IPC in Ambulatory Care Settings: A Patchwork of Practices

The non-acute healthcare environment is continually evolving and expanding, with increasingly complex patients being treated in outpatient and ambulatory settings. As more care shifts out of hospitals and into outpatient clinics, ambulatory surgery centers (ASCs), and other non‑acute settings, infection prevention (IP) programs are being asked to do more with less, often under far more variable conditions.

Patients treated in these settings are increasingly complex, including older adults and immunocompromised populations. For example, patients undergoing total hip, knee or shoulder replacements once spent months recovering in an inpatient bed. As an Infection Preventionist (IP) during those days, I remember focusing heavily on the infection risks associated with the home environment and the level of support required to ensure a successful post‑surgical outcome. Today, nearly half of these procedures are performed in the outpatient setting, with patients discharged directly home.

Why non-acute Infection Prevention and Control (IPC) is getting harder

Several converging factors are driving increased IPC complexity in ambulatory and outpatient environments:

• Higher-acuity patients treated outside the hospital
• Faster discharge timelines and same-day recovery
• Infection risks now extend across homes, clinics and ASCs

Despite this growing complexity, data shows favorable outcomes for procedures like total joint replacement in the outpatient setting¹, which may continue to drive even more procedures to outpatient and ambulatory settings. Most IPs would agree that infection prevention in non-acute settings remains a patchwork of practices, with no one-size-fits-all approach, and day-to-day variability in risk, resources and operational realities.

Varying levels of oversight

Inpatient hospital care is subject to some of the highest levels of regulatory oversight², particularly in infection prevention. The Joint Commission, the Center for Medicare and Medicaid Services (CMS), and local and state health agencies provide extensive oversight in acute care settings. In contrast, non-acute settings are primarily overseen by smaller accrediting bodies, like the Accreditation Association for Ambulatory Health Care (AAAHC), Accreditation Commission for Health Care (ACHC) and Quad A.

Beyond differences in accrediting bodies, licensing and accreditation requirements tend to be far more variable in outpatient and ambulatory settings than in hospitals. Because of this, we often see that the further away you get from inpatient hospitals, the more regulatory oversight decreases. In fact, according to a 2026 study³ analyzing routine evaluations of daily infection prevention practices, less than one in ten health department investigations involve outpatient settings. This lack of oversight contributes to significant variability, seen both between and within non-acute care environments.

Compounding the issue, facilities and practices that are not attached to a health system may rely on individuals without infection prevention-specific training to oversee these responsibilities. In many cases, a nurse or administrator must oversee infection prevention as an added duty, leaving limited time or resources to consistently monitor, assess or improve practices. Unlike inpatient care, ambulatory healthcare settings frequently lack standardized healthcare associated infection (HAI) metrics (as defined by the Centers for Disease Control and Prevention [CDC]), and infections are often detected later at different facilities, making the surveillance framework across settings difficult.

Barriers to effective infection prevention in non-acute care

Looking specifically at environmental cleaning and disinfection, several structural barriers within ambulatory settings prevent easy adoption of evidence-based practices. A critical starting point is the misconception that ambulatory spaces present low or no risk from an IP perspective. As healthcare continues to move more encounters to outpatient environments, patients are increasingly exposed to the risk of HAIs. In fact, patients infected or colonized with C. auris are regularly seen in outpatient environments, prompting health departments to issue targeted guidance for these settings.⁴

Structural and operational barriers often prevent the straightforward adoption of evidence based practices, including:

• Low perceived infection risk, despite increasing HAI exposure in outpatient environments
• Facilities not designed exclusively for healthcare, resulting in limited storage space, shared equipment or repurposed rooms
• Rapid workflows and frequent room turnover, leaving little margin for complex cleaning processes
• Fragmented ownership and contracted services, complicating accountability
• Lean staffing models and variable training, increasing the risk of inconsistency
• Product complexity, such as on-site dilution requirements, long or unrealistic contact times, and unclear surface or equipment compatibility

In the absence of practical solutions, such as ready-to-use products with realistic, compliant contact times that align with fast-paced workflows, staff may struggle, making consistent adherence to best practices difficult to achieve.

Setting the environment up for success

Any one of these barriers can make effective environmental hygiene difficult to sustain. When multiple barriers exist, complexity only increases.

In these non-acute settings, IPs must lean on the foundational tools to set the environment up for success. Everything in our IPC world starts with a risk assessment to identify the highest-risk workflows and surfaces. To effectively do this, it is key to know your priority and focus efforts there.

Developing a standardized, setting-specific cleaning and disinfection protocol with clear responsibilities is imperative. The simpler the workflow (and products), the better. Effective protocols should aim to:

• Minimize the number of products staff must select from
• Eliminate on‑site dilution or mixing whenever possible
• Use products with realistic contact times that align with room turnover
• Ensure compatibility with shared equipment and high‑touch surfaces

Compliance depends on more than education alone. Training enables knowledge transfer, competency validates understanding and monitoring programs confirms adoption. It can be as straightforward as an observation with a checklist or using fluorescent gel, but it must be intentional and consistent. While proper environmental disinfection is essential, accurate monitoring and tracking are equally critical to protecting patients and staff from infection.

Moving from patchwork to practice

Varying levels of ambulatory oversight and incentives have contributed to the current patchwork of infection prevention practices. Implementing clear, efficient and real-world workflows to address high-risk areas creates an environment where staff understand their roles and responsibilities and can execute them accordingly. IPs can develop accountability for these practices through monitoring programs and timely feedback to staff on performance. Leveraging tools like risk assessments, prioritization, training and monitoring, ambulatory healthcare facilities can achieve practical, scalable infection prevention strategies on par with programs in far more highly regulated parts of the industry.

Navigating a patchwork of practices in non-acute settings isn’t easy, but consistency can provide the key to set IPs up for success.