ICP efforts ease patient concerns about endoscopy

Focus on process, not routine culturing

Infection control professionals should heighten awareness about the importance of preventing infections during flexible endoscopy, a potentially life-saving diagnostic procedure that patients may be increasingly wary of due to reports of outbreaks and improper reprocessing, ICPs advise.

Indeed, it was mainstream press coverage and patient questions that prompted clinicians at one medical center to target endoscopy as a quality improvement project even though they were not aware of any infections or problems in their patient population. Taking a lead role in the effort was Dana Barron, RN, CIC, infection control manager at Kaiser Permanente Northwest in Portland, OR.

"There’s been a lot of stuff in the press lately," she says. "There was a Newsweek article that prompted a lot of patients to even ask, Hey, by the way, I’d like to know how you guys do this.’ And so patients were starting to ask, and [we] just thought, We’re doing a good job, but we can do better.’"

The Kaiser Sunnyside Medical Center has 19 affiliated medical offices, many of which perform endoscopy as an outpatient procedure. More than 9,000 flexible endoscopic procedures are performed annually. "We have numerous sites where we do endoscopies, and even though we had policies and procedures in place for some time, we still realized that not everybody was doing everything the same way," she says.

As part of that effort, an outpatient infection control reference manual was developed and distributed to all medical offices. Annual infection control assessments are done, using a checklist to ensure instrument reprocessing and the like are being conducted appropriately. (See checklist, p. 89.) "We were really trying to make sure that the patients all got the same standard of care and that it was a really high standard," Barron says. "Part of what my department does is to do infection control assessment at all of these sites, all of these medical offices. And we actually visit them physically once a year with a big checklist that we have, and we look at all aspects of infection control."

In addition, all staff involved in scope reprocessing must successfully complete a mandatory educational program for reprocessing endoscopes. The program includes a demonstration of reprocessing, a competency evaluation, and a written exam. A performance checklist requires a demonstration observed by the trainer. Successful completion of the program results in certification in endoscope reprocessing by the facility’s Education and Organizational Effectiveness Department. "[Staff] love it because it makes them feel really competent," she says. "They know they’re doing it well, and they know we have a [quality] program."

Health alert raised concerns

Barron’s program already was under way when public health officials warned in a safety alert last year that ICPs and other clinicians should be on guard for possible outbreaks linked to inadequately reprocessed bronchoscopes or other flexible endoscopes. (See Hospital Infection Control, October 1999, pp. 139-140.) A public health advisory on the potential hazard was issued jointly by the Centers for Disease Control and Prevention and the Food and Drug Administration.

The alert followed reports of patient-to-patient transmission of infections following procedures that used bronchoscopes that were inadequately reprocessed in an automated endoscope reprocessor.¹ Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the reprocessing machine. In addition, some bronchoscopes were inadequately reprocessed when inappropriate channel connectors were used with the machine.

"Make sure, with whatever reprocessing equipment you are using, that you have your manuals for your endoscope and for the [reprocessing] equipment. Compare the two," says Carla Alvarado, MS, lead author of recently published infection control guidelines for endoscopy by the Association for Professionals in Infection Control and Epidemiology (APIC).² "That was a problem of incompatibility in the way it was hooked up. The manufacturer’s directions for the endoscope and the manufacturer’s directions for the reprocessor have to be compared and followed."

Flexible endoscopes with fiber optic, video, or computer chip technology are increasingly used for a wide variety of diagnostic and therapeutic treatments in such areas as gastroenterology and pulmonary medicine. While the alert and other reports in the medical literature have certainly raised public awareness and concern, APIC cited data on transmission from 1988 to 1992 suggesting there may be only one infection per 1.8 million endoscopy procedures.³ "It’s a very safe procedure," says Alvarado, director of occupational health and safety at the University of Wisconsin in Madison. "This instrument is a life-saver in early diagnosis of disease. No one should ever fear having the test done with this piece of equipment because they fear an infection. [Infection] is a rare event when things are followed adequately and the process is monitored. It’s a quality issue. You have to monitor the process. You obviously can’t culture every scope and say, That’s a clean one.’ So you have to monitor the process to make sure that people are doing it right."

The tip of the iceberg

The most common factors associated with transmission include inadequacies in the areas of manual cleaning, exposure of surfaces to disinfectant, and rinsing and drying. Most of the outbreaks have involved gram-negative bacteria, but infections with hepatitis C virus and tuberculosis also have been reported in recent years.^4,5 While certainly an uncommon occurrence, there are infections that are likely going unreported, Alvarado adds. "It is a difficult event to report," she says. "Patients often come into tertiary hospitals or clinics and then are referred back and followed by their local physician. So in a sense of surveillance, it’s a difficult thing to get a handle on, but what you know may well be the tip of the iceberg."

The APIC guideline emphasizes clear communication between ICPs and colleagues conducting endoscopy. "By heightened awareness, I mean communication and sharing information with the staff in those other areas and not having an infection control program that’s in a silo,’" Alvarado says. "That’s very important. So if they do suspect that they have a problem, then they will contact you. The infection control professional and the hospital epidemiologist can be involved early on."

ICPs who detect infections linked to endoscopy should contact state and national health officials like the Centers for Disease Control and Prevention, the Food and Drug Administration, and the manufacturer in case there is a problem with endoscopy or reprocessing equipment that could be going undetected elsewhere, she recommends.

References

1. Alvarado CJ, Reichelderfer M. The 1997, 1998 and 1999 APIC Guidelines Committees. APIC guideline for infection prevention and control in flexible endoscopy. Am J Infect Control 2000; 28:138-155.

2. Centers for Disease Control and Prevention. Bronchoscopy-related infections and pseudoinfections — New York, 1996 and 1998. MMWR 1999; 48:557-560.

3. Members of the American Society for Gastrointestinal Endoscopy Ad Hoc Committee on Disinfection. Reprocessing of flexible gastrointestinal endoscopes. Gastrointest Endosc 1997; 20:540-546.

4. Bronowicki JP, Venard V, Botte C, et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997; 337:237-240.

5. Michelle TM, Cronin WA, Graham NMH, et al. Transmission of Mycobacterium tuberculosis by a fiberoptic bronchoscope. JAMA 1997; 278:1,093-1,095.