Infection control in the office: Keeping germs at bay

By Linda A. Waggoner-Fountain, MD, and Leigh Grossman Donowitz, MD

Minimizing the risk that your patients and employees will acquire a contagious disease in your office demands diligent infection control. This review summarizes guidelines and offers recommendations that can reduce the spread of infection—from what soap and lotion to use for handwashing to what immunizations your office staff need.

Although a pediatrician's office is an unchanging physical space, the people who populate it make it a dynamic environment. Coughing, sneezing, runny-nosed children come and go, turning the waiting area and examining rooms into convenient places for the spread of infection. Office equipment, whether disposable or not, can serve as a vehicle for transmitting communicable diseases, too.

Our intent here is to provide you with the information necessary to help minimize the spread of infection, to both your patients and your staff. We'll review six key areas of infection control: handwashing, barrier precautions, isolation, environmental cleaning, sharps disposal, and employee health.

Mother knows best

The most important and frequent mode of infection transmission is direct or indirect contact—touching an infected patient or a contaminated object and thereby either inoculating oneself or transmitting the pathogen to another patient or a common-use object. Other common means by which infections spread include respiratory transmission and needlestick injury.

The single most important measure for preventing infection is handwashing. Your mother always told you that and—guess what—she was right. In the office setting, we recommend handwashing in seven specific situations, listed in Table 1. They are: before and after contact with patients, body fluids, specimens, and contaminated or soiled items; between "clean" and "dirty" procedures on the same patient; after removing gloves; before and after performing invasive procedures; after using the bathroom; before eating; and when your hands are visibly soiled.

TABLE 1
When to wash your hands

Before and after contact with patients, body fluids, specimens, and contaminated or soiled items

Between “clean” and “dirty” procedures on the same patient

After removing gloves

Before and after performing invasive procedures

After using the bathroom

Before eating

When your hands are visibly soiled

Exactly how should you wash your hands? For routine handwashing, there's no need to do a 10-minute surgical scrub. Instead, cover your hands thoroughly with soap and water and rub them together for at least 10 seconds under warm water, washing all surfaces of the hands and fingers. Rinse with a stream of warm water, then dry your hands and fingers with either disposable paper towels or an air dryer. Before performing invasive office procedures—incision and drainage of a superficial abscess, for example—thoroughly wash your hands and up to two inches above your wrists for one minute with an antimicrobial soap, such as chlorhexidine gluconate or povidone-iodine.

Each exam room should have a sink. Sinks should also be accessible in common areas and located as close as possible to exam rooms and the specimen collection area. If a sink does not have a foot- or elbow-operated faucet, paper towels should be available so that users can turn off the tap without recontaminating their hands.

What soaps and lotions should you use?

Handwashing can be classified by the type of cleanser used—plain soap, plain detergent, or an antimicrobial product. Washing with plain soap or detergent, in bar or liquid form, suspends microorganisms and allows them to be rinsed off, a process often referred to as mechanical removal of microorganisms. Washing with an antimicrobial product kills or inhibits the growth of microorganisms, a process often referred to as chemical removal of microorganisms.

For most routine activities, handwashing with plain soap appears to be sufficient, since soap allows most transient microorganisms to be washed off. For routine office procedures, a plain, mild, liquid hand soap is sufficient. When performing invasive procedures, use an antimicrobial soap.

Use self-contained, disposable liquid soap containers wherever possible. When the dispenser is empty, it should either be replaced or cleaned and filled with fresh product; to avoid contamination, liquid soap should not be added to a partially full dispenser. Try to avoid using bar soap because organisms can grow on the soap and in the pooled water that collects underneath it. If you do use bar soap in your office, keep it on a rack that allows the water to drain.

Bear in mind the importance of picking a product that your office staff will like and therefore use. For example, soaps that contain emollients to help prevent dry, cracking skin—which can accompany frequent handwashings—may improve compliance. This is especially true in the wintertime, when dry air and the increased number of patients visiting the pediatrician compound dry skin problems.

Antimicrobial hand lotion can also be used to prevent dry, cracked skin and should be readily available for staff. Disposable, pump-type containers are recommended; we advise against refilling them because they can become contaminated and are very difficult to clean.

Because anionic moisturizing products and surfactants have been shown to interfere with the residual activity of chlorhexidine gluconate, you'll need to consider interactions between chlorhexidine antimicrobial products and lotions when deciding which brands to buy. To assure compatibility, it may be helpful to discuss specific products with the infection control nurse at your local hospital. Since the use of incompatible products can reduce the effectiveness of handwashing, it's more cost-effective in the long run to provide your staff with lotion rather than having them use their own supply.

Alternatives to handwashing

Antimicrobial foams and alcohol hand-disinfectants should be at the ready disposal of staff for those times when a sink is not available. Chlorhexidine gluconate is offered in several preparations, including a 4% detergent and 2% aqueous formulation and foam. Some recently developed preparations contain 60% to 70% ethanol or isopropyl alcohol, with emollients added to minimize dry skin. These preparations have been shown to have excellent antibacterial activity and be quite acceptable to users. The emollients may enhance antibacterial activity by slowing drying time and thus keeping the alcohol in contact with the skin longer.

Taking the right precautions

Standard precautions, previously referred to as universal precautions, acknowledge that blood and certain body fluids are infected and can transmit bloodborne pathogens, such as hepatitis B and C and human immunodeficiency virus (HIV). Body substance precautions state that all body substances may be infectious—stool can contain salmonella, for example—so standard precautions should be taken for contact with any body substance. Common to both sets of precautions is the principle that all patients can harbor bloodborne infections, whether or not they are symptomatic. Therefore, a consistent approach—namely, the use of standard precautions for handling blood and body substances from all patients—is recommended. Handwashing, using gloves and other barrier precautions, and proper handling and disposal of sharps form the basis of these practices.

The most recent guidelines for standard precautions from the Centers for Disease Control and Prevention, published in 1996, were accompanied by pathogen- and syndrome-based precautions for patients infected or colonized with pathogens spread by the airborne, droplet, and contact routes. Table 2 lists the organisms most commonly seen in pediatricians' offices, what type of precautions are necessary for each, and how long the measures should be used. Airborne precautions are necessary for highly infectious respiratory illnesses such as varicella, Mycobacterium tuberculosis, and measles. Airborne precautions include both:

• placement of the patient in an area with appropriate air handling and ventilation, ideally a negative pressure room or a room with an open window with a fan in the window blowing to the outside, and

• the use of respiratory devices by the patient's health-care workers (for example, an N-95 particulate respiratory mask for contagious tuberculosis or a surgical mask for varicella and measles) and by others entering the patient's room.

TABLE 2
Precautions for selected infections

Droplet precautions are necessary for illnesses spread by large droplets, including Bordetella pertussis and meningococcus. These patients should be in a private room, but no special handling is necessary. Health-care workers should wear standard surgical masks when within three feet of the patient, and the patient should wear a mask when leaving the room. Health-care workers, as indicated by standard precautions, should wear gowns and gloves.

Contact precautions are necessary for diseases such as rotavirus, head lice, and viral conjunctivitis. The physician should wear gloves when entering the room and remove them prior to exiting, then wash his or her hands. Gowns should be worn if the health-care worker anticipates substantial contact of his or her clothing with the patient or surfaces in the patient's room. With both droplet and contact precautions, patients with the same illness can be placed together in the same room.

Gloves and gloving

The use of protective gloves in both medical and nonmedical settings has increased dramatically in the past decade. In medical offices, gloves should be worn for any contact with patients or contaminated articles in which direct exposure to blood, body fluids, mucous membranes, nonintact skin, or undiagnosed rashes is anticipated. Routine handwashing, rather than wearing gloves, is acceptable for changing diapers or wiping noses. Nonsterile latex or vinyl gloves should be readily available in patient care areas and utility rooms for routine use. Gloves that are more fitted are recommended when performing procedures that require a sense of touch. Sterile gloves should be used for procedures that require sterile technique. When purchasing gloves, consider whether a nonlatex glove may be an acceptable alternative, given the increasing number of allergic reactions to latex reported by health-care workers.

Gloves are for one-time use only; they must be discarded after each patient or procedure. They may be thrown in the regular trash unless they are heavily soiled with blood or other body fluids, in which case they should be disposed of as medical waste. Other protective wear, such as gowns, eye shields, goggles, and masks, should be worn when body fluids are likely to soil the worker's skin, eyes, mouth, or clothing.

Preventing respiratory transmission

Patients who may have infections transmissible via the respiratory route—such as varicella, disseminated herpes zoster, measles, rubella, pertussis, and tuberculosis—require special attention and precautions, summarized in Tables 2 and 3. With these infections, pathogens enter the body through droplets or droplet nuclei inspired into the respiratory tract. Many outbreaks have occurred after people merely shared the same air for a short period of time. For this reason, office practitioners should adhere to the following recommendations. First, see any patient who may have an infection transmissible by air at the end of the day if her clinical status allows. If a patient needs to come to your office in the middle of the workday, place a surgical mask over her mouth and nose and escort her directly to an exam room to decrease the risk of respiratory transmission. Second, regardless of when a patient arrives, move the patient quickly from the common waiting area to an examining room. Third, once the patient is in the exam room, make sure the door is closed to ensure that visitors and health-care workers do not enter the room unless they are immune to the disease or wearing proper isolation masks. In the case of tuberculosis, it is unusual for children to transmit tuberculosis, due to their inability to effectively cough and spread mycobacterium. Nonetheless, an N-95 particulate respirator mask should be worn when caring for patients with presumed contagious tuberculosis.

TABLE 3
Steps to prevent airborne transmission

See patients who may have a respiratory-transmissible disease at the end of the day if their clinical status allows

Quickly triage the patient out of common waiting areas and into an examining room

Close the exam room door and allow entry only to individuals who have disease immunity or are wearing proper isolation masks

Place a mask on the patient as he is escorted to and from the exam room

General office housekeeping

In an ideal world, pediatricians caring for children with infections would provide them with waiting, examination, and treatment spaces separate from those used by uninfected children. This luxury of space, facilities, and personnel is generally not available, though, and even in situations where it is, the infectious disease is often not diagnosed until after the child has waited and been examined and treated.

Cleaning the office, rather than separating patients, is the more feasible approach to protecting susceptible children. Unless a situation arises that warrants immediate attention, such as body fluid spills, your office should be cleaned at the end of every day. Surfaces, toys, and objects should be cleaned and disinfected with a low-level disinfectant. In some cases, prior mechanical cleaning to remove large particulate matter will be necessary.

Carpets are not recommended for patient-care areas because they can't always be cleaned adequately. If you do have carpeting and a spill occurs, remember that bleach may damage the rug, so another agent should be used. If the carpeting can't be cleaned sufficiently, you'll need to replace it.

Phenolic, iodophor, and quaternary ammonium compounds can be used for daily cleaning and disinfecting of surfaces and objects, including baby scales, table tops, floors, sinks, toilets, and examination tables. Uncovered examination tables should be cleaned between patients. Tables covered with disposable or reprocessible materials, such as linen, paper, and plastic, should be changed between patients. If there is a body fluid spill, the table should be cleaned and disinfected after the cover has been removed; otherwise, the table should be cleaned daily.

Sterilized equipment should be dated and stored in a clean area. Plastic-wrapped packs can be stored for a year. Muslin-wrapped equipment should be used within a few months of sterilization.

A word about toys: Try to choose durable ones that can be cleaned daily. Avoid mouth (chewing or teething), cloth, and plush toys. Frequently touched toys, like board books or puzzles, should be cleaned daily with a freshly prepared 1:100 bleach solution and allowed to air dry. If toys are visibly soiled, they should be washed with soap and water and disinfected.

Handling sharps safely

Bloodborne infections are usually transmitted by sharps injuries. You can minimize the risk of such injuries by following the practices listed in Table 4. Do not recap needles. If a needle must be recapped, use a one-handed method. The use of retractable needles and needleless systems is highly recommended.

TABLE 4
Handling sharps in the office

Do not recap needles; if you must, use a one-handed method

Discard sharps at the point of use in a designated container

Do not pass the sharp to another person; dispose of it yourself

Keep the sharps container in a place accessible to the health-care worker but not to the patient

The person using the sharp should discard it at the point of use in a designated sharps container. If a sharp has to be passed to another person, it must be done carefully to avoid injury. The sharps container should be located as close as possible to the designated "point of use" area, in a place that is easily accessible to health-care workers but not accessible to patients in the exam rooms. Often, keeping the sharps box on the first shelf above the sink allows staff ready access to it while keeping it out of reach of children.

The sharps container should be puncture- and tamper-resistant and leakproof. It should have a carrying handle and a tight-fitting lid, bear a clearly identifiable biologic hazard label, and be designed so that used sharps can be dropped in with one hand. Do not fill the container to the top with sharps. Fill it to only three-quarters capacity, then close the lid securely and replace the container.

Immunizing employees

Medical office workers are regularly exposed to communicable diseases on the job. Thus, immunity to diseases preventable by vaccine should be required of all health-care workers. Review the immunization status of all employees at the time they are hired. It is important that office personnel know their status, especially for common childhood diseases such as varicella, so that appropriate precautions can be taken if they come into contact with an infectious person either at work or at home.

Current vaccinations should include poliomyelitis, measles, mumps, rubella, varicella, influenza, hepatitis A and B, diphtheria, and tetanus. Maintain immunization records on all workers in your office. If documentation of immunity is unavailable and the employee is unsure of his immune status, you should require the employee to be vaccinated in accordance with the guidelines listed in Table 5.

TABLE 5
Recommended immunizations for medical office workers

Diphtheria and tetanus—All employees should have a booster every 10 years

Poliomyelitis—Employees should have completed a primary course of polio immunization

Measles—All adults born after 1957 who do not have a documented record of measles immunization or who are known to be seronegative should be vaccinated

Mumps—All adults who do not have a documented record of mumps immunization or who are known to be seronegative should be vaccinated

Rubella—Female office workers of child-bearing age who do not have a documented record of rubella immunization or who are known to be seronegative should be vaccinated

Influenza—Unless contraindicated, all health-care workers who have extensive contact with high-risk patients or who have a high-risk condition themselves should be immunized annually

Hepatitis A—Immunization is highly recommended by the authors, particularly in high-risk areas and for health-care workers who may be exposed to body secretions of children

Hepatitis B—Universal immunization is recommended, particularly for health-care workers who may be exposed to blood, blood products, or sharps injuries

Varicella—All adults who do not have a documented record of varicella immunization or who are known to be seronegative should be vaccinated

Pneumococcus—All employees who are older than 65 years or who have a medical condition that puts them at high risk for pneumococcal disease should be offered the vaccine

A 5 TU Mantoux PPD skin test is recommended for all health-care workers before the start of their employment. Those known to be tuberculin-positive or who test positive with the two-step method should have medical follow-up to rule out active disease. Routine follow-up skin testing is indicated if a worker has been exposed to a known case of tuberculosis or if clinical symptoms suggesting active tuberculosis develop. Annual follow-up testing is recommended if the worker is at risk of contact with patients who have TB or with specimens taken from these patients.

Each office should have a written plan to decrease the risk of transmission of bloodborne agents to employees. This infection control manual should also state the policies for managing needlestick injuries and other types of exposures and for handling health-care workers' personal illnesses. Finally, this manual can outline policies and procedures for communicating with local health authorities about reportable diseases and suspected outbreaks.

Good infection control practices minimize the spread of infection not only from employees to patients but also from patients to employees. Additional precautions may be necessary, however, for immunocompromised staff—workers taking immunosuppressive drugs, diabetics, and HIV-infected individuals, for example. These people are generally at increased risk of acquiring an infection from patients, and the consequences may be more severe if they do. Where feasible, the job description and patient exposures should be altered accordingly. Encourage all office personnel, particularly the clerical staff, to wash their hands frequently, or at least to use alcohol washes.

Medications and infection control

The medications used most commonly in a pediatrician's office are vaccines. Each vaccine requires special handling to maintain its integrity and efficacy, a topic we won't address here. Infection control policies for vaccines and other medications cover their proper storage and use. In general, an office should have a minimum of two refrigerators: one designated for storing medications only and one designated for laboratory samples. Food and personal items belonging to office staff should be kept in a third refrigerator. The disinfectant you use to clean the office can be used to clean the refrigerators as well.

Make sure you know whether a medication is for single or multiple use. Keep multidose vials only for the recommended duration of use after the initial entry. Employ strict aseptic technique when handling these vials and administering parenteral medications. Discard any vial that you suspect has been contaminated. Keep sterile irrigation solutions in small bottles, and store them at room temperature if possible. At the end of each day, discard all open bottles.

A comprehensive approach

No single measure can halt the spread of infection in medical offices. Controlling infections requires a comprehensive strategy, one that includes routine handwashing, adoption of barrier and isolation precautions, use of appropriate supplies and techniques for environmental cleaning and sharps disposal, and maintenance of accurate and up-to-date health records for employees. By following these measures, you will be able to avert the majority of infection control crises, while demonstrating that the health of your patients and staff is your highest priority.

SUGGESTED READING

Committees on Infectious Diseases and Practice and Ambulatory Medicine: Infection control in physicians' offices. Pediatrics 2000;105(6):1361

Donowitz LG: Infection Control in the Child Care Center and Preschool, ed 4. Philadelphia: Lippincott, Williams & Wilkins, 1999

Drummond DC, Skidmore AG: Sterilization and disinfection in the physician's office. Can Med Assoc J 1991;145(8):937

Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17(1):53

Goodman RA, Solomon SL: Transmission of infectious diseases in outpatient health care settings. JAMA 1991;265:2377

Larson EL: APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23(4):251

Nafziger DA, Lundstrom T, Chandra S, et al: Infection control in ambulatory care. Infect Dis Clin North Am 1997;11(2):279

Peter G (ed): 1997 Red Book: Red Book Report of the Committee on Infectious Diseases, ed 24. Elk Grove, IL: American Academy of Pediatrics, 1997

Rutala WA: Disinfection and sterilization of patient-care items. Infect Control Hosp Epidemiol 1996;17:377

The College of Physicians and Surgeons of Ontario: Infection Control in the Physician's Office. Ontario, Canada, The College of Physicians and Surgeons of Ontario, 1999

DR. WAGGONER-FOUNTAIN is Assistant Professor of Pediatrics, Divisions of Infectious Disease and General Pediatrics, University of Virginia Health System, Charlottesville, VA. She is a consultant for SmithKline Beecham Vaccines and Merck Vaccines and the recipient of a research grant from SmithKline Beecham.

DR. GROSSMAN DONOWITZ is Professor of Pediatrics and Head of Pediatric Infectious Diseases at the University of Virginia Health System, Charlottesville, VA. She is a consultant for Merck and SmithKline Beecham and the recipient of a research grant from Pfizer.

Leigh Donowitz, Linda Waggoner-Fountain. Infection control in the office: Keeping germs at bay.

Contemporary Pediatrics

2000;9:43.