The Human Touches in Endoscope Infection Simon K. Lo, MD Director of Endoscopy Head, Pancreatic Diseases Program Chair Holder, F. Widjaja Family Chair in Digestive Diseases Clinical Professor of Medicine Cedars-Sinai Medical Center Los Angeles, California
CRE in the News
First CRE-ERCP Outbreak in the U.S. Alrabaa. American J of Infection control 2013
Dedicated Cleaning Area & Service Most variable in quality and design Smallest space allotted to cleaning room Little attention paid to cleaning room design and function Leaders usually consider a necessary evil and not a priority Least trained / lowest paid staff for cleaning function Janitorial service runs independent of GI lab
Reprocessing Lapses
Reported Cases in N. America 2005-2012 Langlay. Am J Inf Control 2013
Workflow in Instrument Reprocessing GI Endoscopy Cleaning and Processing Humphries. JCM 2015
Human Factor ( Errors ) Human contact in every step of scope usage and cleaning Many persons involved (scope washer, RN, tech, circulator, MD) Hard to monitor and detect human errors Reflection of staff s attitude Knowledge of disinfection The rushed jobs Potentially the biggest contributor to infection
Infection Opportunities Endoscope Usage Disinfection Storage
Common Endoscope Internal structure Humphries. JCM 2015
Processes Involved in an Endoscopy
Scopes & Supplies Delivery Scopes Supplies Expiration Package integrity Scope carrying case
In-room storage Accessories PPE General supplies Contamination Splashing Handling with dirty gloves Breakage of sealed packages Expired packaging Spillage Good practice Handling with clean hands or gloves Close storage cabinet at all times Remove expired packages
Processes Involved in an Endoscopy
Work Station Reusables Unused supplies Box of gloves Biopsy containers 4x4 s Lubricant jelly Water basin Opened and used accessories Contamination Spillage Hand touching Splashing Confusion about clean and used supplies Good practice Throw everything away at end of procedure Don t place anything not intended for use on work station Avoid close contact with clean supplies
Processes Involved in an Endoscopy
Hospital Telephones & Computers Ciragil. Hospital Infection 2006
Hospital/endoscopy environment Dumford. Am J Infect Control 2009
Processes Involved in an Endoscopy
Intra-procedure Transmission Bacteria transfer o From patient o To patient Improper cleaning of reusable instruments Unknowing use of contaminated accessories Dirty gloves Multiple persons touching many surfaces (equipment, scope, gurney, monitoring devices, cabinets, drawers) Long instruments that may touch the floor or dirty carts
Processes Involved in an Endoscopy
House-keeping Issues GI lab is probably full of important GI contaminants Splashing of fluid and vapors is common Instruments and accessories touch the floor!! Most units do not sweep and mop floors in between cases
Terminal Cleaning impacts C. Diff. Infection 48% reduction in the prevalence density of C Diff after the bleaching intervention (p<0.0001) Hacek. Am J Infect Control 2010
Processes Involved in an Endoscopy
Dirty scopes Clean Filthy!! On the way to the cleaning room Piling up dirty scopes Mechanical cleaning process Dripping of scope residues Drying of surface and channels of scopes Contamination of door knobs, etc. Dirty dishes effects Many steps, contamination of cleaning devices/ accessories, sink, etc.
High Level Disinfection Process Chiu. WJEM 2015
Complex Cleaning Methods 28 2016 Kaiser Foundation Health Plan, Inc. From K Kwok, DDW 2016. Olympus Reprocessing September 26, 2016Manual
Human Factors in Scope Cleaning Endoscope Reprocessing Methods: A Prospective Study on the Impact of Human Factors and Automation observers documented guideline adherence, with only 1.4% of endoscopes reprocessed using manual cleaning methods with automated high-level disinfection versus 75.4% of those reprocessed using an automated endoscope cleaner and reprocessor. The majority reported health problems (i.e., pain, decreased flexibility, numbness, or tingling). Physical discomfort was associated with time spent reprocessing (p =.041). Discomfort diminished after installation of automated endoscope cleaners and reprocessors (p =.001).. Ofstead. Gastroenterology Nursing 2010
Processes Involved in an Endoscopy
Separation of Clean and Dirty Arbitrary line of separation No physical barrier No warning about contaminated gloves, bottles, machines, etc. Vapors spread over to clean area Accidental handling of cleaned scopes with dirty gloves/hands
Hard barrier Examples of Facility Requirements Minimum space requirement for cleaning facility Hard separation of dirty and clean areas Modifications of existing requirements: Surveillance cameras Closed cabinet doors Secured entrance
Processes Involved in an Endoscopy
Cleaned and Dried scopes Vulnerable to mass contamination o Prolonged storage o dirty hands o Poor air dryness o Disgruntled employee
More Scrutiny More Findings Photographs of scope channels and ports of procedure-ready cleaned scopes were taken with a borescope Sterile cotton-tipped swabs collected samples of fluid Samples scanned with Fourier transform infrared spectroscopy (FTIR) Residual fluid observed inside 19/20 endoscopes; 8 had photos showing fluids that resembled simethicone solutions o Scopes contained simethicone fluids despite standard reprocessing o Simethicone is hydrophobic and may reduce reprocessing effectiveness o Simethicone solutions commonly contain sugars and thickeners, which may contribute to microbial growth and biofilm developement Ofstead. Am J Inf Control 2016
NY State TNE Bill A9763 In order to prevent the dangers of sedation and mitigate the risks involved in these upper endoscopic procedures, there shall be requirement that all upper endoscopic procedures be performed by the use of the transnasal esophagoscopy, hereinafter referred to as a TNE procedure, which is performed with the patient fully awake and upright, instead of the alternative method of upper endoscopic procedure, sedated upper endoscopy, which requires anesthesia, is significantly more dangerous, and much more expensive than the TNE procedure. Assemblyman David Weprin Website
Conclusions Our obligation to ensure patient safety Need to consider worst-case scenarios Can never be too clean All of us (endoscopists, nurses, techs, transporters, janitors) must be trained, reminded of and full committed to the absolute necessity to ensure a clean environment for our patients (or else someone else is going to make us do what we don t want to do)