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.

Endocavity Ultrasound Transducers: Why High-Level Disinfection Is Necessary

As a medical imaging modality, ultrasound is used by a wide cross-section of practitioners including radiologists, obstetricians, gynecologists, gastroenterologists, urologists and cardiologists. The increasing popularity of ultrasound as a diagnostic tool is due not only to the ease of use and portability of systems, but also to the perceived safety aspect of the examination. This latter point needs to be examined. As with any reusable medical device, the ultrasound transducer, also known as a probe, could potentially be a vector for the transmission of pathogenic viruses and fungi between patients if not correctly disinfected after each use. This transmission risk is magnified for an endocavity transducer that has come in contact with the vagina, anal canal or oral cavity, as it could be contaminated with organisms transmitted by blood or mucosal, genital or rectal secretions. Based on the Spaulding system, transducers that come in contact with mucous membranes are classified as semi-critical devices that require high-level disinfection (HLD) after each patient procedure. This HLD process should eliminate all microorganisms except high numbers of bacterial endospores. Only a small number of countries worldwide have implemented transducer reprocessing guidelines that adhere to the Spaulding classification and recommend HLD for endocavity transducers. Overall, there is a lack of conformity among global health agencies regarding the use of HLD for endocavity transducers. This is primarily due to the perception that the infection transmission risk is negligible and that if an endocavity transducer has been covered with a single-use sheath for the procedure, then low-level disinfection provides sufficient protection against pathogen transmission. The objective of this study was to review the published risk of infection transmission from endocavity transducers. By highlighting the outbreaks and case reports that implicate pathogen transmission from transducers, we posit that HLD should be a global standard of practice for the reprocessing of endocavity transducers. It requires substantial time for national health administrations to develop and legislate new recommendations, and for practice changes to be accepted and implemented by healthcare providers. We recommend that Joint Commission International (JCI) and other equivalent organizations enforce the use of HLD of endocavity ultrasound transducers during their accreditation reviews.

From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration

In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

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.

Medical Ultrasound Disinfection and Hygiene Practices: WFUMB Global Survey Results

As ultrasound technology rapidly evolves and is used more frequently in every area of medical diagnosis and treatment, it may be overlooked as a potential vector in the transmission of a health care-associated infection. A survey on disinfection and hygiene practice in medical ultrasound was disseminated via the World Federation for Ultrasound in Medicine and Biology (WFUMB) to its six member federations and associated ultrasound societies globally. One thousand twenty-nine responses were obtained across a broad range of ultrasound practitioners. A total of 76% of respondents used transducer covers every time to scan open wounds and 71% when blood and bodily fluids were present or for an interventional procedure. Approved high-level disinfectants are not always used, even when blood comes into contact with the transducer or after endocavity scans. Alcohol-based wipes were used by many respondents to clean both external transducers and endocavity transducers. Open-ended responses indicated that a large caseload hindered the time required for cleaning and that access to clear guidelines would be beneficial. Global survey results indicate that some users do not comply with disinfection practice, and there is a gap in knowledge on basic infection prevention and control education within the ultrasound unit. As the infectious status of a patient is not often disclosed prior to an ultrasound examination, training in suitable protocols for the cleaning and disinfection of ultrasound equipment is imperative to mitigate the risk of potential infection.

[Infection control practices while performing prostate biopsies in France: A CIAFU survey]

In 2008, the French Public Health Committee admitted that associating ultrasound probe protection, and related precautions, and low-level disinfection would be equivalent to the intermediate level disinfection. In 2010, the French Urology Association (AFU) updated guidelines regarding trans-rectal prostate biopsies, namely preventive measures related to cross-transmission of infections. We report an evaluation of compliance to them, driven in 2016 by AFU's infection committee. Although not recommended, almost one third of the urologists still perform biopsies under general anesthesia, and two thirds of them ask for a urine culture before biopsies. Several improvements are still needed: sterilization of needle guide should always be done when not of single use, the ultrasonography gel should be sterile, probes protection should be EC labeled, and compliance to probe processing between two patients should increase. Most of urologists happened to experience blood or feces contamination of probes. Less than half of probes are entirely floodable, and when intermediate level disinfection is done, glutaraldehyde is still referred as disinfectant by one third of the urologists.

LEVEL OF EVIDENCE

4.

Reprocessing semicritical items: Current issues and new technologies

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 minimally require high-level disinfection. Because many of these items are temperature sensitive, low-temperature chemical methods are usually used rather than steam sterilization. Strict adherence to current guidelines is required because more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items undergoing high-level disinfection than any other reusable medical device.

Results from a Large-Scale Epidemiologic Look-Back Investigation of Improperly Reprocessed Endoscopy Equipment

Objective.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Design.

Retrospective cohort study.

Setting.

Four Veterans Affairs medical centers (VAMCs).

Patients.

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Methods.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Results.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Conclusions.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

Results from a Large-Scale Epidemiologic Look-Back Investigation of Improperly Reprocessed Endoscopy Equipment

Objective.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Design.

Retrospective cohort study.

Setting.

Four Veterans Affairs medical centers (VAMCs).

Patients.

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Methods.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Results.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Conclusions.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

New developments in reprocessing semicritical items

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes). Such medical devices require minimally high-level disinfection. Because 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 because more outbreaks have been linked to inadequately cleaned or disinfected endoscopes undergoing high-level disinfection than any other medical device.

Hepatitis C transmission after prostate biopsy

Prostate biopsy is a current and well-codified procedure; antibiotic prophylaxis and rectal enema limit the risk of infection. To date, there has been no reported viral transmission between patients due to a contaminated ultrasound probe. In this study, we report the case of a patient who contracted the hepatitis C virus after transrectal prostate biopsy as part of an individual screening for prostate cancer.

Current risks of occupational blood-borne viral infection

BACKGROUND

Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other viruses remain occupational risks for both surgeons and patients in the operating room environment. In the past, this concern attracted great attention, but recently, this subject has been given much less attention.

METHODS

Review of the literature over the past 50 years on occupational risks of viral infection in the operating room.

RESULTS

Transmission of HIV still looms as a potential pathogen in the operating room, but no case has been documented in the United States. Infection with HBV can be prevented by a safe and effective vaccine. Chronic HCV infection is present in more than three million U.S. residents and remains a risk that can be managed only by adhering to strict infection control practices and avoiding blood exposure.

CONCLUSIONS

The risks of viral infection in the operating room remain the same as a decade ago even though attention to this issue has waned. The avoidance of blood exposure to prevent transmission of both known and unknown blood-borne pathogens continues to be a goal for all surgeons.

Developing a broader approach to management of infection control breaches in health care settings

Our experiences with health departments and health care facilities suggest that questions surrounding instrument reprocessing errors and other infection control breaches are becoming increasingly common. We describe an approach to management of these incidents that focuses on risk of bloodborne pathogen transmission and the role of public health and other stakeholders to inform patient notification and testing decisions.