Guidelines for Reprocessing Ultrasound Transducers

Recommendations for the Cleaning of Endocavity Ultrasound Transducers Between Patients

The COVID-19 pandemic highlighted the importance of infection prevention and control measures for all medical procedures, including ultrasound examinations. As the use of ultrasound increases across more medical modalities, including point-of-care ultrasound, so does the risk of possible transmission from equipment to patients and patients to patients. This is particularly relevant for endocavity transducers, such as trans-vaginal, trans-rectal and trans-oesophageal, which could be contaminated with organisms from blood, mucosal, genital or rectal secretions. This article proports to update the WFUMB 2017 guidelines which focussed on the cleaning and disinfection of trans-vaginal ultrasound transducers between patients.

[Design and Development of a Heat Sealing System for Rapid Reuse of Ultrasonic Probes]

Objective

Ultrasound diagnosis and treatment is easy to perform and takes little time. It is widely used in clinical practice thanks to its non-invasive, real-time, and dynamic characteristics. In the process of ultrasound diagnosis and treatment, the probe may come into contact with the skin, the mucous membranes, and even the sterile parts of the body. However, it is difficult to achieve effective real-time disinfection of the probes after use and the probes are often reused, leading to the possibility of the probes carrying multiple pathogenic bacteria. At present, the processing methods for probes at home and abroad mainly include probe cleaning, probe disinfection, and physical isolation (using probe covers or sheaths). Yet, each approach has its limitations and cannot completely prevent probe contamination and infections caused by ultrasound diagnosis and treatment. For example, when condoms are used as the probe sheath, the rate of condom breakage is relatively high. The cutting and fixing of cling film or freezer bags involves complicated procedures and is difficult to perform. Disposable plastic gloves are prone to falling off and causing contamination and are hence not in compliance with the principles of sterility. Furthermore, the imaging effect of disposable plastic gloves is poor. Therefore, there is an urgent need to explore new materials to make probe covers that can not only wrap tightly around the ultrasound probe, but also help achieve effective protection and rapid reuse. Based on the concept of physical barriers, we developed in this study a heat sealing system for the rapid reuse of ultrasound probes. The system uses a heat sealing device to shrink the protective film so that it wraps tightly against the surface of the ultrasound probe, allowing for the rapid reuse of the probe while reducing the risk of nosocomial infections. The purpose of this study is to design a heat sealing system for the rapid reuse of ultrasound probes and to verify its application effect on the rapid reuse of ultrasound probes.

Methods

1) The heat sealing system for the rapid reuse of ultrasound probes was designed and tested by integrating medical and engineering methods. The system included a protective film (a multilayer co-extruded polyolefin thermal shrinkable film) and a heat sealing device, which included heating wire components, a blower, a photoelectric switch, temperature sensors, a control and drive circuit board, etc. According to the principle of thermal shrinkage, the ultrasound probe equipped with thermal shrinkable film was rapidly heated and the film would wrap closely around the ultrasound probe placed on the top of the heat sealing machine. The ultrasound probe was ready for use after the thermal shrinkage process finished. Temperature sensors were installed on the surface of the probe to test the thermal insulation performance of the system. The operation procedures of the system are as follows: placing the ultrasound probe covered with the protective film in a certain space above the protective air vent, which is detected by the photoelectric switch; the heating device heats the thermal shrinkable film with a constant flow of hot air at a set temperature value. Then, the probe is rotated so that the thermal shrinkable film will quickly wrap around the ultrasound probe. After the heat shrinking is completed, the probe can be used directly. 2) Using the convenience sampling method, 90 patients from the Department of Anesthesiology and Perioperative Medicine, the First Affiliated Hospital of Xi'an Jiaotong University were included as the research subjects. All patients were going to undergo arterial puncture under ultrasound guidance. The subjects were divided into 3 groups, with 30 patients in each group. Three measures commonly applied in clinical practice were used to process the probes in the three groups and water-soluble fluorescent labeling was applied around the puncture site before use. In the experimental group, the probes were processed with the heat sealing system. The standard operating procedures of the heat sealing system for rapid reuse of ultrasonic probes were performed to cover the ultrasonic probe and form a physical barrier to prevent probe contamination. There were two control groups. In control group 1, disinfection wipes containing double-chain quaternary ammonium salt were used to repeatedly wipe the surface of the probe for 10-15 times, and then the probe was ready for use once it dried up. In the control group 2, a disposable protective sheath was used to cover the front end of the probe and the handle end of the sheath was tied up with threads. Comparison of the water-soluble fluorescent labeling on the surface of the probe (which reflected the colony residues on the surface of the probe) before and after use and the reuse time (i.e., the lapse of time from the end of the first use to the beginning of the second use) were made between the experimental group and the two control groups.

Results

1) The temperature inside the ultrasound probe was below 40 ℃ and the heat sealing system for rapid reuse did not affect the performance of the ultrasound probe. 2) The reuse time in the heat sealing system group, as represented by (median [P25, P75]), was (8.00 [7.00, 10.00]) s, which was significantly lower than those of the disinfection wipe group at (95.50 [8.00, 214.00]) s and the protective sleeve group at (25.00 [8.00, 51.00]) s, with the differences being statistically significant (P<0.05). No fluorescence residue was found on the probe in either the heat sealing system group or the protective sheath group after use. The fluorescence residue in the heat sealing system group was significantly lower than that in the disinfection wipes group, showing statistically significant differences (χ 2=45.882, P<0.05).

Conclusion

The thermal shrinkable film designed and developed in this study can be cut and trimmed according to the size of the equipment. When the film is heated, it shrinks and wraps tightly around the equipment, forming a sturdy protective layer. With the heat sealing system for rapid reuse of ultrasonic probes, we have realized the semi-automatic connection between the thermal shrinkable film and the heating device, reducing the amount of time-consuming and complicated manual operation. Furthermore, the average reuse time is shortened and the system is easy to use, which contributes to improvements in the reuse and operation efficiency of ultrasound probes. The heat sealing system reduces colony residues on the surface of the probe and forms an effective physical barrier on the probe. No probes were damaged in the study. The heat sealing system for rapid reuse of ultrasonic probes can be used as a new method to process the ultrasonic probes.

A multicenter study on the effects of different methods of disinfecting medical external-use ultrasound probes

BACKGROUND

Microbial contamination of external-use ultrasound probes is a serious and overlooked issue. We assessed the effects of different methods of disinfecting medical external-use ultrasound probes.

METHODS

On-site disinfection experiments were conducted at 10 hospitals; the tips and sides of external-use ultrasound probes were sampled before and after disinfection, and 3 disinfection methods were assessed (use of a new ultraviolet [UV] ultrasound probe disinfector, wiping with ordinary paper towels or cleaning with disinfectant wipes).

RESULTS

For the new UV probe disinfector, the median microbial death rates for the tips and sides of the external-use ultrasound probe were 93.67% and 97.50%, respectively, which were higher than those for wiping with paper towels and cleaning with disinfectant wipes (12.50% and 10.00% and 20.00% and 21.42%, respectively); the rates of microorganisms exceeding the standard were 15.0% and 13.3%, respectively, which were lower than those for wiping with paper towels and cleaning with disinfectant wipes (53.3% and 60.0% and 46.7% and 38.3%, respectively). The death rates of different species of microorganisms were high, ranging from 87.5% to 100%.

CONCLUSIONS

The new UV ultrasound probe disinfector significantly reduced the risk of potential nosocomial infections according to the low microbial death rate for conventional disinfection methods.

Comparison of Low-Level to High-Level Disinfection in Eliminating Microorganisms From Ultrasound Transducers Used on Skin: A Noninferiority Randomized Controlled Trial

INTRODUCTION

There is a lack of international consensus as to whether high- or low-level disinfection (HLD or LLD) is required for ultrasound (US) transducers used during percutaneous procedures. This study compared the effectiveness of LLD to HLD on US transducers contaminated with microorganisms from skin.

METHODS

Two identical linear US transducers repeatedly underwent either LLD or HLD during the study. Randomization determined which of these transducers was applied to left and right forearms of each participant. Swabs taken from transducers before and after reprocessing were plated then incubated for 4-5 days, after which colony forming units (CFU) were counted and identified. The primary hypothesis was the difference in the proportion of US transducers having no CFUs remaining after LLD and HLD would be less than or equal to the noninferiority margin of -5%.

RESULTS

Of the 654 recruited participants 73% (n = 478) had microbial growth from both transducers applied to their left and right forearms before reprocessing. These were included in the paired noninferiority statistical analysis where, after disinfection, all CFUs were eliminated in 100% (95% CI: 99.4-100.0%) of HLD transducer samples (n = 478) and 99.0% (95% CI: 97.6-99.7%) of LLD transducer samples (n = 473). The paired difference in the proportion of transducers having all CFUs eliminated between LLD and HLD was -1.0% (95% CI: -2.4 to -0.2%, P-value <.001).

CONCLUSIONS

Disinfection with LLD is noninferior to HLD when microorganisms from skin have contaminated the transducer. Therefore, using LLD for US transducers involved in percutaneous procedures would present no higher infection risk compared with HLD.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Short Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Anaesthetist’s adherence to aseptic ultrasound practices when performing Ultrasound Guided Peripheral Intravenous Cannulation (USGPIVC). A quality improvement project

Background: Sterile ultrasound covers and conducting mediums are recommended when performing ultrasound guided percutaneous procedures to minimise risk of infection to the patient. Purpose manufactured ultrasound transducer cover kits meet these requirements. Transparent dressings meet some of these requirements however, they are not approved for use as ultrasound transducer covers. We recognised that our departmental practice may not adhere to these standards. Objective: The primary objective was to identify and improve the rate of adherence to the recommended aseptic precautions by anaesthetists performing ultrasound guided percutaneous procedures at the Department of Anaesthesia, Royal Brisbane and Women’s Hospital, the largest tertiary referral hospital in Queensland, Australia. Secondary objectives were to identify types and rates of use of various probe covers and ultrasound conductive mediums used. Design: A complete quality improvement cycle was undertaken using a plan, do, study, act model. Methods: Firstly, a departmental wide voluntary survey was distributed in March 2019 focused on practitioner’s baseline aseptic practices for ultrasound guided peripheral intravenous cannulation (USGPIVC). Subsequently a suite of interventions were undertaken between May 2019 to April 2020 focusing on highlighting recommended aseptic practices through the use of high-quality sterile transducer covers and sterile conducting mediums for all ultrasound guided percutaneous procedures. Components of the intervention included the development of a departmental policy, educational activities, and improving equipment availability and access. A post- intervention follow up audit was repeated in April 2020 to measure changes in practice. Results: Of 134 anaesthetic consultants or trainees 58 completed the pre-intervention survey and 47 completed the post- intervention survey. After the intervention the use of recommended transducer covers and conducting mediums increased from 10.3% to 76.6% and 58.6% to 83.0% respectively. Participants were more likely to choose both a recommended transducer cover and conducting medium than at least one non-recommended option ([OR] 20.4, 95% CI: 7.1 - 58.4). There was a 122% increase in the number of recommended transducer cover kits ordered when comparing stock inventory over a six-month period before and after the intervention. Conclusion: Adherence to the recommended aseptic precautions for USGPIVC improved after the implementation of educational interventions.

Endocavity Ultrasound Transducers: Why High-Level Disinfection Is Necessary

As a medical imaging modality, ultrasound is used by a wide cross-section of practitioners including radiologists, obstetricians, gynecologists, gastroenterologists, urologists and cardiologists. The increasing popularity of ultrasound as a diagnostic tool is due not only to the ease of use and portability of systems, but also to the perceived safety aspect of the examination. This latter point needs to be examined. As with any reusable medical device, the ultrasound transducer, also known as a probe, could potentially be a vector for the transmission of pathogenic viruses and fungi between patients if not correctly disinfected after each use. This transmission risk is magnified for an endocavity transducer that has come in contact with the vagina, anal canal or oral cavity, as it could be contaminated with organisms transmitted by blood or mucosal, genital or rectal secretions. Based on the Spaulding system, transducers that come in contact with mucous membranes are classified as semi-critical devices that require high-level disinfection (HLD) after each patient procedure. This HLD process should eliminate all microorganisms except high numbers of bacterial endospores. Only a small number of countries worldwide have implemented transducer reprocessing guidelines that adhere to the Spaulding classification and recommend HLD for endocavity transducers. Overall, there is a lack of conformity among global health agencies regarding the use of HLD for endocavity transducers. This is primarily due to the perception that the infection transmission risk is negligible and that if an endocavity transducer has been covered with a single-use sheath for the procedure, then low-level disinfection provides sufficient protection against pathogen transmission. The objective of this study was to review the published risk of infection transmission from endocavity transducers. By highlighting the outbreaks and case reports that implicate pathogen transmission from transducers, we posit that HLD should be a global standard of practice for the reprocessing of endocavity transducers. It requires substantial time for national health administrations to develop and legislate new recommendations, and for practice changes to be accepted and implemented by healthcare providers. We recommend that Joint Commission International (JCI) and other equivalent organizations enforce the use of HLD of endocavity ultrasound transducers during their accreditation reviews.

Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

Ultrasonography has been widely used in medicine for decades but often by specific users such as cardiologists, obstetricians, and radiologists. In the last several years, the use of this imaging modality has moved to the bedside, with clinicians performing and interpreting focused point of care ultrasonography to aid in immediate assessment and management of their patients. The growth of point of care ultrasonography has been facilitated by advancement in ultrasound-related technology and emerging studies and protocols demonstrating its utility in clinical practice. However, considerable challenges remain before this modality can be adopted across the spectrum of disciplines, primarily as it relates to training, competency, and standardization of usage. This review outlines the history, current state, challenges and the future direction of point of care ultrasonography specifically in the field of pediatric critical care medicine.

Infection Transmission Associated With Contaminated Ultrasound Probes: A Systematic Review

A systematic review of seven studies on infections related to contaminated ultrasound probes showed that the infections were related to a failure in the decontamination process of ultrasound devices used on immature skin of neonates in an intensive care unit and transesophageal echocardiography probes. Six of the studies involved outbreaks in patients who underwent transesophageal echocardiography either during or after surgery or as a part of treatment for a nonsurgical cardiac condition. The evidence shows links between the infection outbreaks and environmental contamination, lack of standardized ultrasound probe disinfection processes, inadequate storage, and lack of monitoring of probe integrity. When personnel addressed the deficiencies (eg, improving the disinfection process, cleaning the probes immediately after use, inspecting the probes for defects), the infections ceased. Personnel involved with the reprocessing of ultrasound probes should clean, disinfect, inspect, and store ultrasound probes in a manner that maintains device integrity and prevents contamination.

Australasian emergency ultrasound: A survey on the current status

OBJECTIVE

Emergency ultrasound (EUS) has become an integral part of emergency medicine, and the core pillars of governance, infrastructure, administration, education and quality assurance (QA) are vital for its quality and continued growth. We aimed to assess the status of these vital pillars among Australasian EDs.

METHODS

A survey among the clinical leads in ultrasound (CLUS) in Australasian EDs from November 2020 to April 2021.

RESULTS

We analysed a total of 98 responses from CLUS representing 98 EDs. Most CLUS (85%) held EUS qualifications (CCPU 57%, DDU 18%, other 9%) but 15% had none. Only 66% of CLUS had dedicated clinical support time, and a mere 5% had administrative personnel support. Up to three ultrasound machines in 62% of EDs, but only 26% of EDs had secured image archiving facilities. In-house credentialing and the Australasian College for Emergency Medicine (ACEM) trainee special skills placement were available in 50% and 32% of EDs, respectively. Only 11% of EDs had regular EUS training for FACEMs, and only 66% of EDs had regular EUS education for emergency medicine trainees. Only 20 EDs had sonographer educators. Regarding EUS QA, only 33% of EDs provided formal EUS report, 23% of EDs conducted regular image reviews and 37% of EDs audited EUS performance. Only 35% of EDs had high-level disinfection equipment, and 56% of EDs had formal transducer disinfection protocols.

CONCLUSION

Despite ACEM recommendations for the practice of EUS, Australasian EDs still lack vital governance, administrative support, infrastructure, education and QA processes. Prompt actions such as ACEM mandating these recommendations are required to improve resource allocation by health services.

Improving hospital-based point-of-care ultrasound cleaning practices using targeted interventions: a pre-post study

BACKGROUND

Point-of-care ultrasound (POCUS) devices are becoming more widely used in healthcare and have the potential to act as fomites. The objective of this project was to study the thoroughness of cleaning of POCUS machines before and after a quality improvement initiative. We designed a mixed-methods, pre/post study which took place over the course of one year at a university-affiliated health center. Cleaning rates of four ultrasound machines used by hospital medicine and critical care medicine services were evaluated using fluorescent marking. Interventions targeted physicians' knowledge of best practices and improved access to cleaning supplies. Pre- and post-intervention cleaning rates were compared using a generalized linear model. The impact of the corona virus disease of 2019 (COVID-19) pandemic on baseline cleaning rates was also evaluated. Physicians' attitudes and knowledge of cleaning practices were evaluated via unpaired pre/post surveys.

RESULTS

There was significant improvement in thoroughness of cleaning following intervention (pre 0.62, SE 0.05; post 0.89, SE 0.07), p < 0.0001). There was no difference in baseline cleaning rates before (0.63, SE 0.09) and after (0.61, SE 0.1) the onset of the COVID-19 pandemic (p = 0.78). Post-intervention surveying found improved understanding of guideline-based cleaning practice, better performance on knowledge-based questions, and fewer reported barriers to machine cleaning.

CONCLUSION

Thoroughness of cleaning of POCUS machines can be improved with practical interventions that target knowledge and access to cleaning supplies.

[Disinfection of transvaginal ultrasound probes-A current overview of methods and recommendations]

Disinfection of ultrasound probes, especially of transvaginal probes, has been under discussion during recent years and there have been several new regulations and recommendations as well as trends in the field of disinfection methods. This article provides a review and summary of the current state of knowledge.

Role of Pulmonary Ultrasound in COVID-19 Pandemics

:

Currently, there is a lot of clinical data on the basics of lung ultrasound (US) examination in patients with COVID-19. This article is focused on the principles of pneumonia diagnosis. It is established that the use of ultrasound can be informative at the prehospital stage and triage of patients and also detection of mild forms of the course of the disease.

[Lung ultrasound in patients with SARS-CoV-2 infection]

After taking a patient's history and physical examination, lung ultrasound can immediately reveal numerous causes and complications in patients suffering from respiratory tract infection and/or dyspnea. It can thus facilitate decisions on further diagnostic and first therapeutic procedures, even in patients with a SARS-CoV‑2 infection who present to the emergency room. This review article highlights the typical findings of lung ultrasound in patients with COVID-19 and discusses its value compared to other imaging methods.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Coronavirus disease 2019 (COVID-19) pandemic and pregnancy

The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading globally at an accelerated rate, with a basic reproduction number (R0) of 2-2.5, indicating that 2-3 persons will be infected from an index patient. A serious public health emergency, it is particularly deadly in vulnerable populations and communities in which healthcare providers are insufficiently prepared to manage the infection. As of March 16, 2020, there are more than 180,000 confirmed cases of COVID-19 worldwide, with more than 7000 related deaths. The SARS-CoV-2 virus has been isolated from asymptomatic individuals, and affected patients continue to be infectious 2 weeks after cessation of symptoms. The substantial morbidity and socioeconomic impact have necessitated drastic measures across all continents, including nationwide lockdowns and border closures. Pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks. To date, the outcomes of 55 pregnant women infected with COVID-19 and 46 neonates have been reported in the literature, with no definite evidence of vertical transmission. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure in the gravida. Furthermore, the pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system. These unique challenges mandate an integrated approach to pregnancies affected by SARS-CoV-2. Here we present a review of COVID-19 in pregnancy, bringing together the various factors integral to the understanding of pathophysiology and susceptibility, diagnostic challenges with real-time reverse transcription polymerase chain reaction (RT-PCR) assays, therapeutic controversies, intrauterine transmission, and maternal-fetal complications. We discuss the latest options in antiviral therapy and vaccine development, including the novel use of chloroquine in the management of COVID-19. Fetal surveillance, in view of the predisposition to growth restriction and special considerations during labor and delivery, is addressed. In addition, we focus on keeping frontline obstetric care providers safe while continuing to provide essential services. Our clinical service model is built around the principles of workplace segregation, responsible social distancing, containment of cross-infection to healthcare providers, judicious use of personal protective equipment, and telemedicine. Our aim is to share a framework that can be adopted by tertiary maternity units managing pregnant women in the flux of a pandemic while maintaining the safety of the patient and healthcare provider at its core.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Prevention of pathogen transmission during ultrasound use in the Intensive Care Unit: Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group (USIG)

ICU ultrasonography constitutes important part of modern car patient care. Current standards and practice of infection control and prevention are inadequate. This purpose of this document is to adapt and expand the 2017 Australasian Society for Ultrasound in Medicine (ASUM) and the Australasian College for Infection Prevention Control (ACIPC) guidelines on minimum standards for reprocessing/cleaning of ultrasound transducers to the specifics of intensive care medicine and provide advice to the ICU practitioners and health care administrators. It considers the medical, administrative, financial and practical controversies surrounding implementation, and addresses emerging issues of care for patients with confirmed or suspected Corona Virus Disease 2019 (COVID-19).

COVID-US: A simplified approach to cardiopulmonary ultrasound in suspected and confirmed COVID-19 patients in surge crisis

The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has placed an unprecedented challenge on healthcare systems across the globe. Rapid assessment of the cardiorespiratory function to monitor disease progression and guide treatment is essential. Therefore, we have designed the COVID-US: a simplified cardiopulmonary ultrasound approach to use in suspected and confirmed COVID-19 patients, to aid front-line health workers in their decision-making in a surge crisis.

Effect of a Condom Cover on Vaginal Photoplethysmographic Responses

INTRODUCTION

The vaginal photoplethysmograph (VPP) is a reusable intravaginal device often employed in sexual psychophysiology studies to assess changes in vaginal blood flow, an indicator of sexual arousal.

AIM

To test whether placing a disposable cover on the VPP probe impacts the acquired data. A condom cover would reduce risk of disease transmission and likely increase participant comfort but may negatively impact the VPP signal.

METHOD

The genital responses of 25 cisgender women (mean age = 21.3 years, standard deviation = 2.6) were assessed with VPP in a within-subjects design with 2 conditions-with and without a polyisoprene condom cover. Sexual responses were elicited by audiovisual film clips that varied in erotic intensity: nonsexual (nonsexual male-female interaction), low-intensity sexual (nude exercise), and high-intensity sexual (male-female intercourse). Women continuously rated their sexual arousal during stimulus presentations.

MAIN OUTCOME MEASURE

Change in vaginal pulse amplitude and also self-reported sexual arousal.

RESULTS

The magnitude of sexual response to each stimulus category and the overall pattern of results were found to be highly similar in the cover-off and cover-on conditions. The high-intensity sexual stimulus category elicited a greater sexual response than all other categories. The low-intensity sexual category elicited a (small) genital response in only the cover-on condition, although we suspect this is a spurious finding. There was no difference in the average number of edited movement artifacts across conditions.

CLINICAL IMPLICATIONS

Potential benefits of encasing the VPP probe with a protective cover include enhanced participant safety and comfort, especially if assessing genital responses of high-risk or immunocompromised samples. The use of a cover complies with current guidelines for reprocessing semi-critical medical devices (eg, vaginal ultrasound probes) in many regions.

STRENGTHS & LIMITATIONS

Although the idea of a VPP probe cover had been discussed among sexual psychophysiology researchers, this is the first study to empirically test whether a cover could jeopardize VPP data. Potential limitations include the use of a 10-Hz VPP sampling rate and a cover that was not tailored to the size of the VPP probe.

CONCLUSION

Placing a protective cover on the VPP probe did not appear to meaningfully impact sexual arousal or the VPP data. Based on these results and the potential advantages of a protective cover, researchers may wish to integrate the use a condom cover in their experiment protocols and clinical applications. Sawatsky ML, Lalumière ML. Effect of a Condom Cover on Vaginal Photoplethysmographic Responses. J Sex Med 2020; 17:702-715.

Analysis of the integrity of ultrasound probe covers used for transvaginal examinations

BACKGROUND

Ultrasound probe covers should be used for any ultrasound procedure where there is contact with body fluids or mucous membranes. The type and quality of probe covers used in clinical practice differ widely and studies in the early 1990s showed that condoms were more superior for use with transvaginal examinations than commercial probe covers. Since then, although products have changed, there have been no further studies to assess the breakage rate of different probe covers. The objectives of this study were to assess the integrity of the most commonly used probe covers for transvaginal ultrasound examinations under clinical conditions and report the breakage rate.

METHODS

The study was conducted in public and private hospitals and private practices. A total of 500 covers for each of 10 brands of commercial covers and condoms (latex and latex free) were distributed to ultrasound practitioners. The transvaginal ultrasound examination practice was unchanged except that all covers were placed in a container for assessment instead of discarding post ultrasound examination. All covers were collected and subjected to a water leak test. Covers that broke upon deployment onto the ultrasound probe prior to the ultrasound examination were recorded. All covers that were broken or had microtears or leaks were recorded as well as photographed. Statistical analysis was performed along with Chi-squared analysis of the data and significance considered at P < 0.05.

RESULTS

None of the commercial covers broke upon deployment onto the ultrasound probe prior to ultrasound examination. A total of 5000 probe covers were examined post-transvaginal ultrasound examinations. The breakage rate for condoms ranged from 0.4% to 13% and for commercial covers 0-5%. Statistical analysis of the data by comparison of p-values revealed that the best performing group were the commercial non-latex probe covers and worst performing group were the non-latex condoms.

CONCLUSION

The breakage rates for commercial covers were not as high as previously reported and do not break upon deployment onto the ultrasound probe. This is the first comprehensive study that thoroughly evaluated the integrity of commercial covers and condoms used for transvaginal ultrasound examination in a clinical setting, with regards to brand, numbers and types of covers assessed.

Time to establish pillars in point-of-care ultrasound

Point of care ultrasound (PoCUS) has evolved rapidly and is used by many medical specialties. We propose five essential pillars of PoCUS that are necessary framework for hospital-based PoCUS training and credentialing programs. The pillars are: governance, infrastructure, administration, education and quality. It is time to establish these pillars to ensure the best practice in PoCUS use.

Medical Ultrasound Disinfection and Hygiene Practices: WFUMB Global Survey Results

As ultrasound technology rapidly evolves and is used more frequently in every area of medical diagnosis and treatment, it may be overlooked as a potential vector in the transmission of a health care-associated infection. A survey on disinfection and hygiene practice in medical ultrasound was disseminated via the World Federation for Ultrasound in Medicine and Biology (WFUMB) to its six member federations and associated ultrasound societies globally. One thousand twenty-nine responses were obtained across a broad range of ultrasound practitioners. A total of 76% of respondents used transducer covers every time to scan open wounds and 71% when blood and bodily fluids were present or for an interventional procedure. Approved high-level disinfectants are not always used, even when blood comes into contact with the transducer or after endocavity scans. Alcohol-based wipes were used by many respondents to clean both external transducers and endocavity transducers. Open-ended responses indicated that a large caseload hindered the time required for cleaning and that access to clear guidelines would be beneficial. Global survey results indicate that some users do not comply with disinfection practice, and there is a gap in knowledge on basic infection prevention and control education within the ultrasound unit. As the infectious status of a patient is not often disclosed prior to an ultrasound examination, training in suitable protocols for the cleaning and disinfection of ultrasound equipment is imperative to mitigate the risk of potential infection.

Guidance for the decontamination of intracavity medical devices: the report of a working group of the Healthcare Infection Society

BACKGROUND

Intracavity medical devices (ICMDs) are used in a wide variety of healthcare settings. The approach to their decontamination and the resources available also differ widely. Their potential for infection transmission is considerable.

AIM

To produce a comprehensive risk assessment-based approach to the decontamination of ICMDs, accompanied by an adaptable audit tool.

KEY RECOMMENDATIONS

A new sampling algorithm demonstrates that ultrasound equipment cleanliness can be improved

BACKGROUND

Australia has established guidelines on cleaning for reusable ultrasound probes and accompanying equipment. This is a preliminary study investigating cleanliness standards of patient-ready ultrasound equipment in 5 separate health care facilities within a major city.

METHODS

The cleanliness was assessed using rapid adenosine triphosphate (ATP) testing used with a sampling algorithm which mitigates variability normally associated with ATP testing. Each surface was initially sampled in duplicate for relative light units (RLUs) and checked for compliance with literature recommended levels of cleanliness (<100 RLUs). Triplicate sampling was undertaken where necessary. A cleaning intervention step (CIS) followed using a disposable detergent wipe, and the surface was retested for ATP.

RESULTS

There were 253 surfaces tested from the 5 health care facilities with 26% (66/253) demonstrating either equivocal or apparent lack of cleanliness. The CIS was conducted on 148 surfaces and demonstrated that for >91% (135/148) of surfaces, the cleaning standards could be improved significantly (P > .001). For 6% (9/148) of devices and surfaces, the CIS needed to be repeated at least once to achieve the intended level of cleanliness (<25 RLUs).

CONCLUSIONS

This study indicates that ATP testing is an effective, real-time, quality assurance tool for cleanliness monitoring of ultrasound probes and associated equipment.

Ultrasound probe use and reprocessing: Results from a national survey among U.S. infection preventionists

BACKGROUND

Improper infection prevention practice associated with ultrasound probe use has been linked to increased infection risk, outbreaks, and death. Although guidelines for reprocessing and use of probes exist, it is unclear how extensively these have been adopted in practice.

METHODS

Infection preventionists from U.S. health care facilities were surveyed (N = 358). The anonymous survey had 31 multiple choice, sliding scale, and text response questions. The survey was developed and deployed and the data were stored in the REDCap system.

RESULTS

A high degree of noncompliance with U.S. guidelines was identified. Surface probes used in invasive procedures were not high-level disinfected or sterilized 15% (intraoperative) to 78% (peripheral line placements) of the time. Of invasive procedures, 5%-47% did not use sterile gel (same procedures, respectively). Of the participants, 20% were aware of instances where an ultrasound probe was used but was not correctly reprocessed. Extensive breaches of infection control guidelines were reported. The rapid expansion in use of ultrasound has brought clinical benefit but may be exposing patients to preventable infection risk.

CONCLUSIONS

Infection preventionists are well placed to act as major drivers of change based on their expertise and experience in the management of infection risk across facilities and health systems. They, along with clinicians responsible for probe use and reprocessing, should review practices relating to ultrasound in their facilities. Where practice does not comply with guidelines, policy and training should be updated to ensure patient safety.

Guidelines for the performance of the first trimester ultrasound

The purpose of this document is to guide ultrasound practitioners in providing accurate information on the assessment of gestational age, viability and fetal development in the first trimester. In the presence of twins and higher order multiple pregnancies, it is also intended to assess chorionicity and amnionicity which have implications for risk assessment and continuing antenatal care. This guideline has been adopted by the ASUM Council and is applicable to all ultrasound practitioners.

Infection prevention and control in ultrasound - best practice recommendations from the European Society of Radiology Ultrasound Working Group

OBJECTIVES

The objective of these recommendations is to highlight the importance of infection prevention and control in ultrasound (US), including diagnostic and interventional settings.

METHODS

Review of available publications and discussion within a multidisciplinary group consistent of radiologists and microbiologists, in consultation with European patient and industry representatives.

RECOMMENDATIONS

Good basic hygiene standards are essential. All US equipment must be approved prior to first use, including hand held devices. Any equipment in direct patient contact must be cleaned and disinfected prior to first use and after every examination. Regular deep cleaning of the entire US machine and environment should be undertaken. Faulty transducers should not be used. As outlined in presented flowcharts, low level disinfection is sufficient for standard US on intact skin. For all other minor and major interventional procedures as well as all endo-cavity US, high level disinfection is mandatory. Dedicated transducer covers must be used when transducers are in contact with mucous membranes or body fluids and sterile gel should be used inside and outside covers.

CONCLUSIONS

Good standards of basic hygiene and thorough decontamination of all US equipment as well as appropriate use of US gel and transducer covers are essential to keep patients safe.

MAIN MESSAGES

• Transducers must be cleaned/disinfected before first use and after every examination. • Low level disinfection is sufficient for standard US on intact skin. • High level disinfection is mandatory for endo-cavity US and all interventions. • Dedicated transducer covers must be used for endo-cavity US and all interventions. • Sterile gel should be used for all endo-cavity US and all interventions.

Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures

BACKGROUND

We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia.

METHODS

Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures.

RESULTS

The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism-based typing, demonstrating that all linked isolates clustered together.

CONCLUSION

Arresting the national point-source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution.

Advancing infection control in Australasian medical ultrasound practice

INTRODUCTION/AIMS

Australasia is witnessing a rapidly increasing use of diagnostic medical ultrasound in clinical practice with industry statistics giving a conservative estimate of ten million scans performed annually in Australia and New Zealand. Ultrasound practice has broadened from its traditional use in radiology, obstetrics and gynaecology, vascular and cardiology specialties to embrace emergency medicine, rheumatology, midwifery, physiotherapy, paramedics and other point of care practice. With this expansion of practice comes an increase in the potential risk for ultrasound transmitted bacterial or viral infection due to suboptimal cleaning habits of transducers, cords and keyboards.

RESULTS/CONCLUSION

This study describes results of an Australasian survey on the disinfection and hygiene practice in medical ultrasound. Results highlighted a significant need for updated guidelines and education on infection prevention and control in medical ultrasound.