3310 - Developing an Ambulatory Infection Prevention Program

Session Description: Ambulatory clinics present unique challenges for Infection Prevention (IP) programs due to broad geographic areas, with various leaders, policies, and a variety of procedures at each location. This session will describe how a large academic health system developed an IP program for ambulatory clinics.

This presentation will discuss tools that can be used to conduct ambulatory clinic audits, how to use that information to perform a gap analysis and risk assessment, and how to engage key partners and leadership. Valuable partners during audits may include Regulatory, Environmental Health & Safety, Facilities Management, and Sterile Processing.

Due to the complexity of factors contributing to harm associated with high-level disinfection (HLD) and sterilization, a multi-disciplinary approach is necessary to standardize work across locations. Audits revealed wide variations in reprocessing, lack of standardized workflows, and variability in staff education and competency. Transitioning to a centralized sterilization model has allowed us to streamline processes and dedicate trained staff to perform reprocessing. IP developed a targeted disinfection and sterilization audit tool and implemented routine quality assurance rounding.

Other common challenges found in ambulatory clinics include storage of medications and clean or sterile supplies, as well as environment of care concerns such as airflow, water intrusion events, and construction. This presentation will discuss how the Ambulatory Infection Preventionist can promptly identify and address such challenges.