This document summarizes an educational session on infection prevention in emerging ambulatory care delivery models. It discusses trends driving the shift to outpatient care like declining inpatient volumes and growing outpatient encounters. Emerging models described include micro-hospitals, ambulatory surgery centers, and "hospital at home" programs. These models require new staffing approaches for infection prevention. The document outlines challenges for infection preventionists in these settings and resources available to assist them.

2. Infection Prevention On The Healthcare Frontier:
Emerging Models of Ambulatory Care
APIC ANNUAL CONFERENCE, JUNE 2018

3. Disclosures
Connie Cutler - Nothing to disclose
Brian Dennen - Nothing to disclose

4. Connie’s Subtitle: The Wild, Wild West

5. SESSION OVERVIEW
2
3
1
4
TRENDS IN CARE
EMERGING DELIVERY MODELS
BEST PRACTICES

6. We’re an Infection Preventionist and a Strategic Planner.
Brian Dennen, AIA, NCARB
Managing Consultant
Navigant Consulting, Inc.
• 10+ years of healthcare administration, facility
planning, design & construction experience.
• Licensed Architect, State of Illinois
• Member, American Society for Healthcare
Engineering
• B.Arch, Iowa State University
• MBA, Northwestern University
Constance Cutler, RN, MS, CIC, FSHEA, FAPIC
Manager, Infection Prevention
MacNeal Hospital, Berwyn, IL
• Devoted to the field of infection prevention for
30+ years with degrees in nursing and biology.
• Former board member of Certification Board of
Infection Control (CBIC)
• Fellow of APIC & SHEA
• Manager of Infection Prevention at 347-bed
Level II Trauma Center

7. Objectives for today are to understand broader trends,
describe delivery models, and identify best practices…
Understand trends and projected growth over next decade in
ambulatory/outpatient care across broad specialties and in varied
settings including micro-hospitals, ambulatory surgery centers,
freestanding emergency departments, urgent care, and other locations.
Describe the typical patient profile, procedural capabilities, physical
environment, and staffing structure of these locations and their
relationship to traditional hospital systems.
Identify strategies, best practices, and practical tools to support
patient safety for infection preventionists working in these new settings.

8. SESSION OVERVIEW
2
3
1
4
TRENDS IN CARE
EMERGING DELIVERY MODELS
BEST PRACTICES

9. A continued shift to outpatient care…
Sources: 1. 2017-2027 Total US Market, Truven Analytics.
8,000,000
9,000,000
10,000,000
11,000,000
12,000,000
2017 2022 2027
Demographics Only
Managed Market
+21%
+13%
Outpatient Encounters (2027)
30,000
32,000
34,000
36,000
38,000
40,000
42,000
2017 2022 2027
Demographics Only
Managed Market
Inpatient Discharges (2027)
+16%
+3%

10. Six market forces are driving the transition from volume-
based to value-based care…
1. Compression of margins
2. Care management across the
continuum
3. Contraction of inpatient volumes
4. Consolidation and convergence
5. Consumerism comes to
healthcare
6. Connectivity between
patients/families and providers
7. Competing on Value
Market Forces

11. Inpatient volumes will decline steeply for many specialties…
Growth In Inpatient Discharges, By Service Line (2027)
+29.7%
-70.0%
-60.0%
-50.0%
-40.0%
-30.0%
-20.0%
-10.0%
0.0%
10.0%
20.0%
30.0%
40.0%
Gynecology
Otolaryngology
Endocrine
Cardiology
Urology
Trauma
Ophthalmology
VascularSurgery
GeneralSurgery
Neonatology
ThoracicSurgery
OncologyMedical
Pulmonary
Orthopedics
Neurosurgery
Gastroenterology
Dermatology
Rheumatology
OpenHeart
Hematology
Neurology
Psych/DrugAbuse
Nephrology
GeneralMedicine
-55.9%
10 Year Population Growth (~8%)
Sources: 1. 2017-2027 Total US Market, Truven Analytics.

12. …whereas outpatient volumes will rise across service lines.
Growth In Outpatient Encounters, By Service Line (2027)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
+44.4%
+5.6%
10Y Population
Growth (~8%)
Sources: 1. 2017-2027 Total US Market, Truven Analytics.
`

13. Outpatient revenue is eclipsing inpatient revenue…
Distribution of Outpatient vs. Inpatient Revenues
Sources: 1. “Trendwatch Chartbook 2016”, American Hospital Association.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
PercentageofRevenue
Gross Inpatient
Revenue
Gross Outpatient
Revenue
*When most hospitals were built (and why your CFO is stressed)...
PercentageofRevenue

14. As care has moved to outpatient settings, so have outbreaks…
Outbreaks of Hepatitis B Virus Infection Among Hemodialysis
Patients -- California, Nebraska, and Texas, 19941
Sources: 1. April 12, 2016, Morbidity and Mortality Weekly. 2. Mary Manning, Las Vegas Sun, October 23, 2008.
Nevada Hepatitis C Outbreak Largest in US -
Health officials report 105 possible hepatitis C cases, 20082
Infection Prevention Headlines

15. As care has moved to outpatient settings, so have outbreaks…
Investigation of conjunctivitis in Ophthalmologist office:
Possible transmission by health care workers’ hands, breaks in aseptic technique,
and use of multidose vials, 20021
Sources: 1. Kelsey O Yong et. al. “Health Care–Associated Infection Outbreak Investigations in Outpatient Settings, Los Angeles County, California, USA, 2000−2012”, Emerging Infectious
Diseases, August 21st, 2015. 2. Becker’s Hospital Review, January 2nd, 2018.
New Jersey physician's license suspended after accusations of
reusing catheters, 20182
Infection Prevention Headlines

16. Hepatitis B Transmission in Dialysis Centers - Transmission of
hepatitis B virus in dialysis units: a systematic review of outbreaks
Sources: 1. Int J Artif Organs. 2015 Jan;38(1):1-7. doi: 10.5301/ijao.5000376. Epub 2015 Jan 26.

17. One needle, one syringe, only one time? A survey of physician and
nurse knowledge, attitudes, and practices around injection safety
Sources: 1. Rachel A. Kossover-Smith, MPH et. Al. American Journal of Infection Control 45. 2017.

18. Ambulatory Surgical Center (ASC) 2010 JAMA Assessment…
- More than 5,000 ASCs in the U.S. participated in
the Medicare program in the study period of 2001-
2008 in data from 2009.
- Centers for Medicare and Medicaid Services
piloted an Infection Prevention audit tool in a
sample of ASC inspections to assess adherence to
recommended practices.
- Seven states volunteered and three were selected,
then randomized sample selected of 68 (32 in
Maryland; 16 in North Carolina; and 20 in
Oklahoma)
- Focused on 5 areas: hand hygiene, injection
safety and medication handling, equipment
reprocessing, environmental cleaning, and
handling of equipment for blood glucose
monitoring.
- 46 of 68 ASCs had at least 1 lapse (67.6% with
confidence intervals 55.9%-77.9%)
- 12 of 68 had lapses in 3 to 5 areas (17.6% with
confidence intervals 9.9%-28.1%)
- Common lapses included single-dose
medication vials used on more than 1 patient [18
of 64 (28.1%); CI 18.2%-40.0%]
- Failing to adhere to recommended practices
regarding reprocessing of equipment [19 of 67
(28.4%); CI18.6%-40-%]
- Lapses in handling of blood glucose monitoring
equipment [25 of 54 (46.3%); CI 33.4%-59.6%]
Sources: 1. Source: Schaefer MK, et. al. Infection Control Assessment of Ambulatory Surgical Centers. JAMA. 2010;303(22):2273-2279. doi:10.1001/jama.2010.744
Background Results

19. SESSION OVERVIEW
2
3
1
4
TRENDS IN CARE
EMERGING DELIVERY MODELS
BEST PRACTICES

20. Infection preventionists previously had one location on which
to focus, now they have a portfolio of outpatient sites…
YESTERDAY
TODAY

21. Health systems are taking an increasingly methodological
approach to their ambulatory networks…
-Part-time and full-time
Specialist Practices
-Diagnostic Imaging*
-PT/OT/Sports Medicine*
-Cardiac testing/Cardiac
Rehab
-Retail Pharmacy
-Complementary Alternative
Medicine
-Primary Care Physicians
(6-10)
-Ext. Hours/Urgent
Care/Retail Clinic/ER*
-Lab draw
-Primary Care Physicians
(2-5)
-Ext. Hours/Urgent
Care/Retail Clinic/ER
-X-Ray (potentially
Mammography &
Ultrasound)
-Lab Draw
Model 2
Intermediate (Diagnostic &
Therapy)
-Specialist Office
Space/Centers of
Excellence
-Outpatient Surgery*
-Freestanding ED
-Primary Care Physicians
(16-24, some could be off-
site)
-Ext. Hours/Urgent
Care/Retail Clinic/ER*
-Lab draw
-Diagnostic Imaging*
-PT/OT/Sports Medicine*
-Cardiac testing/Cardiac
Rehab
-Retail Pharmacy
-Complementary Alternative
Medicine
Model 3
Advanced (Comprehensive)
-ED
-Short Stay (2-3 days) and
Outpatient Surgery
-Surgical and/or Specialty
Focus
-Primary Care Physicians
(10-30, some could be off-
site)
-Urgent Care/ER
-Lab draw
-Diagnostic Imaging
-PT/OT/Sports Medicine
-Cardiac testing/Cardiac
Rehab
-Retail Pharmacy
-Complementary
Alternative Medicine
-Specialist Office
Space/Centers of
Excellence
-Inpatient and Outpatient
Surgery
-ICU/CCU beds
-Primary Care Physicians
(12-40, some could be off-
site)
-Urgent Care/ER
-Lab draw
-Diagnostic Imaging
-PT/OT/Sports Medicine
-Cardiac testing/Cardiac
Rehab
-Retail Pharmacy
-Complementary
Alternative Medicine
-Specialist Office
Space/Centers of
Excellence
Model 5
Full Service Hospital
Travel Time Up to 10 Minutes Up to 15 Minutes Up to 20 Minutes Up to 30 Minutes Up to 45 Minutes
Building Area 4,000-10,000 GSF 15,000-40,000 GSF 35,000-100,000 GSF 100,000-200,000 GSF >125,000 GSF
Site Requirements 1-3 Acres 2-5 Acres 7-15 Acres 10-20 Acres 15-40 Acres
Population Base 5,000-12,500 15,000-25,500 40,000-60,000+ 75,000-125,000 100,000-150,000+
Model 1
Basic (Primary Care)
Model 4
Surgical/Specialty Hospital
Acute CareAmbulatory

22. These networks of care delivery sites require new infection
preventionist staffing models…
Sources:
Results: Quantitative needs assessment
revealed actual labor need to be 31%-66%
above current benchmarks of 0.5-1.0 IP per
100 occupied beds. When aggregated
across the organization, the comprehensive
review results yielded a new benchmark of
1.0 infection prevention full-time equivalent
per 69 beds if ambulatory, long-term care,
or home care are included.

23. Microhospitals are one emerging model of care delivery…

24. What are the common components of a microhospital?
MICROHOSPITAL
MEDICAL OFFICE
Medical Office Building to accommodate
primary care and select clinical specialties
DIAGNOSTIC & TREATMENT
May or may not include other outpatient
services such as advance imaging.
PROCEDURE CENTER
Surgery, minor procedures and / or GI Endo.
INPATIENT BEDS
The inpatient unit could start small and later
be expanded; may flex as observation.
EMERGENCY DEPARTMENT
Includes emergency services with supporting
imaging & lab services

25. A few of the health systems building them…
System System Profile Microhospital Strategy
(Indianapolis)
- Ascension Health member
- $2 B+ in revenue
- 20 hospitals and presence in 46
counties
- 8 total planned (4 in 2017)
- Augments network strategy and creates foothold
in suburbs
- 24-7 ED, 8 OP beds, 7 IP beds, imaging (US,
CT, X-ray)
- Planning for 20 patients per day
- Pricing aligned w/ other IP facilities
(Kansas City)
- Faith-based, NFP system
- $2 B+ in revenue
- 10 hospitals across metro Kansas City
- 4 planned
- Extends access in KS suburbs
- 8-10 beds each, with estimated construction
costs of $20M
(Dallas)
- NFP system
- $5.9 B+ in revenue
- 12 acute care hospitals
- 215,000+ member health plan
- 8 total facilities
- ~20,000 sq. feet each
- 24-7 ED (7 bays), lab, imaging (X-ray, CT, US), 8
IP beds
- Lower cost platforms to further penetrate
attractive pockets of DFW

26. Inside a typical microhospital…
Sources: https://www.indystar.com/story/news/local/hamilton-county/2017/07/06/debuts-1st-4-micro-hospitals-comngst-vincent/443820001/

27. Sources: https://www.indystar.com/story/news/local/hamilton-county/2017/07/06/debuts-1st-4-micro-hospitals-comngst-vincent/443820001/
Inside a typical microhospital…

28. Microhospitals rely on sharing central resources (including
IPs!) across facilities …
System Shared Resources
Microhospital Dedicated Resources
Site Administrator
ED/IP Nursing Mgr. Periop. Mgr. Operations Mgr.
Senior Leadership
Functional Area Leaders
Nursing, Perioperative, Quality, HIM, Ancillary
Services, Facilities, EVS, F&N, Security
Other Resources
Revenue Cycle, Telecomm, Marketing, IT,
Pharmacy, Lab, Kitchen
Medical Staff
Satellite Lab & Pharmacy,
Grab & Go Cafe

29. Programs such as “hospital at home” further multiply the
sites where advanced care is provided…
Hospital Level Care - Distinct from home health or physician house
calls, service provides hospital level care and monitoring.
How it Works - Typically “admitted” from ED and transported home by
ambulance, met by nurse and equipment with daily physician rounding.
30%
cost savings
5%
reduction in bed days
38%
mortality reduction
Sources: 1. https://www.johnshopkinssolutions.com 2. https://www.youtube.com/watch?v=cMd0vPxAtB8

30. Sources: https://www.youtube.com/watch?v=cMd0vPxAtB8

31. SESSION OVERVIEW
2
3
1
4
TRENDS IN CARE
EMERGING DELIVERY MODELS
BEST PRACTICES

32. So, what can an IP do?
Review what kind of issues have occurred in the past and
with what frequency.
1
Go out and see for yourself what’s actually happening,
focusing first on the riskiest areas:
#1 Those performing sterilization of instruments.
#2 Those doing high level disinfection.
#3 The others “just” providing routine patient care such as using syringes.
Make the business case that it is “potentially” scary out there but
that regular visits from a qualified infection preventionist can
mitigate the real risks.
2
3

33. Challenges for infection preventionists in outpatient settings
are immense, yet there are many resources that can assist…
Sources: 1. Farhad Memarzadeh, PhD, PE, American Society for Healthcare Engineering. 2. https://www.healthdesign.org/topics/infection-control 3. Guidelines for Design and Construction of Outpatient Facilities.
- Provides extensive
background and
commentary on indoor air
quality (IAQ) and
ventilation, risk
management, and other
facility design &
operational factors that
influence rate of HAIs.
The Environment of Care and
Health Care-Associated
Infections (ASHE)1
- Numerous tools &
templates for safety risk
assessments, design
checklists.
- Hub for articles and other
research on role of facility
design in preventing
infections.
The Center for Health Design2
- Referenced by accrediting
bodies & adopted by law
in many jurisdictions.
- 2018 edition now has a
separate book of
guidelines dedicated to
outpatient facilities.
Guidelines for Design and
Construction
(Facility Guidelines Institute)3

34. Challenges for infection preventionists in outpatient settings
are immense, yet there are many resources that can assist…
Sources: 1. Center for Disease Control and Prevention. 2. Association for Professionals in Infection Control and Epidemiology.
- Near-comprehensive set
of recommendations for
outpatient care.
- Consult the “One and
Only” Campaign from the
CDC.
- See highlighted resources
on following page.
CDC Guide to Infection
Prevention for Outpatient
Settings1
- Great source of sample
policies and procedures,
educational material, and
other documentation.
- Practical guidance written
specifically for infection
prevention professionals.
APIC Infection Prevention
Manual for Construction &
Renovation2
- Numerous professional
societies have
publications that generally
cross reference CDC &
FGI publications.
- Look for “joint” statements
on many issues.
SHEA, TJC, ACS, AORN,
AAMI, SGNA, ACG…

35. Highlighted resources from CDC “Guide to Infection
Prevention for Outpatient Settings”
General Infection Prevention
- CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/HAI/prevent/prevent_pubs.html
Healthcare Personnel Safety
- Occupational Safety & Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention Standard:
http://www.osha.gov/SLTC/bloodbornepathogens/index.html
Injection Safety
- CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety/
Environmental Cleaning
- Guidelines for Environmental Infection Control in Healthcare Facilities:
http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf
*Equipment Reprocessing*
- Guideline for Disinfection and Sterilization in Healthcare Facilities:
http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
- Multi-society guideline on reprocessing flexible GI endoscopes: 2016 update: https://www.asge.org/docs/default-
source/importfiles/publications_and_products/practice_guidelines/doc-multisociety-guideline-on-reprocessing-flexible-
gastrointestinal.pdf
Point-of-Care Testing
- Infection Prevention during Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/blood-
glucose-monitoring.html

36. Something to watch for…
Contact:
Beth Ann Longo, DrPH, RN, MBA, MSN
Associate Director, The Joint Commission
blongo@jointcommission.org

37. Something to watch for…
Sources: https://oascahps.org/
22. At any time after leaving the facility, did you have any signs of infection?
Yes No
Infection Prevention Issues = Reduced Payment Determinations

38. Questions?
- Rate your nervousness?
- What practice locations concern you most?
- What’s the first thing you’ll do back at work?
- How do you make a business case for staffing or resources?

39. Constance Cutler, RN, MS, CIC,
FSHEA, FAPIC
Manager, Infection Prevention
MacNeal Hospital
ccutler@macneal.com
p: 708.783.3389
Brian Dennen, AIA, NCARB
Managing Consultant
Navigant Consulting, Inc.
brian.dennen@navigant.com
p: 312.583.2729
Contact Information