The ECRI Institute released their Top 10 Health Technology Hazards for 2019 this month. Hazard number five, “Mishandling Flexible Endoscopes after Disinfection Can Lead to Patient Infections,” identifies issues that we have seen in Oregon through contributions to the Patient Safety Reporting Program (PSRP) and the Infection Control Assessment and Response (ICAR) visits our infection prevention consultants have made in Oregon healthcare facilities over the past three years.

Device reprocessing is an important part of a facility’s infection control program. Both inside and outside endoscope surfaces are exposed to potential contaminants and they can be difficult to disinfect. For example, “devices may be heat sensitive, and thus cannot be sterilised with steam, and complex design features (eg, elevator mechanisms on duodenoscopes) can make for difficult-to-reach surfaces” (The Lancet Gastroenterology & Hepatology, “Scoping the Problem”). ECRI identified three risks during this process:

• Inadequate drying after high-level disinfection

• Recontamination due to mishandling with unclean gloves

• Recontamination during transportation or storing

Some of the common contributing factors to contaminated device events submitted to PSRP include: distractions or interruptions during reprocessing, inadequate space for reprocessing, inadequate labeling, and the impact of changes to processes over time.

During an ICAR visit, our infection control consultants evaluate device reprocessing. They’ve found than about a fifth of the hospitals assessed don’t allow adequate time for reprocessing and about a fifth of the outpatient facilities assessed haven’t allotted adequate space for reprocessing. They also found that while 90% of hospitals and outpatient facilities provide training when new devices or protocols are introduced, less than 40% routinely audit adherence to reprocessing protocols.

What You Can Do

• Evaluate your protocols: Review your device reprocessing policies and protocols and make sure they adequately address these identified risks.

• Routinely audit implementation of your protocols: routine audits can help you identify and address any gaps in implementing your protocols before harm reaches a patient.

• Follow CDC guidelines and recommendations for device reprocessing: Guideline for Disinfection and Sterilization in Healthcare Facilities and Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2016 update.

• Receive a free ICAR consultation: OPSC is currently scheduling free ICAR consultations – we still have available assessment opportunities, but appointments are filling up fast! Contact us.

Recommendations from an Expert

OPSC Infection Prevention Consultant Anne Eades, BSMT, MPH, CIC, has performed ICAR assessments at hospitals, ambulatory surgery centers, outpatient clinics, long-term care facilities, and dialysis centers. Here are her top four recommendations for facilities:

• Post the process steps, with illustrations, in the work area

• Perform quality checks according to the manufacturers’ instructions

• Maintain staff awareness of the correct high-level disinfectant to use, proper timing, rinsing, and drying

• Provide regular training so staff remain current and proficient in infection control practices

What have you done to address this or similar safety risks? Share what you’ve learned in your organization and contribute to the ongoing learning about adverse events in Oregon through the Patient Safety Reporting Program.

References

The Lancet Gastroenterology & Hepatology. “Scoping the Problem: Endoscopy-Associated Infections.” The Lancet Gastroenterology & Hepatology 3, no. 7 (July 1, 2018): 445. https://doi.org/10.1016/S2468-1253(18)30168-7.