New Developments in the Prevention of Gastrointestinal Scope-Related Infections

Impact of Infection Control Education on Gastrointestinal Endoscopy Procedural Staff

To date, minimal research has been conducted on proper use of personal protective equipment and hand hygiene within endoscopy. The American Society for Gastrointestinal Endoscopy has developed guidelines for infection control within the endoscopy suite. A practice change based upon these guidelines was implemented. Education was provided to endoscopy procedural staff within a Midwestern hospital based upon the World Health Organization 5 Moments for Hand Hygiene initiative and included personal protective equipment. Knowledge, skills, and attitudes of the participant group were compared from paired pre- to posteducation surveys pertaining to hand hygiene and personal protective equipment. Observation of personal protective equipment use and hand hygiene implementation during procedures was also documented pre- to posteducation. The project results revealed both willingness to implement proper donning and doffing of personal protective equipment and improved technique as evidenced by improved observed technique with the endoscopy suite and moderately improved hand hygiene questionnaire results. Although conducted as a quality improvement project, clinical significance was found via observation following education. These practices can aid in reduction of organism transmission from patients to staff.

Does double high-level disinfection for duodenoscopes add any value? A mini-systematic review and meta-analysis

Background

Duodenoscope-emerging infection especially drug-resistant bacteria is considered a major concern nowadays. Different approaches were attempted to overcome this problem, like double high-level disinfection procedure. We performed a systematic review and meta-analysis to evaluate risk difference for positive cultures from duodenoscopes between double high-level disinfection (dHLD) and single (standard) high-level disinfection (sHLD).

Main body

A thorough literature search (in October and November 2019) for studies comparing dHLD and sHLD for duodenoscopes was performed by 3 researchers in the Web of Science, Scopus, PubMed, and Cochran databases. The search terms were “duodenoscope,” “ERCP endoscope,” “disinfection,” “sterilization,” and “reprocessing,” and only randomized clinical trials with the English language were accepted.

Four trials were identified studying dHLD, and only 2 clinical trials comparing dHLD with standard sHLD were found reporting 6193 duodenoscope cultures. Overall sHLD cultures were 2972, and dHLD cultures were 3221; overall positive cultures were 140 in sHLD and 161 in dHLD.

The results of a meta-analysis using the random-effect model showed no significant risk difference (RD) between the 2 procedures for duodenoscope positive cultures (p = 0.53, RD 0.003, 95% CI “− 0.007–0.013”).

Conclusions

Double HLD offered no significant difference over single HLD for duodenoscope disinfection. An alternative strategy to overcome duodenoscope-transmitted infection is a big issue to be resolved.

Duodenoscope-associated infection prevention: A call for evidence-based decision making

Background  Recent outbreaks of duodenoscope-associated multidrug-resistant organisms (MDROs) have brought attention to the infection risk from procedures performed with duodenoscopes. Prior to these MDRO outbreaks, procedures with duodenoscopes were considered safe and low risk for exogenous infection transmission, provided they were performed in strict accordance with manufacturer instructions for use and multisociety reprocessing guidelines. The attention and efforts of the scientific community, regulatory agencies, and the device industry have deepened our understanding of factors responsible for suboptimal outcomes. These include instrument design, reprocessing practices, and surveillance strategies for detecting patient and instrument colonization. Various investigations have made it clear that current reprocessing methods fail to consistently deliver a pathogen-free instrument. The magnitude of infection transmission has been underreported due to several factors. These include the types of organisms responsible for infection, clinical signs presenting in sites distant from ERCP inoculation, and long latency from the time of acquisition to infection. Healthcare providers remain hampered by the ill-defined infectious risk innate to the current instrument design, contradictory information and guidance, and limited evidence-based interventions or reprocessing modifications that reduce risk. Therefore, the objectives of this narrative review included identifying outbreaks described in the peer-reviewed literature and comparing the findings with infections reported elsewhere. Search strategies included accessing peer-reviewed articles, governmental databases, abstracts for scientific conferences, and media reports describing outbreaks. This review summarizes current knowledge, highlights gaps in traditional sources of evidence, and explores opportunities to improve our understanding of actual risk and evidence-based approaches to mitigate risk.

Improving patient safety in the endoscopy unit: utilization of remote video auditing to improve time-out compliance

BACKGROUND AND AIMS

Patient and procedure verification, or the time-out process (TOP), is considered one of the most vital components of patient safety. It has long been a focus of intervention in the surgical community and recently was incorporated into the American Society for Gastrointestinal Endoscopy guidelines for safety in the GI endoscopy unit. The TOP has had limited attention in the endoscopy literature but remains an area for improvement in clinical endoscopy practice. The aim of this study was to identify barriers and improve TOP compliance rates in our endoscopy unit using remote video auditing (RVA).

METHODS

This was a single-center, prospective, pilot initiative in an endoscopy unit at a tertiary care academic medical center. Video cameras with offsite monitoring were installed in each procedure room in our endoscopy suite in November 2016. Baseline TOP compliance rates were audited with RVA over a 2-month period. A multidisciplinary quality improvement team reviewed the data, identified barriers to the TOP, and implemented actionable items in January 2017. TOP compliance rates were again monitored via RVA, and data were collected through October 2018. Pre- and postintervention TOP compliance rates were compared.

RESULTS

Over the baseline period, 692 procedures were audited and TOP compliance documented. Baseline TOP compliance rate was 69.6%. Identifiable barriers to TOP compliance included a lack of designated team member to lead TOP, inconsistent documentation of TOP, irrelevant safety checklist items not applicable to endoscopic procedures, and lack of patient safety culture. Actionable items implemented in response to these barriers included designation of a TOP leader, visual indication of initiation of TOP, creation of a concise endoscopy-specific safety checklist, and formal notification/education of the entire endoscopy team. Postintervention TOP compliance rates were then audited from January 2017 to October 2018 and included 12,008 procedures. The mean TOP compliance rate significantly improved from baseline (95.3% vs 69.6%; 95% confidence interval, 22.4-29.3; P < .0001). Additionally, the improvement was maintained throughout the entire postintervention observation period.

CONCLUSIONS

TOP compliance rates significantly improved in our endoscopy unit through the use of RVA and implementation of 4 actionable items. Future studies should evaluate the reproducibility of this method in other endoscopy units.

What's new in reprocessing endoscopes: Are we going to ensure "the needs of the patient come first" by shifting from disinfection to sterilization?

Millions of gastrointestinal endoscopes are performed each year in the United States. Gastrointestinal endoscopes become highly contaminated during use (ie, internal channels contain 7-10-log₁₀ enteric microorganisms). Currently, endoscopes (eg, bronchoscopes and gastrointestinal endoscopes) are classified as semicritical items because they contact intact mucous membranes and most commonly undergo cleaning followed by high-level disinfection, which may result in as little as a 6-log₁₀ reduction of microorganisms. Therefore, and not surprisingly, in recent years there have been multiple reports that have documented that endoscopes, especially duodenoscopes, frequently remain contaminated with bacterial pathogens after proper cleaning and disinfection. Multiple outbreaks of multidrug-resistant organisms from contaminated duodenoscopes have resulted in substantial death and morbidity. Because duodenoscopes commonly contact nonintact mucous membranes and sterile tissue, such endoscopes should be considered critical items. We propose that to ensure patient safety, we follow the Spaulding scheme and move from high-level disinfection to sterilization of reusable endoscopes or use an alternative diagnostic/therapeutic method (eg, disposable sterile endoscopes).

Medical instrument reprocessing: current issues with cleaning and cleaning monitoring

The complexity of medical devices has increased over the past 10 years, and outbreaks of infections due to contaminated devices have focused attention on the need to adequately clean medical devices in order to ensure the adequacy of disinfection and sterilization. There has been a paradigm shift in reprocessing of medical devices, with increased emphasis on a quality management systems approach that requires validated cleaning instructions from manufacturers and ongoing monitoring by reprocessing personnel to ensure adequacy of cleaning. This article reviews the current issues related to medical device reprocessing and summarizes the approaches used for monitoring cleaning efficacy for surgical instruments and flexible endoscopes.

Biofilms on instruments and environmental surfaces: Do they interfere with instrument reprocessing and surface disinfection? Review of the literature

There is a growing appreciation for the role of biofilm-embedded microbes in many different aspects of infection transmission. The format of biofilm includes traditional hydrated biofilm, build-up biofilm, and dry surface biofilm. The objectives of this article are to discuss how traditional biofilm differs from build-up biofilm and dry surface biofilm, and to review the evidence supporting infection transmission from biofilm that accumulates in reprocessed instruments and from dry biofilm that forms environmental reservoirs.