Hospitals and health systems across the nation have taken notice of the risks associated with some endoscopic procedures and the spread of multidrug-resistant organisms to patients. The "superbug" outbreaks that occurred in Seattle at Virginia Mason, in Los Angeles at UCLA and elsewhere could potentially occur at any facility.
For organizations looking to avoid an outbreak of CRE or other similar MDROs, Barbara Connell, the vice president of clinical services for Medline Industries, Inc. conducted a webinar giving details about multiple MDROs and outlining recommendations from the U.S. Food and Drug Administration and manufacturers on how to appropriately care for and handle flexible endoscopy scopes. The webinar was hosted by Becker's Healthcare.
Many of the recent outbreaks of MDROs associated with endoscopes were caused by carbapenem-resistant Enterobacteriaceae. Enterobacteriaceae is a family of bacteria that includes E. coli and Klebsiella spp., Ms. Connell explained.
Ms. Connell also noted that antibiotic-resistant Enterobacteriaceae is on the rise. The percentage of Enterobacteriaceae that is not susceptible to a carbapenem increased from 1.2 percent in 2001 to 4.2 percent in 2011. As of February 2015, every state had a Centers for Disease Control and Prevention-confirmed CRE case except for two: Idaho and Maine.
"If you're very concerned about these, I really wouldn't consider moving to those states because more than likely the CRE…will find their way to Idaho… [and] creep into Maine," she said.
To prevent CRE infections in hospitals, surgery centers and other healthcare facilities, Ms. Connell recommended the following six core measures as ones to focus on:
- Hand hygiene
- Contact precautions
- Healthcare worker education
- Antimicrobial stewardship
- Inter-facility communication
While those steps are important to prevent CRE infections from spreading generally, CRE and other MDROs can also be spread via certain endoscopes and endoscopic procedures. Even though the recent superbug outbreaks linked with endoscopes were related to flexible endoscopes, Ms. Connell also mentioned rigid endoscopes because "they are not immune to contamination by these types of organisms," she said. "Any type of complicated instrument that's inserted into our bodies, we really need to make sure that we're providing the appropriate cleaning."
The main causes of endoscopic outbreaks are as follows:
- Not following recommended cleaning or disinfection
- Using an expired or substandard disinfectant or insufficient exposure to the endoscope
- Contaminated water bottles and irrigating solutions
- Blocked channels
- Improper use of an automated cleaning system
- Inadequate drying of endoscope channel
- Improper endoscope storage
- Defective equipment, be it the endoscope itself or the reprocessing equipment
So what guidelines should organizations follow to avoid these issues? Ms. Connell first went over the FDA's current recommendations. "Basically what they were saying is, you must closely follow all manufacturer instructions for cleaning and processing," she said. This includes adhering to the reprocessing guidelines without deviating, as there was not a clear advantage to using supplies not recommended by the manufacturer.
Another word of wisdom from the FDA was that if a hospital is having trouble reprocessing or cleaning a scope, they need to report it to the FDA or the manufacturer, "because if they don't hear that you're having a problem, they're not going to be able to do anything about it."
Other best practices for properly reprocessing scopes, according to the FDA, the CDC, Olympus and other sources, include:
- Meticulously cleaning the elevator mechanism and the recesses around it by hand
- Raising and lowering the elevator throughout the manual cleaning process to brush both sides
- Implementing a comprehensive quality control program
- Putting in place writing procedures for monitoring training and adherence to the program
- Thoroughly drying the equipment using forced air and alcohol flushes
As for surveillance cultures, which some hospitals have put in place as an extra step to prevent an outbreak, Ms. Connell said there is no requirement for doing that, and it is not a substitute for good reprocessing practices. She also went over the following three considerations for proper cleaning and reprocessing of the scopes.
Pre-cleaning
Beyond surveillance, it is important to properly pre-clean the scopes before reprocessing to remove bio-burden left from the patient. Ms. Connell recommended using parts bags for detachable equipment, which prevents the scope's internal channels from retaining water. It is also important to use disinfection labels, "so that you can keep track of the last time each scope was reprocessed."
Higher level of disinfection
Beyond just reprocessing, some experts have discussed using ethylene oxide to sterilize the scopes. However, not all devices have been cleared for this type of sterilization, there are problems with toxicities, and it adds time to the reprocessing.
Training
Ms. Connell called this "the most important thing" when it comes to preventing outbreaks associated with scopes. Getting employee training up to date should be of upmost importance. Additionally, it is important to look for issues with staff that may affect the process, like interruptions, time constraints or staff shortages.
"The people who are cleaning your scopes really need to have a thorough understanding of the structure of the device that they're cleaning. They need to know that instrument inside and out," she said.
Because these scopes have been tied to several outbreaks of MDROs, experts are looking into long-term solutions to the problem beyond proper reprocessing, Ms. Connell said. Those include duodenoscope redesign, new or modified reprocessing and improved or validated reprocessing assessment.
To view the presentation on YouTube, click here.