In vitro and in vivo evaluation of a reusable double-channel sphincterotome

Single-use accessories and endoscopes in the era of sustainability and climate change-A balancing act

Gastrointestinal (GI) endoscopy is among the highest waste generator in healthcare facilities. The major reasons include production of large-volume non-renewable waste, use of single-use devices, and reprocessing or decontamination processes. Single-use endoscopic accessories have gradually replaced reusable devices over last two decades contributing to the rising impact of GI endoscopy on ecosystem. Several reports of infection outbreaks with reusable duodenoscopes raised concerns regarding the efficacy and adherence to standard disinfection protocols. Even the enhanced reprocessing techniques like double high-level disinfection have not been found to be the perfect ways for decontamination of duodenoscopes and therefore, paved the way for the development of single-use duodenoscopes. However, the use of single-use endoscopes is likely to amplify the net waste generated and carbon footprint of any endoscopy unit. Moreover, single-use devices challenge one of the major pillars of sustainability, that is, "reuse." In the era of climate change, a balanced approach is required taking into consideration patient safety as well as financial and environmental implications. The possible solutions to provide optimum care while addressing the impact on climate include selective use of disposable duodenoscopes and careful selection of accessories during a case. Other options include use of disposable endcaps and development of effective high-level disinfection techniques. The collaboration between the healthcare professionals and the manufacturers is paramount for the development of environmental friendly devices with low carbon footprint.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

Reprocessing and Reuse of Endoscopic Accessories

Endoscopic accessories are critical devices that breach sterile body sites. They have unique reprocessing difficulties compared with other medical and surgical devices because of their complex structure, narrow lumens, thermolabile construction materials, and application through a semicritical endoscopic device. In addition, there is the possibility of functional derangement of endoscopic accessories with reprocessing, and most are now marketed as single-use devices. While reprocessing of endoscopes has been the subject of numerous societal guidelines, the issue of reprocessing endoscopic accessories and ancillary detachable devices used with the endoscope is seldom addressed. We summarize the existing data on the cleaning and reprocessing of endoscopic accessories.

Impact of FDA policy change on the reuse of single-use medical devices in Michigan hospitals

BACKGROUND

Reuse of single-use devices (SUDs) was a common practice in many health care centers in the United States. In August 2000, the FDA presented a guidance document indicating their policy change that meant the FDA would regulate centers that reprocess SUDs.

OBJECTIVE

Our objective was to survey Michigan health care centers to determine the level of action that has been taken regarding this policy change and determine whether there has been a shift in the extent of reuse of SUDs.

METHODS

We developed a telephone survey tool and contacted the infection control personnel in the 54 Michigan hospitals that had more than 200 beds.

RESULTS

The response rate to the telephone survey was 48 of 54 (89%). Prior to the FDA policy change, 46%, 17%, and 37% performed on-site, third-party, or no reprocessing of SUDs, respectively. Currently, 21%, 35%, and 44% performed on-site, third-party, or no SUD reuse, respectively. The major shift has been to utilization of third-party reprocessors as opposed to stopping reuse of SUDs. In the 27 centers that currently reprocess SUDs, the most common items included the following: compression sleeves, 13 of 27; pulse oximeters, 8 of 27; PTCA cardiovascular catheters, 7 of 27; and biopsy forceps, 5 of 27. There were 61% (11/18) that resterilized open but unused SUDs with an equal split between on-site versus third-party resterilization. There were 3 sites that stopped reprocessing SUDs completely as a result of the FDA policy change and 4 that previously did not reprocess SUDs that started using a third-party reprocessor.

CONCLUSIONS

The FDA policy change has impacted how SUD reprocessing is being performed in Michigan. Few centers (1/48) reprocessing any high or medium-risk SUDs on-site at the time of the survey. There has been little overall reduction in SUD reprocessing, but there has been a shift to use of third-party reprocessors.

Reliability, cost-effectiveness, and safety of reuse of ancillary devices for ERCP

BACKGROUND

The choice between reusable and single-use devices for ERCP depends on various medical and economic criteria. This study evaluated the reliability and the safety (risk of cross-contamination) of reusable devices. A cost analysis of the use of reusable devices also was conducted.

METHODS

All patients referred for ERCP that required use of a sphincterotome or a retrieval basket were eligible for inclusion in a clinical study of 4 different devices (3 types of sphincterotome, 1 type of retrieval basket). All devices were steam sterilized. Before each use, each device was subjected to bacteriologic and virologic tests (hepatitis C virus, hepatitis B virus markers). Devices were examined before and after each procedure. The numbers of safe and efficient procedures that could be performed with each device were assessed. Three strategies were compared in a cost analysis: internal reprocessing (strategy 1), external reprocessing (strategy 2), and single-use (strategy 3). Inputs used were the results of the clinical study, hospital data for 1 year of endoscopic activity, and market prices.

RESULTS

A total of 342 patients underwent the following procedures: sphincterotomy (248 patients), stent insertion (59 patients), use of basket without sphincterotomy (14 patients), and diagnostic ERCP/unsuccessful cannulation (21 patients). At the time of ERCP, 36 patients had viral or bacterial infection. Fifty instruments were used (20 single-lumen sphincterotomes, 10 double lumen sphincterotomes, 20 retrieval baskets). Overall, the median number of efficient uses per device was 10. The median number of efficient uses by each type of device was the following: single-lumen sphincterotome, 12; double-lumen sphincterotome, 8; and, retrieval baskets, 10. All virologic and bacteriologic tests for all instruments were negative. The cost-optimization analysis found that strategy 1 is cost effective (euro37,283/y) compared with strategy 2 (euro40,101/y) and especially with Strategy 3 (euro115,210/y).

CONCLUSIONS

Reuse of the sphincterotomes and baskets evaluated in this study during ERCP is safe in terms of infectious hazards. Because they endure numerous uses, reusable instruments are cost effective, especially when compared with single-use accessories.

Improving water quality can reduce pyrogenic reactions associated with reuse of cardiac catheters

OBJECTIVE

To report the results of our preintervention investigation and subsequent 19-month three-phase intervention study designed to reduce pyrogenic reactions among patients undergoing cardiac catheterization using reprocessed catheters.

DESIGN

A case-control study for the preintervention period and a prospective cohort study for the intervention period.

SETTING

A 400-bed hospital in Belo Horizonte, Brazil.

PARTICIPANTS

Any patient undergoing cardiac catheterization in the hospital.

INTERVENTIONS

Three intervention phases were implemented to improve the quality of the water supplied to the cardiac catheter reprocessing laboratory. Standard operating procedures for reprocessing cardiac catheters were established and reprocessing staff were trained and educated.

RESULTS

The rate of pyrogenic reactions decreased significantly during the intervention phases, from 12.8% (159 of 1,239) in phase 1 to 5.3% (38 of 712) in phase 2 to 0.5% (4 of 769) in phase 3 (chi-square test for linear trend, 97.5; P < .001).

CONCLUSION

Improving water quality and using standard operating procedures for reprocessing catheters can prevent pyrogenic reactions in hospitalized patients.

Inadequacy of manual cleaning for reprocessing single-use, triple-lumen sphinctertomes: simulated-use testing comparing manual with automated cleaning methods

BACKGROUND AND AIMS

Despite widespread reuse of single-use sphinctertomes, publications regarding the adequacy of reprocessing are conflicting and the cautery wire channel is seldom evaluated. Our objective was to use thickened artificial test soil containing microorganisms to perform simulated-use tests combined with in-situ and destructive testing to evaluate cleaning efficacy and ethylene oxide sterilization of single-use triple lumen sphinctertomes.

METHODS

New triple-lumen sphinctertomes were soiled with thickened artificial test soil containing 6 log(10) per milliliter of Enterococcus faecalis and Bacillus stearothermophilus by inoculation through the distal end and dried for 1 hour, 24 hours, or 7 days before cleaning. The efficacy of manual cleaning was compared with that of automated cleaning with the Medisafe SI-Auto narrow-lumen cleaner. After cleaning, Bradford's reagent was injected into the channels as a direct method of detecting residual protein. Destructive testing was done to determine the levels of residual protein, carbohydrate, hemoglobin, endotoxin, and viable bacteria in the cleaned device. Destructive sterility testing of the devices also was performed after ethylene oxide sterilization.

RESULTS

Both in-situ and destructive testing demonstrated that manual cleaning and automated washers connected via the luer ports did not remove soil or organisms from the cautery wire channel. Only retro-flushing in the SI-Auto provided adequate cleaning of all 3 channels. If reprocessing was delayed for more than 24 hours, retro-flush cleaning was no longer effective. Ethylene oxide sterilization failure was detected only for devices held for 7 days before cleaning and sterilization. In-use testing showed that patient secretions gained access to the cautery wire channel.

CONCLUSIONS

Only retro-flushing done within 24 hours of use provided adequate cleaning for multi-lumen, single-use sphinctertomes. Our data validate the efficacy of reprocessing sphinctertomes once with SI-Auto retro-flush cleaning followed by 2 hours of ethylene oxide sterilization.