Transcript Pathogens of concern

PATHOGENS OF CONCERN
Keeping Our Patients Safe
in Endoscopy
Holly Knauf RN, MSN, AGTS
Clinical Education Specialist
MEDIVATORS
Disclosures
1. Successful completion: Participants must complete the
entire program and submit required documentation.
2. Conflict of interest: Planners disclose no conflict; the
speaker discloses employment with Medivators, thereby
declaring a conflict of interest
3. Commercial company support: Fees are underwritten by
education funding provided by Medivators.
4. Non-commercial company support: None.
5. Non-endorsement of products: Accredited status does not
imply endorsement by the provider, Educational
Dimensions, or ANCC of any commercial products or
services from the commercial entity.
6. Alternative/Complementary therapy: None
Learner Objectives
Upon completion of this presentation, participants
will be able to:
• Discuss potential complications resulting from the
presence of various pathogens in endoscopy
equipment
 Discuss the role biofilm plays in contamination of
endoscopes
 Recognize the impact of infections related to
endoscopy
 State the steps required to correctly reprocess an
endoscope in the clinical area
Microbiology
 Microorganisms in our environment
 Evolution & Purpose
 Requirements for growth
 Transmission
 Types & Location
 Bacteria
 Viruses
 Fungi
 Worms & Insects
 Pathogens
Pathogenic Bacteria
 Staphylococcus aureus (“Staph”)
 Streptococcus pyogenes
 Pseudomonas aeruginosa
 Escherichia coli (“E coli”)
 Helicobacter pylori (“H. pylori”)
 Mycobacterium tuberculosis (TB)
Endospores
 Resistant, dormant, survival form of bacteria
 Spore producing organisms
 Bacillus anthractis
 Anthrax
 Clostridium tetani
 Tetanus
 Clostridium botulinum
 Food poisoning
 Clostridium difficile
 C diff
Four Major C. difficile-Associated Disease
(CDAD) Clinical Problems
 Inability to prevent CDAD in high-risk settings
such as the hospital
 Lack of a sensitive and rapid diagnostic test for
CDAD
 Absence of a treatment that will prevent
recurrence of CDAD
 Inability to effectively treat fulminant CDAD
Viruses
 Characteristics
 Species specific
 Cell specific
 Hepatitis B – Liver
 HIV – Certain White Blood Cells (WBCs)
 Hepatitis C
 Cytomegalovirus – AIDS
 Cryptosporidium – Diarrhea
 Human Papillomavirus (HPV) – Condyloma
Unicellular Organisms
 Protozoa
 Complex organism
 Complex life cycles
 Mode of
transmission
 Cause of diarrheal
illnesses
Unicellular Organisms
 Fungi
 Exist in yeast or mold
 Tinea pedis
 Candida albicans
Biofilm
 Micro-organisms surrounded by the slime they
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produce
Exists wherever surfaces contact water
Bacteria live in biofilm communities
Interferes with disinfection
All surfaces easily colonized
Difficult to remove
Physical properties
Endoscopy Related Infection in the News
 2000 – New Jersey: Reprocessing Machine
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Malfunction
2001 – Tennessee: Outbreak!
2002 – Maryland: Pseudomonas aeruginosa
Outbreak at Major Medical Center
2002 – USA Today: Medical Community
Debates Scope Cleaning Procedures
2002 – Good Morning America: Contamination
Controversy: Are endoscopes being disinfected
properly?
Gastrointestinal (GI) Endoscopy
 Benefits
 Useful for many GI procedures
 Safer than surgery
 Patient Safety Considerations
 Potential for patient harm
 Potential for infection transmission
 Identification of Risk
Spaulding Classification System
 Classification system for device disinfection and
sterilization processes
 Critical – Sterilization, i.e., reusable biopsy
forceps
 Semi-critical – Sterilization or high-level
disinfection, i.e., endoscopes
 Non-critical – Germicide or soap & water, i.e.,
BP cuffs, stethoscopes
Factors Affecting High Level Disinfection
and Sterilization Efficacy
 Complex endoscope design
 Biofilm formation
 Cleaning impacts efficacy of disinfection /
sterilization
 Considerations for use of germicides
 Resistant microorganisms to destruction methods
Training and Safety
 Training & policy development major influencers
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of infection prevention & safe practice
Reprocessing has narrow margin of safety
Ongoing education
Annual competency requirement
New equipment & instrument training
Strict adherence to policies
Accuracy of documentation
Staff safety considerations
Quality Assurance Standards
 Highest priority
 Documentation requirements
 Procedure date and time
 Patient’s name & medical record number
 Person performing the procedure
 Endoscope model & serial number or other
identifier
 Automated endoscope reprocessor (AER) model
& serial number or other identifier
 Staff member(s) reprocessing the endoscope
Reprocessing Overview
 Designated area
 Adequate space
 Proper airflow
 Adequate ventilation
 User-friendly work area design
 Delineation of clean and dirty areas
 Identification mechanism for clean vs dirty scopes
 Availability of recommended chemicals
 Availability of reprocessing equipment
Reprocessing Policy Development
 Manufacturer instruction manual
 Organizational policy & procedure
 Adherence to federal (CDC) and professional
standards (AORN & SGNA)
 Timing
 Use of PPE
 Procedural steps
 Environmental cleaning
Reprocessing Equipment
 Personal protective equipment (gloves, eye
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protection, impervious gown, face shield or
simple surgical mask that will not trap vapors)
Leak-testing equipment
Channel cleaning adapters (per OEM)
Large basin or sink
Detergent solution prepared according to
manufacturer's instructions
Channel cleaning brushes
Sponge and/or lint-free cloth
Precleaning
 Wipe down the insertion tube with a detergent
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soaked lint free cloth
Immerse distal tip in detergent; depress suction
valve to aspirate detergent for 30 seconds
Remove distal tip from detergent solution and
depress suction valve to aspirate air for 10
seconds; repeat till clear
Alternating air and suction will assist in removal
of debris from channel; flush with clean water
Attach air/water channel cleaning adapter and set
the light source airflow to HIGH
Precleaning
 Immerse the distal tip in clean water; depress
air/water channel cleaning adapter and feed
water for 30 seconds, release the air/water
channel cleaning adapter for 10 seconds or more
to let air through the channels
 Use a syringe to flush the auxiliary water channel
or ERCP elevator channel till clear
 Turn OFF light source; attach protective video cap
and transport endoscope to the reprocessing area
in a covered container
Environment
 Between patients, the procedure room, equipment
(monitors, video processors, light sources) and all
surfaces should be wiped clean and disinfected
with a surface disinfectant designed for this
purpose.
 Follow disinfectant contact time recommendations
Reprocessing Procedure
 Precleaning
 Leak Testing
 Manual Cleaning
 Manual High-Level Disinfection
 Automated Endoscope Reprocessors
 Drying
 Accessories
Leak Testing
● Remove all valves
● Pressurize the instrument using a manual or automated leak
tester
● Identify that the distal tip is inflated
● Submerge the scope in water to observe for leaks
● Some automated leak testers may not require submersion
● If bubbles are seen, keep scope pressurized
● If bubbles are not seen, deflate and disconnect the leak tester
from the device
Manual Cleaning (1)
 Fill a sink or basin with cleaning solution
following manufacturer’s recommendations
 Immerse the endoscope; wash all debris from the
exterior of the endoscope by brushing and wiping
the instrument while submerged
 Use a small, soft brush to clean all removable
parts
 Brush all accessible endoscope channels
including the body, insertion tube and the
umbilicus of the endoscope
Manual Cleaning (2)
 After each passage, rinse the brush in detergent
solution; continue brushing until there is no
debris visible on the brush
 Attach the endoscope manufacturer’s cleaning
adapters for suction, biopsy, air and water
channels
 Attach the manufacturer’s cleaning adapters for
special endoscope channels
 Flush all channels with the detergent solution to
remove debris
Manual Cleaning (3)
 Soak the endoscope and its internal channels for
the period of time specified by the label, if using
an enzymatic detergent or biofilm detaching
agent
 Thoroughly rinse the endoscope and all
removable parts with clean water to remove
residual debris and detergent
 Purge water from all channels using forced air
 Dry the exterior of the endoscope with a soft, lint-
free cloth before immersing
Manual Reprocessing
 Follow manufacturer’s recommendations for use
 Make sure the scope is completely submerged in the
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disinfectant
Using a syringe draw fluid into all channels so that all
internal and external surfaces have disinfectant contact
After the recommended contact time remove the scope and
rinse with clean water with the number of recommended
separate rinses
Use a syringe and flush alcohol through all the channels
Use forced air to dry internal channels after alcohol flush
Dry the external surface with a lint free cloth
High Level Disinfection using an Automated
Endoscope Reprocessor
 Place the endoscope into the AER basin
 Connect all appropriate channels to the AER
hookups
 Test the disinfectant for minimal effective
concentration level according to the
manufacturer’s recommendations
 Determine correct cycle for the endoscope
processing and start the cycle
 Complete all documentation required for high
level disinfection
Automated Endoscope Reprocessing
 Make sure an alcohol purge and air purge were
completed during the AER reprocessing
 When removing the endoscope from the AER use a
dry lint free cloth to dry any damp areas on the
scope surface
Time Out: Test Your Knowledge
 Why does the ERCP elevator wire channel have to
be processed separately?
 Most reprocessors do not have adequate pressure to
flow this very narrow lumen. Pseudomonas colonized
in this channel has been responsible for many
infections.
 Why is drying such an important part of
reprocessing?
 If a scope is not completely dry, waterborne bacteria
will grow as biofilm in the scope channels.
Storage
 Scopes should be hung vertically to promote any
drainage of residual fluids
 Storage area should be well ventilated
 All accessories should stay removed from the scope
during storage
 There should be limited access to the storage area
Breaking the Chain of Infection
 Following Guidelines and Recommended
Practices from professional organizations
 Yearly competency testing for staff
 Quality Improvement Programs
Conclusion
 Our patients are at risk
 We have a responsibility for consistent adherence
to guidelines and practices
 Rigid adherence will ensure safety and quality for
both patients and staff
Resources:
 CDC
 Guideline for Disinfection & Sterilization in
Healthcare Facilities (http://www.cdc.gov)
 SGNA
 Standards of Infection Control in Reprocessing of
Flexible Gastrointestinal Endoscopes
(http://www.sgna.org)
 AORN
 Recommended Practices for Cleaning & Processing
Flexible Endoscopes and Accessories
(http://www.aorn.org)