The Human Touches in Endoscope Infection
Simon K. Lo, MD Director of Endoscopy
Head, Pancreatic Diseases ProgramChair Holder, F. Widjaja Family Chair in Digestive Diseases
Clinical Professor of MedicineCedars-Sinai Medical Center
Los Angeles, California
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CRE in the News
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First CRE-ERCP Outbreak in the U.S.
Alrabaa. American J of Infection control 2013
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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
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Reprocessing Lapses
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Reported Cases in N. America 2005-2012
Langlay. Am J Inf Control 2013
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Workflow in Instrument Reprocessing
Humphries. JCM 2015
GI Endoscopy Cleaning and
Processing
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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
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Endoscope
Infection “Opportunities”
• Usage
• Disinfection
• Storage
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Common Endoscope Internal structure
Humphries. JCM 2015
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Processes Involved in an Endoscopy
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• Scopes
• Supplies
• Expiration
• Package integrity
• Scope carrying case
Scopes & Supplies Delivery
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• 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
In-room storage
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Processes Involved in an Endoscopy
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• 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
Work Station
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Processes Involved in an Endoscopy
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Hospital Telephones & Computers
Ciragil. Hospital Infection 2006
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Hospital/endoscopy environment
Dumford. Am J Infect Control 2009
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Processes Involved in an Endoscopy
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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
Intra-procedure Transmission
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Processes Involved in an Endoscopy
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• 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
House-keeping Issues
Scope InfectionHacek. Am J Infect Control 2010
Terminal Cleaning impacts C. Diff. Infection
48% reduction in the prevalence density of C Diff after the bleaching intervention (p<0.0001)
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Processes Involved in an Endoscopy
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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.
Dirty scopes
Clean Filthy!!
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High Level Disinfection Process
Chiu. WJEM 2015
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Complex Cleaning Methods
From K Kwok, DDW 2016. Olympus Reprocessing Manual 28| © 2016 Kaiser Foundation Health Plan, Inc. September 26, 2016
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Human Factors in Scope Cleaning
…… 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
Endoscope Reprocessing Methods: A Prospective Study on the Impact of Human Factors and Automation
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Processes Involved in an Endoscopy
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• 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
Separation of Clean and Dirty
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• Minimum space requirement for cleaning facility
• Hard separation of dirty and clean areas
• Modifications of existing requirements:
– Surveillance cameras
– Closed cabinet doors
– Secured entrance
Examples of Facility Requirements
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Processes Involved in an Endoscopy
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Vulnerable to mass contamination
o Prolonged storage
o “dirty hands”
o Poor air dryness
o Disgruntled employee
Cleaned and Dried scopes
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• 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
More Scrutiny More Findings
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NY State TNE Bill A9763
Assemblyman David Weprin Website
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.
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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)
