Disinfection of tonometers and contact lenses in the office setting: are current techniques adequate?

PURPOSE

To determine whether routine office techniques used to disinfect tonometer prisms and trial contact lenses are sufficient to prevent transmission of ocular infections.

METHOD

We reviewed the current literature on the efficacy of certain disinfection protocols against commonly encountered viral, bacterial, and fungal pathogens as well as Acanthamoeba.

RESULTS

Some commonly used disinfecting solutions and techniques may be inadequate for disinfection of viruses such as hepatitis C virus and organisms such as Acanthamoeba. When used in accordance with guidelines published by the United States Centers for Disease Control and Prevention (CDC) and the American Academy of Ophthalmology (AAO), 3% hydrogen peroxide is a very effective disinfectant against a wide variety of microorganisms. Specifically, tonometer prisms disinfected by a 5-minute soak in 3% hydrogen peroxide (or 70% isopropyl alcohol or a 1:10 dilution of sodium hypochlorite) are adequately disinfected against most ocular pathogens, with the exception of Acanthamoeba. Trial contact lenses that are disinfected with a 2-hour soak in 3% hydrogen peroxide are effectively rid of all pathogens of concern. After disinfection, rigid lenses should be stored dry, and soft lenses should be stored in a sterile, preserved solution. Repeat disinfection should be routinely performed at 1-month intervals to prevent regrowth of organisms.

CONCLUSION

A safe office environment can be maintained by following current CDC recommendations for disinfection, as well as instituting some additional procedures.

Are physicians' office laboratory results of comparable quality to those produced in other laboratory settings?

CONTEXT

In 1995, California adopted a bill that brought laboratory laws in line with the 1988 Clinical Laboratory Improvement Amendments' standards for clinical laboratories and mandated a study comparing results in physicians' office laboratories (POLs) with other settings.

OBJECTIVE

To determine whether persons conducting tests in POLs produce accurate and reliable test results comparable to those produced by non-POLs.

DESIGN

Survey of clinical laboratories using proficiency testing data.

SETTING

All California clinical laboratories participating in the American Association of Bioanalysts proficiency testing program in 1996 (n=1110).

MAIN OUTCOME MEASURES

"Unsatisfactory" (single testing event failure) and "unsuccessful" (repeated testing event failure) on proficiency testing samples.

RESULTS

The unsatisfactory failure rate for POLs was nearly 3 times (21.5% vs 8.1%) the rate for the non-POLs and about 1.5 times (21.5% vs 14.0%) for POLs that used laboratory professionals as testing or supervisory personnel (P<.001). The POL unsuccessful rate was more than 4 times (4.4% vs 0.9%) the rate for non-POLs and more than twice (4.4% vs 1.8%) the rate for the POLs using laboratory professionals (P<.001).

CONCLUSIONS

Significant differences exist among POLs, POLs using licensed clinical laboratory scientists (medical technologists), and non-POLs. Testing personnel in many POLs might lack the necessary education, training, and oversight common to larger facilities. We must better understand the contributing factors that result in the poorer results of POLs relative to non-POLs. In the meantime, patients should be aware that preliminary findings suggest that differences in quality of laboratory tests based on testing site may exist. Laboratory directors at all testing sites must ensure that they understand laboratory practice sufficiently to minimize errors and maximize accuracy and reliability. Directors must understand their obligation when they elect to oversee those assigned testing responsibility. Legislators may wish to reconsider the wisdom of further easing restrictions on those to whom we entrust our laboratory specimens.

Correction of deficiencies in flexible fiberoptic sigmoidoscope cleaning and disinfection technique in family practice and internal medicine offices

To assess whether deficiencies exist in the processing of contaminated flexible fiberoptic sigmoidoscopes in family practice and internal medicine offices and whether training of office personnel results in a correction of identified deficiencies, we conducted a prospective review of sigmoidoscope processing in family practice and internal medicine offices before and after a training course. Participants were questioned on their current endoscope processing for 17 standards before and 2 months after receiving training. The 19 offices had between 4 and 11 deficiencies per office before training, with an average of 6.8 deficiencies per office. After training, deficiencies ranged from 0 to 8, with an average of 0.9 deficiencies per office (P < or = .001; Student t test). Personnel responsible for processing flexible sigmoidoscopes in family practice and internal medicine offices are insufficiently trained for this function. Endoscopes are not being processed according to current standards. After a 2-hour training period, these persons maintain their equipment close to or according to standards.

Making our offices universally accessible: guidelines for physicians

OBJECTIVE

To develop recommendations for office-based physicians who wish to make their offices accessible to all patients.

OPTIONS

Include taking steps to make offices more accessible, or not; offices may be accessible to varying degrees.

OUTCOMES

Outcomes of accessibility involve patient-care, economic, ethical and legal issues. Stakeholders in these outcomes include patients, physicians, government and society.

EVIDENCE

Data were obtained from a series of searches of MEDLINE, CINAHL and Healthstar (previously Health) databases for articles on disability and family medicine, primary (health) care and family practice, and on access and offices, and health services accessibility, and from a telephone survey of 50 stakeholders.

VALUES

A high value was placed on services to persons with disabilities and on stakeholder input. Universal accessibility was valued as an overall goal; improved accessibility was also highly valued.

BENEFITS, HARMS AND COSTS

Benefits to patients include improved access to care as guaranteed by the Canada Health Act and in keeping with provincial Human Rights Codes. Benefits to physicians include contact with a broader patient population and freedom from fear of litigation. Costs of improved accessibility vary depending on individual circumstances and on whether an office is being built or renovated; some improvement costs are minimal.

RECOMMENDATIONS

All physicians should take measures to improve practice accessibility. Improved access should be considered in each of the following areas: transportation and entrance to the facility, entrance to the office, waiting rooms, rest rooms, examination rooms, general building features and other features.

VALIDATION

No similar guidelines exist. To assess the content validity of these guidelines, the authors had a draft document reviewed by 18 stakeholders. All specific recommendations met the minimum criterion of adherence to current legislation, including national and provincial building codes. The specific recommendations are endorsed by the Canadian Paraplegic Association (national and Ontario offices), the DisAbled Women's Network (Ontario) and the Centre for Independent Living (Toronto).

SPONSORS

Development of these guidelines was supported in part by the Department of Family and Community Medicine, Toronto Hospital, Toronto, Ont.

Clinical laboratory performance on proficiency testing samples--United States, 1994

Regulation of laboratory testing for human health is mandated by law in the United States; the most recently enacted regulatory law is the Clinical Laboratory Improvement Amendments of 1988 (CLIA). In accordance with this law, as of August 1995 a total of 154,721 laboratories had registered with the Health Care Financing Administration (HCFA), which is responsible for implementing the CLIA regulations. Of these laboratories, only 11% were subject to the federal laboratory practice regulations that existed before the enactment of CLIA. Under CLIA regulations, all laboratories were required to begin participation in a U.S. Department of Health and Human Services (DHHS)-approved proficiency testing (PT) program by January 1, 1994, for a prescribed group of tests (e.g., hematocrit), analytes (e.g., glucose), and testing specialties (e.g., bacteriology) if performed routinely. This report summarizes an assessment of the performance of laboratories participating in PT programs with a certificate of registration from HCFA in 1994 (n = 40,711) and indicates that physician office laboratories (POLs) and other newly regulated testing sites (OTSs) had higher rates of unsatisfactory PT performance than previously regulated hospital and independent laboratories (HIs).

The cost of implementation of the Clinical Laboratory Improvement Amendments of 1988--the example of pediatric office-based cholesterol screening

OBJECTIVE

To measure the additional costs of office-based laboratory testing due to the implementation of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), using cholesterol screening for children as an example.

METHODS

Four- to ten-year-old children who received their well child care at one of seven participating pediatric practices were screened for hypercholesterolemia. The average number of analyses per day and days per month were derived from the volume of testing completed by the practices. Nurses and technicians time in the screening process were measured and personnel costs were calculated based on salary and fringe benefit rates. Costs of supplies, analyzing control samples, instrument calibration, and instrument depreciation were included. Costs estimates of screening were then completed. CLIA '88 implementation costs were derived from appropriate proficiency testing and laboratory inspection programs.

RESULTS

In six practices completing a low volume of testing, 2807 children (5 to 6 children per week) were screened during the observation period, while 414 (about 25 children per week) were screened in one high-volume practice implementing universal screening over a 4-month period. For the six low-volume practices, the cost of screening was $10.60 per child. This decreased to $5.47 for the high-volume practice. Estimated costs of CLIA '88 implementation, including additional proficiency testing and laboratory inspection, added $3.20 per test for the low-volume practices, and $0.71 per test for the high-volume testing.

CONCLUSIONS

Implementation of CLIA adds significantly to the cost of office-based chemistry laboratory screening. Despite these additional expenses, the cost of testing is still within a reasonable charge for laboratory testing, and is highly sensitive to the volume of tests completed.

Passing a Clinical Laboratory Improvement Act (CLIA) inspection

Any physician's office can pass a CLIA inspection if it is prepared and knows what to expect. Offices that pass an inspection feel a great sense of pride knowing the laboratory meets the same standards of quality as a hospital or clinical laboratory.