Infection Control Today

AUG 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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14 ICT August 2018 during procedures is common given the patient populations, and reprocessing quality was poor in two of the three sites. Damaged broncho- scopes were in use at all sites, and previous studies have shown that damaged endoscope surfaces may foster the formation of bioflm. Results of tests done on a new bronchoscope at Site C in this study suggest contaminants were introduced to the bronchoscope during manual cleaning, as microbial growth and high levels of protein were detected after initial cleaning (before any clinical use). Cross-contamination from dirty environmental surfaces could explain the presence of gastrointestinal bacteria in bronchoscopes, as all sites reprocessed bronchoscopes in AERs also used for gastro- intestinal endoscopes. Site B had intentionally disabled the cleaning cycle on their AERs to save time (approximately 20 minutes per cycle). This presumably had a negative impact on reprocessing effectiveness and possibly fostered the accumulation of bioflm in their AERs. The study protocol did not include performing additional tests needed to assess the impact of this breach, and further research will be necessary to determine the prevalence and impact of disabling AER cycles … Results of tests done on a new bronchoscope at Site C in this study suggest contaminants were introduced to the bronchoscope during manual cleaning, as microbial growth and high levels of protein were detected after its initial cleaning. Storage conditions could also have contaminated reprocessed bronchoscopes, as visual inspections and ATP tests determined that storage cabinets were not clean. Other researchers recently reported that similar bacteria were detected on settle plates placed inside storage cabinets and in samples taken from fully reprocessed duodenoscopes stored in the cabinets for 24 to 72 hours. Guidelines currently recommend cleaning storage cabinets regularly to reduce the risk of re-contaminating reprocessed endoscopes. Additionally, nursing staff at Sites B and C were observed handling and transporting patient-ready bronchoscopes with bare hands, potentially exposing bronchoscopes to contaminants." Speaking at the most recent APIC annual meeting and presenting the results of the study published in Chest, Cori Ofstead, MSPH, principal of Ofstead & Associates, Inc., reminded the audience, "We have been looking at the effectiveness of reprocessing for about 10 years now; we have done studies in nine states and we have looked at the reprocessing of more than 900 scopes and we have looked at them from head to toe." She added, "When you think about bronchoscopy and you ponder whether it deserves a lot of attention when it comes to reprocessing effectively, we have to think about what we are using them for and who we are using them on. They are used for procedures that are routine and often very quick, such as assisting with intubation or removing a foreign object, and for diagnostic procedures, very often doing biopsies, and it becomes very important that we don't have any contaminated scopes. We have done a lot of work with GI scopes and I thought colonoscopes would be as bad as it gets in terms of gooey things and then we started doing traces and watching procedures and the bronchoscope procedures are really messy; you can do a colonoscopy and have no blood, but the bronchoscopes are messy and often they will be draining pus or fuid and secretions, resecting tumors strictures or performing ablation-type procedures and placing stents or valves and doing advanced procedures with these scopes." In her presentation at APIC, Ofstead emphasized the continuance of breaches in protocols. "In theory and accordance with the IFUs, bronchoscopes are supposed to be reprocessed starting immediately after use; and the frst thing that is supposed to happen is a bedside pre-cleaning as soon as that bronchoscope comes out of the patient's body," Ofstead says. "When that's done, they should be transported to a reprocessing area where they would undergo a leak test and then they would be thoroughly cleaned and rinsed off. After that, they are supposed to get a visual inspection to make sure that you got all the gunk off, and that is supposed to be performed with lighted magnifcation. The guidelines from AAMI and AORN now recommend that there also be biological testing for cleaning verifcation, so because the scope is black and you can't see inside of it, you must do something to make sure that the cleaning you did in the dark, so to speak, actually worked. Once you verify that it is clean, and if it's not clean, you clean it again, then it would either be sterilized or high-level disinfected and dried before storage. In some of the guidelines it is also specifed that it should get a visual inspection right before use. I caution people that we often boil down the steps into this short, compact list that sounds easy but what we know when we go in to perform audits there are numerous steps when following the guidelines and depending on the scope, there might be 100 to 140 steps they must do and they generally must do them in an order that is specifc. So, it's a lot to remember." Kovaleva (2015) reminds us of the risks associated with bronchoscopy; she writes, "The exogenous microorganisms most frequently associated with transmission of infection during bronchoscopy are Pseudomonas aeruginosa and mycobacteria. These microorganisms can be transmitted from previous patients or contaminated reprocessing equipment by contaminated endoscopes or accessory equipment. Exogenous infection should be prevented by strict endoscope disinfection procedures. During the period 1970-2012, 48 outbreaks of exogenous bronchoscopy-related infections and cross-contaminations involving 198 infected patients were reported in the literature. Several outbreaks of bronchosco- py-related transmission of multidrug-resistant P. aeruginosa and carbapenemase-producing Klebsiella pneumoniae have been published during the past few years." She points to the need for scrupulous reprocessing of bronchoscopes: "Accurate reprocessing of flexible bronchoscopes is a multistep procedure involving cleaning followed by sterilization or high-level disin- fection (HLD) with further rinsing and drying before storage. Most fexible bronchoscopes belong to semi-critical devices which contact mucous membranes during use and have a moderate degree of infection risk if contaminated at the time of use. They should receive at least HLD resulting in elimination of all vegetative bacteria, mycobacteria, fungi, and viruses, except for small numbers of bacterial spores. Flexible bronchoscopes used for therapeutic purposes in sterile body cavities belong to critical devices and should be sterilized after each procedure to eliminate all forms of microbiological life, including bacterial spores. Due to their material composition, most flexible bronchoscopes cannot be steam sterilized. They tolerate ethylene oxide and hydrogen peroxide plasma sterilization, which are expensive, can destroy mechanical We have been looking at the efectiveness of reprocessing for about 10 years now ; we have done studies in nine states and we have looked at the reprocessing of more than 900 scopes and we have looked at them from head to toe. Ò ÑCori Ofstead, MSPH

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