services provided, and the health care personnel who deliver the care. Ambulatory care settings should develop infection prevention policy and procedures utilizing best practices and standards. Facilities should:

  • Designate an individuals with infection prevention and control training to lead the infection prevention program.
  • Perform a risk assessment, at least annually, to assess for the potential risks for infection and exposures, the potential impact these risks can have on the facility, and the facilities readiness to eliminate or mitigate the risk. Situational risk assessments may also be conducted to assess new or current situations, problems, processes, or practices within the facility.
  • Audit infection prevention practices to gather process data to drive an infection control program.

General resources

Resources for specific settings

More information on infection prevention programs can be found on the HAI Starter Kit webpage.

View webpage here

Health care personnel should be educated on job-specific infection prevention topics. Trainings should occur prior to starting and at least annually or when gaps in practice are identified. Knowledge should be assessed to ensure staff understand and are competent. Education should be provided on the following topics:

  • Standard and transmission based precautions
  • Hand hygiene
  • Personal protective equipment
  • Environmental cleaning and disinfection
  • Injection and medication safety
  • Disinfection and sterilization of reusable medical equipment

Education materials on various topics can be found on the HAI Starter Kit webpages or the HAI Infection Prevention Education webpage.

Additional resources

HAI surveillance can be challenging in the outpatient setting due to the short duration of encounters, inefficient data systems, and inconsistent follow up. Additionally, the standard definitions utilized in acute care settings can be difficult to apply in the outpatient setting. However, there are practices that ambulatory care settings can implement to collect outcome data and process measures.

  • Instruct patients to notify the facility of any signs and symptoms of infection after a procedure.
  • Develop partnerships with local physician’s offices, surgical clinics, hospitals, or emergency departments and urgent cares so that they can notify the facility of any patients that present with signs and symptoms of infection after having a procedures at your facility.
  • Create processes for discharge surveillance after procedures such as phone calls, emails, postcards, or patient satisfaction surveys to inquire about infections.
  • Review cultures and lab reports and coordinate with reference labs to set up a system to notify the facility of positive results.
  • Standardize surveillance definitions for consistent application and benchmark trending.
  • Implement a robust audit process, provide just in time teaching and trend audit results.
  • Provide feedback from audit results to drive process improvement.

National Healthcare Safety Network (NHSN)

In 2019, NHSN developed the Outpatient Procedure Component, specifically for ambulatory surgical centers (ASCs), to allow the use of epidemiologically sound infection definitions to assist in benchmarking ASC outcome data. Collecting data through NHSN allows facilities to stratify surgical site infections (SSIs) rates according to risk factors associated with SSI development and allow data feedback. There are currently 30 different Current Procedural Terminology (CPT®) code categories that can be included in surveillance. New codes are added each year as the procedure landscape continues to evolve in the outpatient setting.

Enrollment in NHSN is voluntary and allows facilities to use risk assessments to determine which operative procedure to monitor.

Learn more about NHSN

Communicable disease reporting

All facilities are required to have communicable diseases reporting processes in place, according to Wis. Stat. ch. 252. Further information on requirements and how to report can be found on the DHS Disease Reporting webpage.

Learn more about disease reporting requirements

Water management programs in health care facilities are an important way to help protect vulnerable patient populations as well as staff and visitors. While water management programs are not required in most ambulatory settings, all facility types should at a minimum assess any risks from water sources and put in place mitigation plans to reduce those risks.

  • Develop a water management program that identifies risks from water sources and proactively implement corrective actions that minimizes the growth and spread of waterborne pathogens.
  • Implement measures that will reduce the risk of splashing from sinks and drains such as installing splash guards or modifying sink basins. These measures are especially important if medication preparation occurs or supplies are stored within 3 feet of the sink.
  • Avoid discarding patient waste, beverages, or IV fluids down sinks, especially sinks intended for hand hygiene.
  • Consider using an EPA-registered biofilm disinfectant for drain cleaning.
  • Avoid stagnant water by flushing, at minimum, weekly.
  • Identify “dead legs” and contract with a certified plumber to remediate them.
  • Identify unused water sources such as sinks or hoppers and include them on the flushing schedule.
  • Develop protocols for addressing external (for example, water main breaks) and internal (for example, planned construction) disruptions of water flow to the facility.

Resources

Infection prevention and control support for your ambulatory practice

The Wisconsin HAI Prevention Program aims to enhance infection prevention and control (IPC) education in ambulatory care settings across the state. The program provides resources to assist ambulatory care settings in developing effective IPC measures that ensure the health and safety their staff and patients as well as build relationships with public health.

Services provided are educational, collaborative, non-regulatory, and free of charge to Wisconsin ambulatory care settings in Wisconsin. Services offered include:

  • Performing on-site or remote infection control assessments of health care facilities.
  • Participating in outbreak and infection control breach investigations.
  • Reviewing infection prevention processes to help identify needs and gaps.
  • Providing education and technical assistance on a variety of infection prevention topics.

Contact us

Contact us by emailing DHSWIHAIPreventionProgram@dhs.wisconsin.gov

Glossary

 
Last revised December 22, 2025