- Email: [email protected]
217 Endoscope Storage Time: Assessment of Microbial Colonization 21 Days After Reprocessing
Abstracts
subjected to HLD and subsequently used in patients. More research is needed to determine optimal methods of ensuring endoscopes are free of contamination prior to patient use.
215 A Prospective Study Assessing the Safety and Cost Efficacy of Physician Directed Nurse Administered Balanced Propofol Sedation (PhD NAPS) in Low Risk Patients Undergoing Endoscopy and Colonoscopy Rajvinder Singh*1,2, Dharshan Sathananthan1, Amanda Ovenden2, Garry Nind1, Biju George1, Angela Ashby1, Sharon Drummond1, Kasia Redel1, Philip Carrington1, Shane P. Selvanderan3, Neville Green4 1 Gastroenterology, Lyell McEwin Hospital, Adelaide, SA, Australia; 2 Department of Medicine, University of Adelaide, Adelaide, SA, Australia; 3School of Medicine, University of Adelaide, Adelaide, SA, Australia; 4Department of Anaesthesia, Lyell Mc Ewin Hospital, Adelaide, SA, Australia
advanced endoscopic procedures were performed on 1408 patients during this period (EGD, colonoscopy, ERCP, EUS, enteroscopy and flexible sigmoidoscopies). 259/1408 (18.4%) were intubated compared to 1149/1408 (81.6%) not intubated. An indication for intubation was not mentioned in 64.2% of the cases while risk of aspiration, difficult airway and comorbidities accounted for 26.1% of intubations. Figure 1 shows the distribution of procedure types for intubated vs. non-intubated patients. Intubation rates were the highest for ERCP and deep enteroscopy. Endoscopy unit efficiency metrics are shown in Table 1. All metrics were significantly longer for intubated patients. On average, the Total Time from patient entry into the endoscopy room until exit was prolonged by an additional 27.2 minutes (74.0 vs. 46.8 min, pZ0.0001) for intubated patients. Additionally, TOT was significantly longer for intubated patients (45.7 min vs. 34.3 min, pZ0.0001). Conclusions: Endotracheal intubation for interventional endoscopy significantly increases the time spent in the endoscopy room and negatively impacts endoscopy unit efficiency. Careful assessment of the need for endotracheal intubation is crucial to ensure patient safety yet maximize efficiency in interventional endoscopy units.
Background and aim: Despite numerous studies demonstrating the safety of Propofol in gastrointestinal procedures, concerns of the agent being administered by nonanaesthetists have been repeatedly voiced. We conducted a prospective study to assess the safety and cost efficacy of Propofol administered by trained Nurse sedationists [Physician-Directed Nurse-Administered balanced Propofol Sedation (PhD NAPS)] in low risk patients undergoing endoscopy, colonoscopy or both procedures. Methods: Consecutive patients with an ASA score of 1-2 presenting with any indication were recruited. The induction, procedural and recovery time as well as the complications during and after the procedure were analysed. Balanced sedation (Propofol and Midazolam) was administered by a trained Nurse sedationist (NS), under the guidance of the proceduralist. NS’s were ALS (Advanced Life Support) certified and underwent extensive training in sedation and recovery. Recovery time was defined as the length of time from the end of procedure to the time taken to achieve a sedation score of 0 (awake and alert), following which patients were discharged from the endoscopy unit. Results: A total 981 patients (451 male) with a mean age of 53 years (range: 16 - 87) were prospectively recruited from January 2010 to October 2012. 440 endoscopies, 420 colonoscopies and 121 combined procedures were performed. The average ASA score was 1.66. The mean Propofol and Midazolam doses administered per patient were 206mg (range 40 - 660) and 1.1 mg (range 0.5 - 5.5) respectively. The average duration for an endoscopy, colonoscopy and combined procedure were 12.05, 23.13 and 31.40 minutes respectively. There were no major intra-procedural complications. Hypotension was observed in 4 of the 981 patients (0.41%). This was managed successfully with intravenous fluid boluses in all cases. Bradycardia was observed in 4 of the 981 patients (0.41%). No intervention was required for these episodes as the heart rate spontaneously improved. There were no episodes of hypoxia. The average recovery time was 23.44 minutes. The estimated cost of an NS for this period was USD$125,000 (USD$70,000, salary and USD$55,000, training) vs. a hypothetical cost of USD$250,000 for an Anaesthetist. Conclusion: PhD NAPS is safe when strict patient selection criteria are used. In addition, a significant benefit (50% reduction) in the cost can be achieved.
216 Impact of Endotracheal Intubation on Interventional Endoscopy Unit Efficiency Metrics At a Tertiary Academic Medical Center Robert J. Summerlee1, Dennis Yang1, Alejandro L. Suarez2, Yaseen B. Perbtani2, Jonathan B. Williamson1, Charles W. Shrode1, Anand Gupte1, Shailendra S. Chauhan1, Peter V. Draganov1, Christopher E. Forsmark1, Mihir S. Wagh*1 1 Division of Gastroenterology, University of Florida, Gainesville, FL; 2 Department of Medicine, University of Florida, Gainesville, FL Background: Measures for evaluating interventional endoscopy unit efficiency are increasingly important, especially with the growing involvement of anesthesia services and need for endotracheal intubation for endoscopy. Aims: To identify and compare endoscopy unit efficiency metrics between intubated and non-intubated patients undergoing interventional endoscopic procedures at an academic medical center. Methods: The prospectively collected endoscopy unit metrics database at the University of Florida was reviewed for procedures performed in two interventional endoscopy rooms from 1/1/13 to 6/30/13. All procedures were performed under anesthesiologist-administered propofol or general anesthesia. Parameters included hospital-mandated metrics in the database: Total Delay Time was defined as the time between actual patient entry into the endoscopy room and the scheduled procedure start time. Anesthesia Ready Time (ART) was defined as the time between patient entry into the endoscopy room and the time reported by the anesthesia team that the patient was appropriately sedated and ready for endoscopy. Endoscopist Ready Time (ERT) was defined as the time from ART to the insertion of the endoscope. Procedure Time (PT) was defined as the time between endoscope insertion and removal. Room Exit Time (RET) was defined as the time from endoscope removal to patient exit from the procedure room. Total Time was defined as ART + ERT + PT + RET. Room Turnover Time (TOT) was defined as the time from patient exit from the procedure room until the time of next patient entry in the room. Results: 1479
AB120 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
217 Endoscope Storage Time: Assessment of Microbial Colonization 21 Days After Reprocessing Andrew Brock*1, Lisa L. Steed2, Janice Freeman1, Bernadette Garry3, Phyllis Malpas1, Peter B. Cotton1 1 Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC; 2Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC; 3Quality Management and Patient Safety/Infection Control, Medical University of South Carolina, Charleston, SC Background: Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to variable reprocessing intervals amongst institutions, with some as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for up to 21 days without risk of clinically significant contamination. Aims: To demonstrate whether flexible endoscopes may be stored for up to 21 days after reprocessing without colonization by pathogenic microbes. Methods: Samples were collected from the air-water channel, biopsy channel and elevator wire channel (for duodenoscopes) of 4 duodenoscopes, 4 colonoscopes
www.giejournal.org
Abstracts
and 2 upper endoscopes on days 0, 7, 14 and 21 following standard protocol for mechanical cleaning and high level disinfection using an automated endoscope reprocessor. Endoscopes were stored hanging per institutional practice. A 1mL aliquot of each sample was inoculated onto trypticase soy agar with 5% sheep blood (blood agar), thiogycollate broth, a CDC anaerobic blood agar plate, and Sabouraud dextrose agar (for yeast and molds). All media were incubated at 2535C for 7 days. Organisms were identified using standard microbiological techniques; results were reported in colony forming units. Results: There were 33 positive cultures from 28 out of the 96 sites tested (29.2% overall contamination rate). 30/33 isolates were typical skin or environmental contaminants, thus clinically insignificant (Table 1). Three potential pathogens were cultured, including
enhanced staff training and monitoring. Within a month, there was a dramatic increase in the gastroscope passage rate, exceeding 90%. This trend persisted for the 6 month follow up period from January to June 2013, and ultimately resulted in a 95% passage rate (Fig. 2). Conclusion: Meticulous cleaning of endoscopes must precede high-level disinfection of these instruments to prevent pathogen transmission between patients. Using ATP-detection technology, we instituted changes to the gastroscope pre-cleaning algorithm that resulted in a rapid and durable improvement in gastroscope cleanliness. While such improvement may partially be the result of the Hawthorne Effect, the robustness of this improvement suggests that it is primarily related to a significant reduction in gastroscope bioburden during the pre-cleaning process.
Non-pathogens Microbe
Total positive cultures
Colonoscope
Duodenoscope
Upper endoscope
Suction channel
Biopsy channel
Elevator
18 6 3 1 1 1
2 2 1 1
4 2 1
3
4 2 1
11 3 2 1 1 1
3 1
Coag neg staph Micrococcus Bacillus Aureobasidium pullalans Corynebacterium Propionibacerium acnes
1 1
1
enterococcus, Candida parapsilosis and alpha hemolytic strep; all were likely clinically insignificant as each was only recovered at one time point on one site and all were far below the standard 100 cfu/mL threshold (Table 2). There were no definite pathogenic isolates. Conclusion: Endoscopes can be stored for up to 21 days with low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.
Potential pathogens Microbe Enterococcus Candida parapsilosis Alpha hemolytic strep
Total positive cultures
Endoscope
Channel
1 1 1
Colonoscope Duodenoscope Upper endoscope
Biopsy Biopsy Biopsy
218 Dramatic Improvement in Endoscope Cleanliness Using a Commercial Bioburden Detection System and Implementation of a Modified Cleaning Algorithm Jonathan N. Mazurek*, David Hudesman, Andrew S. Korman, Frances Glennon, Brett B. Bernstein Beth Israel Medical Center, New York, NY Background and Objective: Meticulous endoscope reprocessing is critical in the prevention of pathogen transmission between patients. While transmission was previously thought to be rare, evidence now suggests that it may be as high as 42%, and is directly related to lapses in adherence to cleaning protocols. Adenosine triphosphate (ATP) is present in all living cells, and therefore serves as an ideal marker for the presence of organic residue. The 3M Clean-TraceÔ Hygiene Management System (3M Clean-TraceÔ, 3M, St. Paul, Minnesota) measures levels of ATP present on the surface and interior lumen of an endoscope. After swabbing these areas, the test-swab is mixed with an enzyme solution that reacts with ATP to produce light. The 3M Clean-TraceÔ Luminometer measures the light generated by this reaction, and generates a result expressed in Relative Light Units (RLUs). The greater the level of ATP, the higher the RLU level, thus reflecting a higher level of residual bioburden on the endoscope. Utilizing ATP hygiene monitoring technology we developed an algorithm and monitoring program with the aim of achieving a 90% pass rate in the pre-cleaning of gastroscopes prior to high level disinfection. Methods: From September to December 2012, we implemented the monitoring of gastroscope cleanliness utilizing the 3M Clean-TraceÔ system by randomly testing two gastroscopes per day, that were pre-cleaned per the manufacturer’s instructions. Scope surface and luminal testing was performed. Data was uploaded to the 3M Clean-TraceÔ online software, and monthly reports were generated. Using this data, we implemented changes to the gastroscope precleaning algorithm (Fig. 1), retrained all staff in this process and monitored compliance. We then monitored gastroscope cleanliness for a six month follow-up period from January to June 2013. Results: Initial data obtained by swabbing the distal end of the gastroscopes identified a 63% passage rate and a 37% failure rate. This led to the implementation of a meticulous cleaning algorithm as well as
www.giejournal.org
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB121
subjected to HLD and subsequently used in patients. More research is needed to determine optimal methods of ensuring endoscopes are free of contamination prior to patient use.
215 A Prospective Study Assessing the Safety and Cost Efficacy of Physician Directed Nurse Administered Balanced Propofol Sedation (PhD NAPS) in Low Risk Patients Undergoing Endoscopy and Colonoscopy Rajvinder Singh*1,2, Dharshan Sathananthan1, Amanda Ovenden2, Garry Nind1, Biju George1, Angela Ashby1, Sharon Drummond1, Kasia Redel1, Philip Carrington1, Shane P. Selvanderan3, Neville Green4 1 Gastroenterology, Lyell McEwin Hospital, Adelaide, SA, Australia; 2 Department of Medicine, University of Adelaide, Adelaide, SA, Australia; 3School of Medicine, University of Adelaide, Adelaide, SA, Australia; 4Department of Anaesthesia, Lyell Mc Ewin Hospital, Adelaide, SA, Australia
advanced endoscopic procedures were performed on 1408 patients during this period (EGD, colonoscopy, ERCP, EUS, enteroscopy and flexible sigmoidoscopies). 259/1408 (18.4%) were intubated compared to 1149/1408 (81.6%) not intubated. An indication for intubation was not mentioned in 64.2% of the cases while risk of aspiration, difficult airway and comorbidities accounted for 26.1% of intubations. Figure 1 shows the distribution of procedure types for intubated vs. non-intubated patients. Intubation rates were the highest for ERCP and deep enteroscopy. Endoscopy unit efficiency metrics are shown in Table 1. All metrics were significantly longer for intubated patients. On average, the Total Time from patient entry into the endoscopy room until exit was prolonged by an additional 27.2 minutes (74.0 vs. 46.8 min, pZ0.0001) for intubated patients. Additionally, TOT was significantly longer for intubated patients (45.7 min vs. 34.3 min, pZ0.0001). Conclusions: Endotracheal intubation for interventional endoscopy significantly increases the time spent in the endoscopy room and negatively impacts endoscopy unit efficiency. Careful assessment of the need for endotracheal intubation is crucial to ensure patient safety yet maximize efficiency in interventional endoscopy units.
Background and aim: Despite numerous studies demonstrating the safety of Propofol in gastrointestinal procedures, concerns of the agent being administered by nonanaesthetists have been repeatedly voiced. We conducted a prospective study to assess the safety and cost efficacy of Propofol administered by trained Nurse sedationists [Physician-Directed Nurse-Administered balanced Propofol Sedation (PhD NAPS)] in low risk patients undergoing endoscopy, colonoscopy or both procedures. Methods: Consecutive patients with an ASA score of 1-2 presenting with any indication were recruited. The induction, procedural and recovery time as well as the complications during and after the procedure were analysed. Balanced sedation (Propofol and Midazolam) was administered by a trained Nurse sedationist (NS), under the guidance of the proceduralist. NS’s were ALS (Advanced Life Support) certified and underwent extensive training in sedation and recovery. Recovery time was defined as the length of time from the end of procedure to the time taken to achieve a sedation score of 0 (awake and alert), following which patients were discharged from the endoscopy unit. Results: A total 981 patients (451 male) with a mean age of 53 years (range: 16 - 87) were prospectively recruited from January 2010 to October 2012. 440 endoscopies, 420 colonoscopies and 121 combined procedures were performed. The average ASA score was 1.66. The mean Propofol and Midazolam doses administered per patient were 206mg (range 40 - 660) and 1.1 mg (range 0.5 - 5.5) respectively. The average duration for an endoscopy, colonoscopy and combined procedure were 12.05, 23.13 and 31.40 minutes respectively. There were no major intra-procedural complications. Hypotension was observed in 4 of the 981 patients (0.41%). This was managed successfully with intravenous fluid boluses in all cases. Bradycardia was observed in 4 of the 981 patients (0.41%). No intervention was required for these episodes as the heart rate spontaneously improved. There were no episodes of hypoxia. The average recovery time was 23.44 minutes. The estimated cost of an NS for this period was USD$125,000 (USD$70,000, salary and USD$55,000, training) vs. a hypothetical cost of USD$250,000 for an Anaesthetist. Conclusion: PhD NAPS is safe when strict patient selection criteria are used. In addition, a significant benefit (50% reduction) in the cost can be achieved.
216 Impact of Endotracheal Intubation on Interventional Endoscopy Unit Efficiency Metrics At a Tertiary Academic Medical Center Robert J. Summerlee1, Dennis Yang1, Alejandro L. Suarez2, Yaseen B. Perbtani2, Jonathan B. Williamson1, Charles W. Shrode1, Anand Gupte1, Shailendra S. Chauhan1, Peter V. Draganov1, Christopher E. Forsmark1, Mihir S. Wagh*1 1 Division of Gastroenterology, University of Florida, Gainesville, FL; 2 Department of Medicine, University of Florida, Gainesville, FL Background: Measures for evaluating interventional endoscopy unit efficiency are increasingly important, especially with the growing involvement of anesthesia services and need for endotracheal intubation for endoscopy. Aims: To identify and compare endoscopy unit efficiency metrics between intubated and non-intubated patients undergoing interventional endoscopic procedures at an academic medical center. Methods: The prospectively collected endoscopy unit metrics database at the University of Florida was reviewed for procedures performed in two interventional endoscopy rooms from 1/1/13 to 6/30/13. All procedures were performed under anesthesiologist-administered propofol or general anesthesia. Parameters included hospital-mandated metrics in the database: Total Delay Time was defined as the time between actual patient entry into the endoscopy room and the scheduled procedure start time. Anesthesia Ready Time (ART) was defined as the time between patient entry into the endoscopy room and the time reported by the anesthesia team that the patient was appropriately sedated and ready for endoscopy. Endoscopist Ready Time (ERT) was defined as the time from ART to the insertion of the endoscope. Procedure Time (PT) was defined as the time between endoscope insertion and removal. Room Exit Time (RET) was defined as the time from endoscope removal to patient exit from the procedure room. Total Time was defined as ART + ERT + PT + RET. Room Turnover Time (TOT) was defined as the time from patient exit from the procedure room until the time of next patient entry in the room. Results: 1479
AB120 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
217 Endoscope Storage Time: Assessment of Microbial Colonization 21 Days After Reprocessing Andrew Brock*1, Lisa L. Steed2, Janice Freeman1, Bernadette Garry3, Phyllis Malpas1, Peter B. Cotton1 1 Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC; 2Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC; 3Quality Management and Patient Safety/Infection Control, Medical University of South Carolina, Charleston, SC Background: Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to variable reprocessing intervals amongst institutions, with some as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for up to 21 days without risk of clinically significant contamination. Aims: To demonstrate whether flexible endoscopes may be stored for up to 21 days after reprocessing without colonization by pathogenic microbes. Methods: Samples were collected from the air-water channel, biopsy channel and elevator wire channel (for duodenoscopes) of 4 duodenoscopes, 4 colonoscopes
www.giejournal.org
Abstracts
and 2 upper endoscopes on days 0, 7, 14 and 21 following standard protocol for mechanical cleaning and high level disinfection using an automated endoscope reprocessor. Endoscopes were stored hanging per institutional practice. A 1mL aliquot of each sample was inoculated onto trypticase soy agar with 5% sheep blood (blood agar), thiogycollate broth, a CDC anaerobic blood agar plate, and Sabouraud dextrose agar (for yeast and molds). All media were incubated at 2535C for 7 days. Organisms were identified using standard microbiological techniques; results were reported in colony forming units. Results: There were 33 positive cultures from 28 out of the 96 sites tested (29.2% overall contamination rate). 30/33 isolates were typical skin or environmental contaminants, thus clinically insignificant (Table 1). Three potential pathogens were cultured, including
enhanced staff training and monitoring. Within a month, there was a dramatic increase in the gastroscope passage rate, exceeding 90%. This trend persisted for the 6 month follow up period from January to June 2013, and ultimately resulted in a 95% passage rate (Fig. 2). Conclusion: Meticulous cleaning of endoscopes must precede high-level disinfection of these instruments to prevent pathogen transmission between patients. Using ATP-detection technology, we instituted changes to the gastroscope pre-cleaning algorithm that resulted in a rapid and durable improvement in gastroscope cleanliness. While such improvement may partially be the result of the Hawthorne Effect, the robustness of this improvement suggests that it is primarily related to a significant reduction in gastroscope bioburden during the pre-cleaning process.
Non-pathogens Microbe
Total positive cultures
Colonoscope
Duodenoscope
Upper endoscope
Suction channel
Biopsy channel
Elevator
18 6 3 1 1 1
2 2 1 1
4 2 1
3
4 2 1
11 3 2 1 1 1
3 1
Coag neg staph Micrococcus Bacillus Aureobasidium pullalans Corynebacterium Propionibacerium acnes
1 1
1
enterococcus, Candida parapsilosis and alpha hemolytic strep; all were likely clinically insignificant as each was only recovered at one time point on one site and all were far below the standard 100 cfu/mL threshold (Table 2). There were no definite pathogenic isolates. Conclusion: Endoscopes can be stored for up to 21 days with low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.
Potential pathogens Microbe Enterococcus Candida parapsilosis Alpha hemolytic strep
Total positive cultures
Endoscope
Channel
1 1 1
Colonoscope Duodenoscope Upper endoscope
Biopsy Biopsy Biopsy
218 Dramatic Improvement in Endoscope Cleanliness Using a Commercial Bioburden Detection System and Implementation of a Modified Cleaning Algorithm Jonathan N. Mazurek*, David Hudesman, Andrew S. Korman, Frances Glennon, Brett B. Bernstein Beth Israel Medical Center, New York, NY Background and Objective: Meticulous endoscope reprocessing is critical in the prevention of pathogen transmission between patients. While transmission was previously thought to be rare, evidence now suggests that it may be as high as 42%, and is directly related to lapses in adherence to cleaning protocols. Adenosine triphosphate (ATP) is present in all living cells, and therefore serves as an ideal marker for the presence of organic residue. The 3M Clean-TraceÔ Hygiene Management System (3M Clean-TraceÔ, 3M, St. Paul, Minnesota) measures levels of ATP present on the surface and interior lumen of an endoscope. After swabbing these areas, the test-swab is mixed with an enzyme solution that reacts with ATP to produce light. The 3M Clean-TraceÔ Luminometer measures the light generated by this reaction, and generates a result expressed in Relative Light Units (RLUs). The greater the level of ATP, the higher the RLU level, thus reflecting a higher level of residual bioburden on the endoscope. Utilizing ATP hygiene monitoring technology we developed an algorithm and monitoring program with the aim of achieving a 90% pass rate in the pre-cleaning of gastroscopes prior to high level disinfection. Methods: From September to December 2012, we implemented the monitoring of gastroscope cleanliness utilizing the 3M Clean-TraceÔ system by randomly testing two gastroscopes per day, that were pre-cleaned per the manufacturer’s instructions. Scope surface and luminal testing was performed. Data was uploaded to the 3M Clean-TraceÔ online software, and monthly reports were generated. Using this data, we implemented changes to the gastroscope precleaning algorithm (Fig. 1), retrained all staff in this process and monitored compliance. We then monitored gastroscope cleanliness for a six month follow-up period from January to June 2013. Results: Initial data obtained by swabbing the distal end of the gastroscopes identified a 63% passage rate and a 37% failure rate. This led to the implementation of a meticulous cleaning algorithm as well as
www.giejournal.org
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB121