Public health investigations in outpatient healthcare settings nationwide, August 2019 to July 2023.

BACKGROUND

Outbreaks and other adverse patient safety events can occur in any healthcare setting and warrant investigation to minimize harm; however, national-level data for outpatient setting investigations are limited. We reviewed data reported by health departments to characterize these investigations.

METHODS

Health department investigations of novel or targeted multidrug-resistant organisms (nMDRO investigations) or clusters of healthcare-associated infections (HAIs) caused by non-nMDROs and infection control breaches with or without reported infections (HAI investigations) conducted from August 1, 2019 to July 31, 2023, were reported to the Centers for Disease Control and Prevention and reviewed to describe investigations involving outpatient settings only. SARS-CoV-2 investigations were excluded.

RESULTS

Among 4,182 reported investigations, 330 (8%) involved ≥ 1 outpatient settings. Of these, 230 (70%) involved outpatient settings only, including 38 dental (17%), 21 ambulatory surgery (9%), and 21 urology (9%) investigations. Of the 230, 148 (64%) were HAI investigations, and 82 (36%) were nMDRO investigations. Infection control breaches were reported in 100 of 148 (68%) HAI investigations, including in 78 (53%) without reported infections. Device reprocessing (56, 56%) breaches were most common overall.

CONCLUSIONS

Infection risks were identified across a variety of outpatient settings, highlighting the role of health departments in addressing urgent outpatient safety issues.