Reprocessing semicritical items: Outbreaks and current issues

Recommendations and guidelines for endoscope reprocessing: Current position statement of digestive endoscopic society of Taiwan

Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers.

Use of real-time immersive digital training and educational technologies to improve patient safety during the processing of reusable medical devices: Quo Vadis?

Hospital acquired infections stemming from contaminated reusable medical devices are of increasing concern. This issue is exaggerated with the introduction of complex medical devices like endoscopes and robotic instrumentation. Although medical device manufacturers validate their cleaning instructions for use, evidence in the literature demonstrates that effective device processing is not being performed consistently within sterile processing departments in clinical settings. The result is increased risks to patient safety. As a solution to this problem, focused one-on-one training increases compliance to the medical device manufacturer's processing instruction. However, often this is not a practical solution for the volume of healthcare staff responsible for device processing activities. This constitutes the first paper to address the blended use of educational and digital technologies to address these challenges and as a result inform safety and sustainability for the medical device sector. Cognitive learning theory is an evidence-based framework for learning. It supports the use of immersive educational experiences using emerging extended reality technologies (e.g., virtual or augmented reality) to increase learning comprehension. The delivery of educational content via these technologies provides an innovative option for repeatable leaning and training outcomes. The motivation is to decrease patient risk of contaminated reusable medical devices. The proposed approach while primary motivated by safety can also enhance sustainability and efficiency enabled by artificial intelligence and robotic instrumentation.

Biofilms on medical instruments and surfaces: Do they interfere with instrument reprocessing and surface disinfection

BACKGROUND

Biofilms are surface-attached communities of bacteria embedded in an extracellular matrix. This matrix shields the resident cells from desiccation, chemical perturbation, invasion by other bacteria, and confers reduced susceptibility to antibiotics and disinfectants. There is growing evidence that biofilms on medical instruments (especially endoscopes) and environmental surfaces interfere with cleaning and disinfection.

METHODS

The English literature on the impact of biofilms in medicine was reviewed with a focus on the impact of biofilms on reusable semicritical medical instruments and hospital environmental surfaces.

RESULTS

Biofilms are frequently present on hospital environmental surfaces and reusable medical equipment. Important health care...associated pathogens that readily form biofilms on environmental surfaces include Staphylococcus aureus, Pseudomonas aeruginosa, and Candida auris. Evidence has demonstrated that biofilms interfere with cleaning and disinfection.

DISCUSSION

New technologies such as ..úself-disinfecting..Ñ surfaces or continuous room disinfection systems may reduce or disrupt biofilm formation and are under study to reduce the impact of the contaminated surface environment on health care...associated infections.

CONCLUSIONS

Future research is urgently needed to develop methods to reduce or eliminate biofilms from forming on implantable medical devices, reusable medical equipment, and hospital surfaces.

Risk of disease transmission to patients from "contaminated" surgical instruments and immediate use steam sterilization

BACKGROUND

There are several sources of pathogens that cause surgical site infections (SSI) to include the patients endogenous microflora and exogenous sources (e.g., air, surfaces, staff, surgical equipment).

METHODS

We searched the published English literature (Google, Google Scholar, PubMed) for articles on reprocessing surgical instruments, effectiveness of sterilization methods, microbial load on surgical instruments, frequency of "contaminated" instruments, and the infection risk associated with "contaminated" surgical instruments and immediate use steam sterilization.

RESULTS

There is substantial redundancy in instrument reprocessing to include: even if a patient was exposed to a "contaminated" instrument, the decontamination and sterilization process would have removed and/or inactivated the contaminating pathogens due to the exceptional effectiveness of the manual and mechanical cleaning (i.e., washer-disinfector) and the remarkable robustness of sterilization technology; and the low-level of microorganisms on surgical instruments after use and before cleaning.

CONCLUSIONS

A critical review of the literature suggests that the risk of acquiring an SSI from instruments used in surgery is essentially zero if the sterilization cycle is validated.

Disinfection and sterilization: New technologies

BACKGROUND

Adherence to professional guidelines and/or manufacturer's instructions for use regarding proper disinfection and sterilization of medical devices is crucial to preventing cross transmission of pathogens between patients. Emerging pathogens (e.g., Candida auris) and complex medical devices provide new challenges.

METHODS

A search for published English articles on new disinfection and sterilization technologies was conducted by Google, Google scholar and PubMed.

RESULTS

Several new disinfection methods or products (e.g., electrostatic spraying, new sporicides, colorized disinfectants, "no touch" room decontamination, continuous room decontamination) and sterilization technologies (e.g., new sterilization technology for endoscopes) were identified.

CONCLUSIONS

These technologies should reduce patient risk.

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

Using the Manufacturer's Instructions for Use and Spaulding Classification System to Assess Disinfection Practices for Ultrasound Transducers in the Perioperative Setting

Proper use and disinfection of medical devices and instruments is essential to preventing infection and providing safe patient care. Because of an increase in the complexity of medical devices and patient interventions, it has become more difficult for perioperative staff members to ensure that equipment is properly used and disinfected according to the manufacturer's instructions for use and the Spaulding classification system. One type of medical device that may have multiple clinical uses is the ultrasound transducer. In the perioperative setting, ultrasound transducers can be used for surface, percutaneous, and endocavitary procedures. They also may be used at multiple times before, during, and after a procedure, which may make it challenging for perioperative staff members to know the correct disinfection practice. They should use the device's instructions for use and the Spaulding classification system to guide their clinical practice.

A review of Spaulding's classification system for effective cleaning, disinfection and sterilization of reusable medical devices: Viewed through a modern-day lens that will inform and enable future sustainability

Despite advances in medicine and innovations in many underpinning fields including disease prevention and control, the Spaulding classification system, originally proposed in 1957, remains widely used for defining the disinfection and sterilization of contaminated re-usable medical devices and surgical instruments. Screening PubMed and Scopus databases using a PRISMA guiding framework generated 272 relevant publications that were used in this review. Findings revealed that there is a need to evolve how medical devices are designed, and processed by cleaning, disinfection (and/or sterilization) to mitigate patient risks, including acquiring an infection. This Spaulding Classification remains in use as it is logical, easily applied and understood by users (microbiologists, epidemiologists, manufacturers, industry) and by regulators. However, substantial changes have occurred over the past 65 years that challenge interpretation and application of this system that includes inter alia emergence of new pathogens (viruses, mycobacteria, protozoa, fungi), a greater understanding of innate and adaptive microbial tolerance to disinfection, toxicity risks, increased number of vulnerable patients and associated patient procedures, and greater complexity in design and use of medical devices. Common cited examples include endoscopes that enable non- or minimal invasive procedures but are highly sophisticated with various types of materials (polymers, electronic components etc), long narrow channels, right angle and heat-sensitive components and various accessories (e.g., values) that can be contaminated with high levels of microbial bioburden and patient tissues after use. Contaminated flexible duodenoscopes have been a source of several significant infection outbreaks, where at least 9 reported cases were caused by multidrug resistant organisms [MDROs] with no obvious breach in processing detected. Despite this, there is evidence of the lack of attention to cleaning and maintenance of these devices and associated equipment. Over the last few decades there is increasing genomic evidence of innate and adaptive resistance to chemical disinfectant methods along with adaptive tolerance to environmental stresses. To reduce these risks, it has been proposed to elevate classification of higher-risk flexible endoscopes (such as duodenoscopes) from semi-critical [contact with mucous membrane and intact skin] to critical use [contact with sterile tissue and blood] that entails a transition to using low-temperature sterilization modalities instead of routinely using high-level disinfection; thus, increasing the margin of safety for endoscope processing. This timely review addresses important issues surrounding use of the Spaulding classification system to meet modern-day needs. It specifically addresses the need for automated, robust cleaning and drying methods combined with using real-time monitoring of device processing. There is a need to understand entire end-to-end processing of devices instead of adopting silo approaches that in the future will be informed by artificial intelligence and deep-learning/machine learning. For example, combinational solutions that address the formation of complex biofilms that harbour pathogenic and opportunistic microorganisms on the surfaces of processed devices. Emerging trends are addressed including future sustainability for the medical devices sector that can be enabled via a new Quintuple Helix Hub approach that combines academia, industry, healthcare, regulators, and society to unlock real world solutions.

Criteria for the Use, Processing, and Disposal of Flexible Endoscope Cleaning Brushes

Objectives: To ensure effectiveness in the endoscope channel cleaning process, using functional brushes that are in good condition is necessary. This study sought to identify the criteria for acquiring, using, and disposing of cleaning brushes at endoscopy facilities in Brazil. We further sought to evaluate the conditions of the cleaning brushes in use in the facilities. Methods: This cross-sectional study was conducted between July 2021 and January 2022. Personnel responsible for processing endoscopes were interviewed regarding the use, processing, and disposal of flexible endoscope cleaning brushes. In addition, the brushes used to clean the equipment were inspected. Results: All participants interviewed reported the practice of brushing endoscope channels. Of them, 60% noted the use of disposable brushes, with 40% using reusable brushes. None of the facilities interviewed reported discarding disposable brushes after use. The protocols for disposal of brushes included disposing due to bristle wear (70%), disposal at the end of the day (20%), and an absence of disposal protocols (10%). In addition, 30% of facilities did not clean the bristles before reintroducing them into the channel/lumen, and no facility had an established routine for cleaning brushes between uses. Inspection of brushes revealed that only 20% of facilities had new brushes with no signs of wear or damage. Conclusion: The use of inappropriate brushes/sponges for cleaning endoscope channels and the lack of criteria for the reuse and disposal of brushes increases the risk of cross-contamination, internal damage to channels, and biofilm formation.

High-level disinfection evaluation in the ambulatory setting

High level disinfection (HLD) is a complex process, requiring appropriate materials and highly trained personnel. An investigation of the HLD process was performed at an outpatient urology practice upon notification of expired chemical test strips being utilized. Infection Prevention (IP) identified various breaches in the reprocessing of flexible cystoscopes and transrectal prostate biopsy probes. Contributing factors identified were gaps in staff training, availability of all necessary supplies and staff supervision.

Knowledge and practice of dentists in processing polishing points: A cross-sectional study

BACKGROUND

Adequately processing polishing points used to polish composite resin restorations is necessary for microbiological control in dentistry, but there is no specific protocol to guide professionals. Therefore, this study aimed to assess the knowledge and practice of dentists in processing these instruments.

METHODS

This cross-sectional observational study included the application of an online questionnaire via Google Forms and social media promotion. The study evaluated the association of field of activity, time since graduation, age, and sex of professionals with processing practice. The statistical analysis was performed with absolute and relative frequencies and logistic and Poisson regressions at a 5% significance level.

RESULTS

Overall, 473 questionnaires were analyzed. A rate of 51% of professionals reported using inadequate processing methods, and almost 68% claimed to have good knowledge of the topic. Both regression analyses were significantly associated, showing a direct effect of age and time since graduation on adequate processing practices.

CONCLUSIONS

Although most professionals reported understanding the processing of polishing points, they do not perform it most adequately.

CLINICAL SIGNIFICANCE

An expressive number of dentists process polishing points improperly. The topic is significant for representing a semi-critical instrument extensively used in esthetic restorations.

Good Practices on Endoscope Reprocessing in Italy: Findings of a Nationwide Survey

Background: Correct reprocessing and microbiological surveillance on endoscopes are fundamental for preventing the transmission of multi-drug resistant strains and device-related infections. Methods: A questionnaire with three domains was created: (1) centre characteristics; (2) endoscope reprocessing procedures; and (3) application of microbiological surveillance. Nurses working in endoscopic units across Italy were invited to anonymously fill out the questionnaire on the SurveyMonkey platform between November 2021 and February 2022. Results: A total of 82 out of 132 endoscopic centres participated in the survey, with at least one centre from each Italian region. Data found different concerns regarding the current practice of both reprocessing and microbiological surveillance. According to respondents, the training on reprocessing was performed through theoretical training and only in 10% of centres; the microbiological surveillance was regularly performed in 59% of centres; and sampled endoscopes were not excluded for use in 31% of centres performing the surveillance until the outcome was pending, and when positive, 72% maintained them in quarantine until a successive negative result. Conclusions: Reprocessing and microbiological surveillance currently present several criticisms along the endoscopic centres in Italy. Our survey highlights the need for the correct application of the national recommendations in each endoscopic centre to prevent the potential transmission of endoscope-related infections.

Infection Prevention in the Neonatal Intensive Care Unit

Although many aspects of infection prevention and control (IPC) mirror institutional efforts, optimization of IPC practices in the neonatal intensive care unit requires careful consideration of its unique population and environment, addressed here for key IPC domains. In addition, innovative mitigation efforts to address challenges specific to limited resource settings are discussed.

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.

The Centers for Disease Control and Prevention Guidance on Flexible Gastrointestinal Endoscopes: Lessons Learned from Outbreaks, Infection Control

Flexible endoscopes require cleaning, high-level disinfection, and sterilization between each patient use to reduce risk of transmitting pathogens. Public health investigations have identified concerns, including endoscope damage, mishandling, and reprocessing deficiencies, placing patients at risk for transmission of bacterial, viral, and other pathogens. Findings from outbreak investigations and other studies have led to innovations in endoscope design, use, and reprocessing, yet infection risks related to contaminated or damaged endoscopes remain. Strict adherence to infection control guidelines and manufacturer instructions for use, utilization of supplemental guidance, and training and oversight of reprocessing personnel, reduce risk of pathogen transmission by flexible endoscopes.

SpyGlass application for duodenoscope working channel inspection: Impact on the microbiological surveillance

BACKGROUND

Patient-ready duodenoscopes were designed with an assumed contamination rate of less than 0.4%; however, it has been reported that 5.4% of clinically used duodenoscopes remain contaminated with viable high-concern organisms despite following the manufacturer’s instructions. Visual inspection of working channels has been proposed as a quality control measure for endoscope reprocessing. There are few studies related to this issue.

AIM

To investigate the types, severity rate, and locations of abnormal visual inspection findings inside patient-ready duodenoscopes and their microbiological significance.

METHODS

Visual inspections of channels were performed in 19 patient-ready duodenoscopes using the SpyGlass visualization system in two endoscopy units of tertiary care teaching hospitals (Tri-Service General Hospital and National Taiwan University Hospital) in Taiwan. Inspections were recorded and reviewed to evaluate the presence of channel scratches, buckling, stains, debris, and fluids. These findings were used to analyze the relevance of microbiological surveillance.

RESULTS

Seventy-two abnormal visual inspection findings in the 19 duodenoscopes were found, including scratches (n = 10, 52.6%), buckling (n = 15, 78.9%), stains (n = 14, 73.7%), debris (n = 14, 73.7%), and fluids (n = 6, 31.6%). Duodenoscopes > 12 mo old had a significantly higher number of abnormal visual inspection findings than those ≤ 12 mo old (46 findings vs 26 findings, P < 0.001). Multivariable regression analyses demonstrated that the bending section had a significantly higher risk of being scratched, buckled, and stained, and accumulating debris than the insertion tube. Debris and fluids showed a significant positive correlation with microbiological contamination (P < 0.05). There was no significant positive Spearman’s correlation coefficient between negative bacterial cultures and debris, between that and fluids, and the concomitance of debris and fluids. This result demonstrated that the presence of fluid and debris was associated with positive cultures, but not negative cultures. Further multivariate analysis demonstrated that fluids, but not debris, is an independent factor for bacterial culture positivity.

CONCLUSION

In patient-ready duodenoscopes, scratches, buckling, stains, debris, and fluids inside the working channel are common, which increase the microbiological contamination susceptibility. The SpyGlass visualization system may be recommended to identify suboptimal reprocessing.

Disinfection, sterilization, and antisepsis: An overview

All invasive procedures involve contact by a medical device or surgical instrument with a patient's sterile tissue or mucous membranes. The level of disinfection or sterilization is dependent on the intended use of the object. Critical (items that contact sterile tissue, such as surgical instruments), semicritical (items that contact mucous membranes, such as endoscopes), and noncritical (devices that contact only intact skin, such as stethoscopes) items require sterilization, high-level disinfection, and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program, as well as other uses, such as surgical hand antisepsis and preoperative skin preparation.

Reprocessing semicritical items: Outbreaks and current issues

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. As many of these items are temperature sensitive, low-temperature chemical methods must be used rather than steam sterilization. Strict adherence to current guidelines is required as more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items than any other reusable medical devices.