More Support to Reduce the Burden of Respiratory Illnesses through Improved Infection Prevention and Control in Ambulatory Settings
(See the article by Simmering et al, on pages 251–256.)
Anyone who has worked in an ambulatory pediatric setting or taken their own child to their pediatrician during the winter months has certainly noted the infants, children, and adolescents crowded in the waiting room with cough, rhinorrhea, fever, and malaise, lying on or slumped against their parents. It is likely many have then thought, “Wow, this is the perfect setting for transmission of respiratory viral pathogens” or “Oh no, if she isn’t sick yet, she is (or I am) going to get sick from all of these sick kids!”
To confirm this empiric observation, Simmering et al1 have used an enormous database from the Agency for Healthcare Research and Quality’s (AHRQ’s) Medical Expenditure Panel Survey2 to analyze noninpatient medical care from more than 84,000 families collected from 1996 to 2008. Using multivariate logistic regression, the investigators found that well-child visits for children less than 6 years of age that occurred during a risk window (defined as the same week or the 2 prior weeks) were associated with subsequent influenza-like illness (ILI) visits (P < .0001). ILI visits were more frequent not only among the children who had the well-child visit but among their family members as well. The model controlled for family factors associated with ILI visits: lack of insurance was associated with reduced odds of an ILI visit, while whites and those with higher education and income were more likely to have an ILI visit. The association held up with assessment of the interaction between influenza season and well-child visits and in sensitivity analyses that examined a shortened risk window of 1 week or children 3 years of age or younger.
The risk was small; the probability increased by 3.17% (interquartile range, 2.44%–3.91%). However, the investigators note that given the large number of well-child visits conducted in the United States, this small incremental risk could result in nearly 800,000 potentially avoidable ILI visits per year. The authors concluded that these potentially avoidable visits cost $492 million annually (based on an estimated cost of $650 per case of outpatient influenza). As only a fraction of ILI visits result in ambulatory visits, the true costs of ILI are much higher, as many more cases are likely to result in missed workdays or school days.3-5 Furthermore, ILI visits are associated with inappropriate antimicrobial use.5,6
The authors muse about reducing the risk of ILI by limiting well-child visits during the winter months but rightfully state that the majority of preventive services for the pediatric population occur during such visits, including immunizations. Thus, altering schedules for well-child visits could adversely impact vaccination rates, including vaccination rates for influenza. Such a strategy would clearly be unwise.
However, the authors emphasize that their findings provide additional support for reinforcing and implementing current infection prevention and control guidelines, but practicing infection prevention and control in the ambulatory setting can be very challenging. In 2011, the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee issued the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care,7 a distillation of existing guidelines. To improve implementation, the guidance includes an infection prevention checklist for administrative policies and facility practices that includes the basic tenets of infection prevention and control: develop infection prevention and control policies, provide adequate supplies for standard precautions and hand hygiene, provide staff education and training in infection prevention and control practices, have occupational health services available, monitor compliance with mandatory reporting requirements, promote injection safety, perform environmental cleaning and disinfection, and ensure appropriate reprocessing, sterilization, and high-level disinfection of reusable instruments and devices.
The guidelines also emphasize respiratory hygiene/cough etiquette and hand hygiene for patients with respiratory illnesses to prevent transmission. Implementation of such practices by patients with ILI and accompanying family members requires a well-designed education strategy tailored to the target audience; ready availability of masks, tissues, trash receptacles, and hand hygiene supplies; and monitoring adherence and providing feedback to patients and families.
One can imagine the complexity of implementing infection prevention and control practices to prevent ILI in a pediatric primary care setting, and numerous barriers exist to do so. These include knowledge, attitude, and practice barriers.8 Staff in ambulatory settings may not be well informed about infection prevention and control recommendations to prevent ILI; generally, infection prevention and control practices been developed for and focus on inpatient settings. Evidence for the success of infection prevention and control practices is also derived from inpatient settings. Attitude barriers experienced by staff may include disagreement with the recommendations, lack of confidence that infection prevention and control practices can be implemented in the ambulatory care setting, lack of belief that the practices may improve their patients’ outcomes (particularly if ILI outcomes are not tracked and trended), and the inertia of current practice. Practice barriers may be particularly relevant for ambulatory settings and include lack of time, space, money, administrative support, and/or ancillary personnel.
In recognition of the shift in care patterns from inpatient to outpatient settings, challenges of implementing infection prevention and control practices in ambulatory care settings were described more than a decade ago, with an understandable focus on outbreaks, appropriate injection practices, disinfection and sterilization of equipment, and ambulatory surgical practices.9,10 However, novel surveillance methods for a broader array healthcare-associated infections (HAIs) linked to the ambulatory care setting, such as those described by Simmering et al1 for ILI, must be developed not only for disease surveillance but also to measure the impact of infection prevention and control practices and to grow an evidence base for best practices in ambulatory care. These goals are aligned with recent increases in research support to reduce HAIs in ambulatory and long-term care settings.11
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here.
- 1. Simmering JE, Polgreen LA, Cavanaugh JE, Polgreen PM. Are well-child visits a risk factor for subsequent influenza-like illness visits? Infect Control Hosp Epidemiol 2014;35:251–256 (in this issue).
- 3. Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10 1999;1–203.
- 4. Principi N, Esposito S, Marchisio P, Gasparini R, Crovari P. Socioeconomic impact of influenza on healthy children and their families. Pediatr Infect Dis J 2003;22(suppl 10):S207–S210.
- 5. Nichol KL, D’Heilly S, Ehlinger E. Colds and influenza-like illnesses in university students: impact on health, academic and work performance, and health care use. Clin Infect Dis 2005;40:1263–1270.
- 6. Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis 2001;33:757–762.
- 7. Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. http://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html. Accessed December 12, 2013.
- 8. Cabana MD, Rand CS, Powe NR. Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282:1458–1465.
- 9. Herwaldt LA, Smith SD, Carter CD. Infection control in the outpatient setting. Infect Control Hosp Epidemiol 1998;19:41–74.
- 10. Jarvis WR. Infection control and changing healthcare delivery systems. Emerg Infect Dis 2001;7:170–173.