Infection Control Today

FEB 2019

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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29 January/February 2019 ICT before concluding the procedure—are standard practice, but they are prone to error. If such errors result in a retained sponge, complications can ensue, with consequences for both the patient and the healthcare facility. Accurate data on the incidence of retained surgical sponges is hard to come by; for one thing, incidents may not be identifed unless (or until) the patient returns with a complaint of pain or discomfort. Nevertheless, we know the problem persists. Available data suggests that every year thousands of U.S. patients could experience a retained surgical item (RSI), with surgical sponges being the most commonly retained item. Technologies that supplement the manual counting process are available and have been found to be effective when used correctly. ECRI Institute contends that broader adoption of these technologies could further reduce the risk that a surgical sponge will be unintentionally retained during a procedure." The third infection prevention-related issue is mishandling fexible endoscopes after disinfection, which can lead to patient infections. As the ECRI Institute report indicates, "Cleaning and disinfecting fexible endoscopes between uses is known to be a challenging process. Failure to precisely follow a robust reprocessing protocol can lead to debilitating or even fatal infections. Less well known is that improper handling and storage practices can re-contaminate previously disinfected scopes, heightening the risk of patient infections." "Patient infections caused by endoscopes can be serious and, in some instances, have led to deaths, as illustrated by the 2015 CRE outbreak related to duodenoscopes," emphasizes Chris Lavanchy, engineering director of the Health Devices Group at ECRI Institute. "The seriousness of the infection can depend on the condition of the patient and whether they are immunocompromised, the part of the body colonized, and the specifc infectious organism. In the case of the CRE infections, these were patients that already had serious comorbidities (e.g., cancer) that compromised their immune system and the particular infectious agent was a bacterium resistant to even the most potent antibiotics." The ECRI Institute report adds, "If endoscopes are not completely dried after being subjected to high-level disinfection, any remaining viable microbes can rapidly proliferate and colonize the instruments. To promote drying, ECRI Institute and relevant professional societies recommend purging endoscope channels with clean air at the end of the reprocessing process. The disinfected status of endoscopes can also be compromised if the instruments are handled with unclean gloves—a practice that ECRI Institute has observed. Endoscopes that have been cleaned but not yet high-level disinfected are still contaminated with viable microbes; thus, gloves used to handle an endoscope at that stage must not be used to remove the scope from the reprocessing machine. Recontamination can also occur when transporting and storing endoscopes. Disinfected and dried endoscopes should be transported in a clean enclosed container, dedicated to that purpose, and should be prevented from contacting potentially unclean surfaces." "The risk of endoscope-related infections has been a perennial concern for a number of reasons and is especially challenging to address," Lavanchy acknowledges. "Flexible endoscopes are among the most complex medical instruments in their design and their features like internal channels running the length of the scope can make it especially challenging to disinfect every surface. Although reprocessing often involves the use of automated equipment, there are still many steps in reprocessing which are manually intensive and technique dependent. Experts have also noted that reprocessing procedures offer very small margins of safety, which means even small deviations can result in contaminated scopes. Because the scopes are costly, healthcare facilities often have lean inventories, which means that when demand is high reprocessing staff are under pressure to turn the scopes over quickly. These factors when combined, create a situation that invites compromised reprocessing." Lavanchy points to the numerous obstacles that hamper efforts to redesign fexible endoscopes to make them simpler to reprocess, and although this seems like the obvious solution to address the concern, it's easier said than done. "The reasons issues persist with endoscope reprocessing are multifac- torial," he explains. "To begin with, ECRI believes there has generally been a low level of awareness about how critical it is for reprocessing staff to closely follow recommended procedures. Some staff may even have the attitude that if I miss something its no big deal because the disinfection or sterilization process will take care of it. ECRI Institute has worked hard to change this thinking and to emphasize the importance of adhering to procedure by regularly discussing related reprocessing issues in our annual Top 10 Health Technology Hazards. As with many things related to work performance, drawing attention to the importance of adherence to procedure by itself is rarely successful and requires monitoring and regular refreshing to achieve consistent results." Lavanchy continues, "How healthcare facilities handle reprocessing though is only one part of the challenge. Endoscope vendors have invested signifcant resources to develop fexible scope designs that that meet the needs of physicians performing minimally invasive diagnostic Ò Patient infections caused by endoscopes can be serious and, in some instances, have led to deaths , as illustrated by the 2015 CRE outbreak related to duodenoscopes. — Chris Lavanchy

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