Infection Prevention in Outpatient Cancer Clinics: CDC's Model Plan

Infections remain a major cause of illness and death in people with cancer, whose immune systems are weakened by the disease and by chemotherapy. They also visit health care settings often, where they can meet others with transmissible infections, and many need indwelling intravascular devices or surgery. An estimated 1.5 million new U.S. cancer cases were diagnosed in 2010, and more than one million patients a year get outpatient chemotherapy or radiation.

Most cancer care has moved to outpatient settings — physician offices, hospital clinics and cancer centers — where attention to infection control varies widely. CDC wrote a model infection prevention plan for these facilities, meeting the minimum expectations of its Guide to Infection Prevention in Outpatient Settings. Facilities without a plan can adopt it and tailor it; those with one should check it covers these elements. Every facility still needs regular access to someone trained in infection prevention. The complete plan and a pocket guide are available.

Outside its scope: issues unique to blood and marrow transplant centers; occupational protection when handling antineoplastic and hazardous drugs (see OSHA and NIOSH); compounding sterile medications; and antimicrobial prescribing and neutropenia risk assessment.

The foundations

Standard Precautions — the minimum for all patient care, whatever a patient's infection status — are hand hygiene, personal protective equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and cleaning and disinfection. Transmission-Based Precautions — contact, droplet and airborne — are added for patients known or suspected to carry certain pathogens.

Training: all staff, contractors included, are trained in PPE and task-specific practices at orientation, at least yearly, and whenever policies change, by trainers who are themselves competent; competency is documented, and hand hygiene and cleaning are audited.

Surveillance: define the healthcare-associated infections tracked (such as central line–associated bloodstream infections), analyze the data, report it to staff, and meet reporting requirements for notifiable diseases and outbreaks.

Hand hygiene

Alcohol-based hand rub is preferred, except when hands are visibly soiled or after caring for patients with C. difficile or norovirus in an outbreak — then use soap and water, rubbing for at least 15 seconds. Clean hands:

• before touching a patient — even if wearing gloves;
• before leaving the patient's care area;
• after contact with blood, body fluids, excretions or wound dressings;
• before an aseptic task, such as accessing a port or preparing an injection;
• when moving from a contaminated to a clean body site;
• after removing gloves.

Protective equipment

Respiratory hygiene

• Signs at reception ask patients and companions to report symptoms and cover coughs; masks, tissues, no-touch bins and hand rub are at hand.
• Coughing patients get a mask and an exam room with a closed door, or a seat far from others; sick companions wait outside.
• Patients who call ahead with symptoms are booked for quieter times — or, if non-urgent, after they recover.
• Staff with respiratory infections avoid direct patient care (or mask), know the sick-leave policy, and are up to date on vaccines, including yearly flu vaccine.
• In flu season and other high-activity periods, pre-screen patients by phone and screen everyone on arrival.

Safe injections and medications

• Use aseptic technique; prefer prefilled or pharmacy-prepared syringes.
• Never use one syringe for more than one patient — even with a new needle or through intervening tubing — or reuse a syringe to enter a vial.
• Single-dose vials, ampoules and IV bags are for one patient only — never a shared saline bag.
• Wipe vial tops with 70% alcohol and let it dry. Multi-dose vials are best kept to one patient; if shared, they stay in the medication room, never the treatment area. Their preservative doesn't stop viruses.
• Never leave a needle in a vial's septum for repeated draws.
• Use single-use lancets for fingersticks — no pen-type holders; don't share IV tubing.
• Discard opened single-dose vials by the maker's time limit or at the end of the procedure; date opened multi-dose vials and discard within 28 days unless the maker says otherwise.
• Phlebotomy: in a dedicated area if possible; bring only needed supplies to the patient; don't reuse tube holders; keep blood specimens away from medications.
• Refrigerated medicines go in a dedicated, labeled fridge, with temperatures logged (at least twice a day for vaccines) and a backup plan for power failures.

Cleaning and disinfection

• Clean patient-care areas, medication areas and bathrooms at least daily; use EPA-registered disinfectants suited to the germ, following label directions.
• Between patients: chemotherapy chairs, IV poles and pumps, side tables and any medication preparation area; and any device touching broken skin or body fluids, or that tests blood, such as glucose meters.
• Focus on high-touch surfaces — exam beds, blood pressure cuffs, stethoscopes, door knobs. For infectious diarrhea of unknown cause, use bleach (1:10, freshly mixed).
• Blood spills: gloves and PPE, forceps for sharps; absorb large spills (over 10 mL) first, then disinfect — bleach at 1:100, or 1:10 first for large spills.
• Linens: handle with minimal agitation, and don't sort or rinse them in patient-care areas.

Transmission-Based Precautions

Central venous catheters: the plan's step-by-step procedures for accessing and caring for PICCs, tunneled catheters and implanted ports are adapted from the Oncology Nursing Society's access device guidelines; follow those, the Infusion Nurses Society standards, and CDC's catheter infection guidelines.

Sources

Based on "Basic Infection Control and Prevention Plan for Outpatient Oncology Settings," Centers for Disease Control and Prevention; a work of the United States government in the public domain. The plan's catheter procedures, adapted with permission from the Oncology Nursing Society, are not reproduced.