At the Clinic, Care ... and Infection

By LAURA LANDRO

As hospitals get better at keeping serious infections from spreading to patients, a new source of worry is emerging: outpatient clinics, where reports of dangerous transmissions of bacteria and viruses have been on the rise.  

The Centers for Disease Control and Prevention on Tuesday is launching a campaign to reduce the rate of infection among the more than one million cancer patients a year who receive chemotherapy and radiation treatments in outpatient oncology clinics.
Health care provided by outpatient clinics, including surgical, medical and diagnostic services, has surged in recent years because the centers are typically cheaper and more convenient than hospitals. Unlike hospitals, however, the clinics are not tightly regulated or inspected and may not have formal infection-control programs. In the past decade, the CDC says, more than 125,000 patients have had to be notified of potential exposure to disease from unsafe injection practices alone.
The CDC this month released a report about its findings at a New Jersey hematology-oncology clinic, where in 2009 systematic breaches of infection control led to transmission of hepatitis B. About 2,700 patients of the now-closed clinic were notified of possible exposure, due to practices such as improper medication preparation in blood-processing areas, common use of saline bags and re-use of single-dose vials. Twenty-nine cases of hepatitis B were identified.
In another case, Mississippi health officials closed a chemotherapy clinic this summer after an outbreak of bacterial infections linked to the re-use of needles.
Cancer patients are especially vulnerable because their immune systems are suppressed from their disease and its treatment. Nearly 60,000 cancer patients a year have to be hospitalized with an infection.
"Cancer patients are often struggling to maintain their health and these preventable infections can undermine their progress," says Joseph Perz, an epidemiologist leading the CDC's prevention team. "Not all outpatient providers understand or recognize the importance of infection control."
The CDC campaign, which is voluntary for outpatient clinics, will promote strict adherence to hand-hygiene guidelines, sterile techniques for preparing and administering medications, and safe-injection practices. A new patient website, preventcancerinfections.org, helps patients assess their risk for infection and avoid infections at home and in the community. The campaign is part of a wider effort to reach outpatient clinics. The CDC in July, for instance, issued a new infection-prevention guide for outpatient care in surgery centers, pain-management clinics and other settings. The effort comes as the CDC reported last week that hospitals have significantly reduced the number of patients contracting several serious types of infections by adopting prevention strategies.
Evelyn McKnight, 56, was being treated for a recurrence of breast cancer in 2002 when she learned she had hepatitis C, which was traced to a now-closed chemotherapy outpatient clinic in Nebraska. An investigation found that a nurse inadvertently spread the virus by routinely using the same syringe for multiple patients to draw blood from catheters and to draw catheter-flushing solution from saline bags. Close to 100 patients were found to be infected.
Ms. McKnight says the hepatitis treatment was worse than the effects of chemotherapy. "I crawled into bed for a couple of years and couldn't do anything," she says. After receiving a clean bill of health in 2008, Ms. McKnight wrote a book about her experience, "A Never Event," and used funds from a malpractice suit to start a nonprofit group called Honoreform, which advocates for safe-injection practices. "We still don't have a centralized way of enforcing safe practices in freestanding clinics," she says.
Medical-industry guidelines for preventing infection call for needles, syringes, saline-solution bags and medication vials to be used only once for a single patient. But such measures aren't always followed.
A survey of 5,446 health-care professionals who prepare or administer injections published last year in the American Journal of Infection Control, found that 6% "sometimes or always" use single-dose vials for more than one patient. More than 15% reported re-using a syringe to enter a vial of medication for one patient, and close to half of those respondents reported saving the vial for use on another patient.
"I don't think anyone comes to work at a clinic intending to harm anybody, but there is a real lack of awareness of even basic sterile techniques," says Gina Pugliese, director of the Safety Institute at hospital purchasing alliance Premier Inc., which conducted the survey.
M. Sitki Copur, medical director of oncology at Saint Francis Cancer Treatment Center in Grand Island, Neb., says his center has introduced several strategies to help prevent infection. The clinic's oncology pharmacists prepare drugs in a special cabinet in a "clean room" where negative pressure is used to sweep away contaminants, Dr. Copur says. Three years ago the clinic added a device, PhaSeal, which transfers chemotherapy medication from vials into syringes in a closed system with no opportunity for leakage. This protects health-care workers from exposure to toxic chemicals and prevents infectious agents from entering the chemotherapy bag, he says.
Helen Snow, 64, says she notices the extra precautions when she goes to the Saint Francis clinic for chemotherapy to treat a recurrence of colon cancer. Clinic staffers who administer her medications wear masks, plastic aprons and gloves, and she sits in a private enclosure where she is shielded from other patients' germs, she says.
"Everything they use, they throw away, and they sanitize their hands when they come in and when they leave," Ms. Snow says. "I really feel secure knowing what they are doing here."