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Evaluation of Reprocessing Effectiveness for Flexible Ureteroscopes
Oral Abstracts / American Journal of Infection Control 45 (2017) S2-S15
factors in mitigating the risk of transmitting infection via these devices. Our goal was to develop and implement a standardized audit tool to identify opportunities for process improvement in flexible endoscope reprocessing and infection prevention practices. METHODS: An electronic observation and interview-based audit tool was developed to assess adherence to reprocessing guidelines, manufacturer’s instructions for use (IFU), infection prevention best practices, and regulatory standards. Multiple assessments were conducted in endoscopy labs at six acute care hospitals within a healthcare system between May 2015 and October 2016. Each completed tool auto-calculated an overall compliance score by dividing the number of compliant observations by the total number scored. Auditors provided feedback to staff and communicated findings, scores, and improvement recommendations to department managers. Facilities monitored progress by tracking audit scores, findings, and responses to intervention activities over time. Overall compliance scores, common issues, and novel interventions were monitored by corporate infection prevention and shared with all facilities at system level council meetings. RESULTS: Process improvement opportunities were identified at all six facilities. Initial audit scores ranged from 14%-96% overall compliance, mean score was 64%. Missing or improperly worn personal protective equipment (PPE) was noted at every facility one or more times. Failure to correctly perform crucial endoscope leak testing was identified at least once at 67% of facilities. After interventions, facilities (with more than one audit) had improved scores on subsequent audits. Mean compliance on final audits was 91%. CONCLUSIONS: Routine observation of flexible endoscope cleaning, high level disinfection, and infection prevention practices utilizing a standardized audit tool is valuable in consistently and systematically identifying opportunities for improvement.
Session: CDCH-217 Presentation Number: 1202 Cleaning Challenges Associated with Surgical Instrument Design: A Proactive Approach Laura E. Staubitz, MEd, BSN, RN, CIC, Infection Prevention Practitioner, Providence St. Peter Hospital; Marion Ray, RN, CIC, CHI FH Division Director Infection Prevention/Employee Health, CHI Franciscan Health; Jeanette J. Harris, MS, MSM, BS, MT(ASCP), CIC, FAPIC, Infection Prevention—Surgical Services, MultiCare Health System BACKGROUND: Contaminated surgical instruments have resulted in infections and deaths. An instrument’s design may prevent thorough cleaning before disinfection/sterilization. Rongeurs are surgical instruments with precise edges and curved tips used to obtain tissue/bone samples. Some rongeurs by design stay connected for cleaning. This study demonstrates the inability to get these rongeurs clean and the necessity of proactive instrument review and communication. METHODS: In 2014 a surgical technologist broke open a cleaned rongeur against manufacturer’s instructions. Discovery of bio burden inside the rongeur chamber facilitated an investigation. After cleaning and sterilization additional rongeurs were opened. Photographs and cultures were taken. An emergent multidisciplinary meeting followed to craft the response plan to this infection risk. A Manufacturer and User Facility Device Experience (MAUDE) report was filed. A 2009 MAUDE report documenting this concern
S5
was found. Information on the inability to effectively clean the rongeurs was disseminated to nearby hospitals and at the local Association for Professionals in Infection Control and Epidemiology chapter. RESULTS: Bio burden was visualized in the rongeurs. Two cultures after sterilization revealed Coagulase negative Staphylococcus. The hospital replaced the rongeurs with a model that disassembled for cleaning. A second hospital also began an intense instrument review process. Eight of ten rongeurs had bio burden after sterilization. To evaluate the hospital’s instrument maintenance process, six rongeurs were examined by the vendor. After sterilization, the vendor also found bio burden. The instrument maintenance process was enhanced and the closed rongeurs and other instruments of this type were replaced. CONCLUSIONS: Front line staff are critical in determining surgical instrument infection risk. There are other surgical instruments that by design may be impossible to effectively clean. A systematic, proactive approach to surgical instrument infection risk and a method of broadly communicating this risk may avoid surgical site infections and outbreaks.
Session: CDCH-218 Presentation Number: 1202 Evaluation of Reprocessing Effectiveness for Flexible Ureteroscopes Cori L. Ofstead, MSPH, President and CEO, Ofstead & Associates; Otis L. Heymann, BA, Research Associate, Ofstead & Associates, Inc.; Mariah R. Quick, MPH, Research Projects Manager, Ofstead & Associates, Inc.; John E. Eiland, RN, MS, Senior Research Associate, Ofstead & Associates, Inc.; Harry P. Wetzler, MD, MSPH, Medical Director, Ofstead & Associates, Inc. BACKGROUND: Endoscope reprocessing guidelines recommend using cleaning verification tests to detect residual contamination on endoscopes before high-level disinfection or sterilization. Routine microbial surveillance of reprocessed endoscopes has been implemented by some institutions. This study aimed to evaluate levels of organic material and bioburden remaining on reprocessed ureteroscopes used for kidney stone removal and other therapeutic procedures. METHODS: Researchers following strict aseptic technique sampled sterilized ureteroscopes at two institutions. Channel ports were swabbed with sterile swabs moistened with sterile water. A flushbrush-flush technique was used to obtain channel effluent. The swabs and 2 mL of effluent were placed in vials containing liquid Amies solution. Samples were sent in coolers to an external microbiology laboratory. Samples were filtered, plated, and incubated at 26°30°C for one day followed by incubation at 34°-36°C for up to six days. Remaining effluent was used for adenosine triphosphate (ATP), protein, and hemoglobin tests. Visual examinations were conducted using a borescope and lighted magnification. RESULTS: Microbial growth was found on two of 16 (12.5%) sterilized ureteroscopes. No growth was seen during the first 48 hours. Growth was detected on day 3 (Micrococcus luteus) and day 4 (Corynebacterium glaucum). One ureteroscope (6%) exceeded the 2.2 μg/ mL hemoglobin benchmark, one (6%) exceeded the 200 RLU ATP benchmark, and 100% exceeded the 6.4 μg/mL protein benchmark (range 9-32 μg/mL). Hemoglobin below benchmark was detected on 9 (56%) ureteroscopes. Visual inspections identified debris protruding into channels, oily deposits, white lint, and white foamy residue.
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
S6
Oral Abstracts / American Journal of Infection Control 45 (2017) S2-S15
CONCLUSIONS: All ureteroscopes had contamination exceeding benchmarks for clean endoscopes despite undergoing manual cleaning and sterilization. Incubation time >48 hours was necessary to detect growth. Suboptimal reprocessing and surface damage may have contributed to the contamination found. This study demonstrates the importance of actively monitoring reprocessing outcomes to ensure reprocessed flexible ureteroscopes are sterile and safe for patient-use.
Session: CDCH-219 Presentation Number: 1202 Impact of Sampling and Microbial Culture Methods on Results of Tests for Residual Contamination on Colonoscopes and Gastroscopes Cori L. Ofstead, MSPH, President and CEO, Ofstead & Associates; Otis L. Heymann, BA, Research Associate, Ofstead & Associates, Inc.; Mariah R. Quick, MPH, Research Projects Manager, Ofstead & Associates, Inc.; John E. Eiland, RN, MS, Senior Research Associate, Ofstead & Associates, Inc.; Harry P. Wetzler, MD, MSPH, Medical Director, Ofstead & Associates, Inc. BACKGROUND: Endoscope reprocessing guidelines recommend using lighted magnification, biochemical tests, and microbial cultures to identify problems with reprocessing effectiveness. Methods used for sampling and conducting tests may affect results. This study evaluated the impact of sampling and culturing techniques on microbial growth. Visual inspections and biochemical tests were also conducted. METHODS: After reprocessing, 20 gastrointestinal endoscopes (gastroscopes and colonoscopes) were sampled using aseptic technique. Sterile swabs moistened with sterile water were rotated in biopsy ports and placed in vials containing liquid Amies solution. The flush-brush-flush technique was used with sterile water and brushes to obtain channel effluent. These samples were transported in coolers to an external laboratory. Samples were split, filtered, plated, and incubated using tryptic soy agar (TSA; 3035°C) and blood agar (28-32°C). Plates were checked daily for 5-7 days, with speciation after day 5. Borescope examinations were performed, and port and effluent samples were tested for adenosine triphosphate (ATP) and protein. RESULTS: Samples from 12 reprocessed endoscopes (60%) had growth. Colonies formed only on TSA for six endoscopes, only on blood agar for four endoscopes, and on both media for two endoscopes. Samples from four endoscopes had no growth until >2 days. Potential pathogens (Corynebacterium spp and Methylobacterium extorquens) appeared on days 5 and 6. Maximum growth occurred after 48 hours on samples from seven endoscopes. Growth occurred in both swab and effluent samples for five endoscopes, in only effluent samples for four endoscopes, and in only swab samples for three endoscopes. Protein and ATP levels exceeded benchmarks after manual cleaning for ≥20% of endoscopes. Borescope examinations identified numerous irregularities. CONCLUSIONS: Sampling multiple components, using two culture media, and extending incubation times detected more growth and prevented false negative results. These microbial culture methods along with biochemical tests and borescope examinations identified damaged and contaminated endoscopes.
Device-Associated Infection Prevention Session: DAIP-220 Presentation Number: 1203 Use of a Foley Insertion Gap Analysis to Reduce Incidence Rates of Catheter-Associated Urinary Tract Infections Dana Piatek, MSN, RN, CIC, Infection Prevention Coordinator, UPMC Horizon Background: During Fiscal Year 2015 a significant increase was observed in our Catheter Associated Urinary Tract Infection (CAUTI) incidence rate. Concerns were raised regarding staff insertion practices which prompted a Foley insertion gap analysis to determine the most common areas of error procedurally and in aseptic technique. By utilizing the results of the gap analysis to educate staff on proper insertion techniques we will reduce our incidence rate. Methods: Nurses from across our inpatient areas and surgical services area were observed during the gap analysis on August 24, 2015 for compliance with three areas: pre-insertion peri-care completion, aseptic insertion practices, and sequence of directions for use (DFU) procedural steps. The results of the analysis were shared with all nurses as part of their annual skills lab in addition to practical education regarding proper Foley insertion techniques. We measured CAUTI incidence rates during the baseline period of July 1, 2014 through June 30, 2015, prior to completion of the education sessions in November and December 2015, and post education sessions for a period of 10 months. Results: The gap analysis showed that pre-insertion peri-care was provided only 64% of the time. The aseptic insertion rate was non-aseptic 88% of the time. 100% variation in the sequence of DFU procedural steps for Foley Insertion was observed with 35% of the time participants either performed a step incorrectly or omitted one. CAUTI incidence decreased from 1.23 per 1,000 Device Days during the baseline period to 0.31 prior to completion of the education sessions and 0 post education for a 10 month period of observation. Conclusions: We found that use of a Foley insertion gap analysis was associated with a significant reduction in the incidence rates of CAUTIs within our hospital. The project also allowed for engagement of front line staff in establishing a sustainable improvement process.
Session: DAIP-221 Presentation Number: 1203 Catheter Associated Urinary Tract Infection (CAUTI) Targeted Assessment for Prevention (TAP) Effective Practices DeAnn E. Richards, RN, CIC, Infection Prevention Project Specalist, Lake Supeior Quality Innovation Network Background: TAP strategy is a data-driven approach provided by the Center for Disease Control and Prevention (CDC). This tool determines if current best practices is utilized and was completed
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
factors in mitigating the risk of transmitting infection via these devices. Our goal was to develop and implement a standardized audit tool to identify opportunities for process improvement in flexible endoscope reprocessing and infection prevention practices. METHODS: An electronic observation and interview-based audit tool was developed to assess adherence to reprocessing guidelines, manufacturer’s instructions for use (IFU), infection prevention best practices, and regulatory standards. Multiple assessments were conducted in endoscopy labs at six acute care hospitals within a healthcare system between May 2015 and October 2016. Each completed tool auto-calculated an overall compliance score by dividing the number of compliant observations by the total number scored. Auditors provided feedback to staff and communicated findings, scores, and improvement recommendations to department managers. Facilities monitored progress by tracking audit scores, findings, and responses to intervention activities over time. Overall compliance scores, common issues, and novel interventions were monitored by corporate infection prevention and shared with all facilities at system level council meetings. RESULTS: Process improvement opportunities were identified at all six facilities. Initial audit scores ranged from 14%-96% overall compliance, mean score was 64%. Missing or improperly worn personal protective equipment (PPE) was noted at every facility one or more times. Failure to correctly perform crucial endoscope leak testing was identified at least once at 67% of facilities. After interventions, facilities (with more than one audit) had improved scores on subsequent audits. Mean compliance on final audits was 91%. CONCLUSIONS: Routine observation of flexible endoscope cleaning, high level disinfection, and infection prevention practices utilizing a standardized audit tool is valuable in consistently and systematically identifying opportunities for improvement.
Session: CDCH-217 Presentation Number: 1202 Cleaning Challenges Associated with Surgical Instrument Design: A Proactive Approach Laura E. Staubitz, MEd, BSN, RN, CIC, Infection Prevention Practitioner, Providence St. Peter Hospital; Marion Ray, RN, CIC, CHI FH Division Director Infection Prevention/Employee Health, CHI Franciscan Health; Jeanette J. Harris, MS, MSM, BS, MT(ASCP), CIC, FAPIC, Infection Prevention—Surgical Services, MultiCare Health System BACKGROUND: Contaminated surgical instruments have resulted in infections and deaths. An instrument’s design may prevent thorough cleaning before disinfection/sterilization. Rongeurs are surgical instruments with precise edges and curved tips used to obtain tissue/bone samples. Some rongeurs by design stay connected for cleaning. This study demonstrates the inability to get these rongeurs clean and the necessity of proactive instrument review and communication. METHODS: In 2014 a surgical technologist broke open a cleaned rongeur against manufacturer’s instructions. Discovery of bio burden inside the rongeur chamber facilitated an investigation. After cleaning and sterilization additional rongeurs were opened. Photographs and cultures were taken. An emergent multidisciplinary meeting followed to craft the response plan to this infection risk. A Manufacturer and User Facility Device Experience (MAUDE) report was filed. A 2009 MAUDE report documenting this concern
S5
was found. Information on the inability to effectively clean the rongeurs was disseminated to nearby hospitals and at the local Association for Professionals in Infection Control and Epidemiology chapter. RESULTS: Bio burden was visualized in the rongeurs. Two cultures after sterilization revealed Coagulase negative Staphylococcus. The hospital replaced the rongeurs with a model that disassembled for cleaning. A second hospital also began an intense instrument review process. Eight of ten rongeurs had bio burden after sterilization. To evaluate the hospital’s instrument maintenance process, six rongeurs were examined by the vendor. After sterilization, the vendor also found bio burden. The instrument maintenance process was enhanced and the closed rongeurs and other instruments of this type were replaced. CONCLUSIONS: Front line staff are critical in determining surgical instrument infection risk. There are other surgical instruments that by design may be impossible to effectively clean. A systematic, proactive approach to surgical instrument infection risk and a method of broadly communicating this risk may avoid surgical site infections and outbreaks.
Session: CDCH-218 Presentation Number: 1202 Evaluation of Reprocessing Effectiveness for Flexible Ureteroscopes Cori L. Ofstead, MSPH, President and CEO, Ofstead & Associates; Otis L. Heymann, BA, Research Associate, Ofstead & Associates, Inc.; Mariah R. Quick, MPH, Research Projects Manager, Ofstead & Associates, Inc.; John E. Eiland, RN, MS, Senior Research Associate, Ofstead & Associates, Inc.; Harry P. Wetzler, MD, MSPH, Medical Director, Ofstead & Associates, Inc. BACKGROUND: Endoscope reprocessing guidelines recommend using cleaning verification tests to detect residual contamination on endoscopes before high-level disinfection or sterilization. Routine microbial surveillance of reprocessed endoscopes has been implemented by some institutions. This study aimed to evaluate levels of organic material and bioburden remaining on reprocessed ureteroscopes used for kidney stone removal and other therapeutic procedures. METHODS: Researchers following strict aseptic technique sampled sterilized ureteroscopes at two institutions. Channel ports were swabbed with sterile swabs moistened with sterile water. A flushbrush-flush technique was used to obtain channel effluent. The swabs and 2 mL of effluent were placed in vials containing liquid Amies solution. Samples were sent in coolers to an external microbiology laboratory. Samples were filtered, plated, and incubated at 26°30°C for one day followed by incubation at 34°-36°C for up to six days. Remaining effluent was used for adenosine triphosphate (ATP), protein, and hemoglobin tests. Visual examinations were conducted using a borescope and lighted magnification. RESULTS: Microbial growth was found on two of 16 (12.5%) sterilized ureteroscopes. No growth was seen during the first 48 hours. Growth was detected on day 3 (Micrococcus luteus) and day 4 (Corynebacterium glaucum). One ureteroscope (6%) exceeded the 2.2 μg/ mL hemoglobin benchmark, one (6%) exceeded the 200 RLU ATP benchmark, and 100% exceeded the 6.4 μg/mL protein benchmark (range 9-32 μg/mL). Hemoglobin below benchmark was detected on 9 (56%) ureteroscopes. Visual inspections identified debris protruding into channels, oily deposits, white lint, and white foamy residue.
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
S6
Oral Abstracts / American Journal of Infection Control 45 (2017) S2-S15
CONCLUSIONS: All ureteroscopes had contamination exceeding benchmarks for clean endoscopes despite undergoing manual cleaning and sterilization. Incubation time >48 hours was necessary to detect growth. Suboptimal reprocessing and surface damage may have contributed to the contamination found. This study demonstrates the importance of actively monitoring reprocessing outcomes to ensure reprocessed flexible ureteroscopes are sterile and safe for patient-use.
Session: CDCH-219 Presentation Number: 1202 Impact of Sampling and Microbial Culture Methods on Results of Tests for Residual Contamination on Colonoscopes and Gastroscopes Cori L. Ofstead, MSPH, President and CEO, Ofstead & Associates; Otis L. Heymann, BA, Research Associate, Ofstead & Associates, Inc.; Mariah R. Quick, MPH, Research Projects Manager, Ofstead & Associates, Inc.; John E. Eiland, RN, MS, Senior Research Associate, Ofstead & Associates, Inc.; Harry P. Wetzler, MD, MSPH, Medical Director, Ofstead & Associates, Inc. BACKGROUND: Endoscope reprocessing guidelines recommend using lighted magnification, biochemical tests, and microbial cultures to identify problems with reprocessing effectiveness. Methods used for sampling and conducting tests may affect results. This study evaluated the impact of sampling and culturing techniques on microbial growth. Visual inspections and biochemical tests were also conducted. METHODS: After reprocessing, 20 gastrointestinal endoscopes (gastroscopes and colonoscopes) were sampled using aseptic technique. Sterile swabs moistened with sterile water were rotated in biopsy ports and placed in vials containing liquid Amies solution. The flush-brush-flush technique was used with sterile water and brushes to obtain channel effluent. These samples were transported in coolers to an external laboratory. Samples were split, filtered, plated, and incubated using tryptic soy agar (TSA; 3035°C) and blood agar (28-32°C). Plates were checked daily for 5-7 days, with speciation after day 5. Borescope examinations were performed, and port and effluent samples were tested for adenosine triphosphate (ATP) and protein. RESULTS: Samples from 12 reprocessed endoscopes (60%) had growth. Colonies formed only on TSA for six endoscopes, only on blood agar for four endoscopes, and on both media for two endoscopes. Samples from four endoscopes had no growth until >2 days. Potential pathogens (Corynebacterium spp and Methylobacterium extorquens) appeared on days 5 and 6. Maximum growth occurred after 48 hours on samples from seven endoscopes. Growth occurred in both swab and effluent samples for five endoscopes, in only effluent samples for four endoscopes, and in only swab samples for three endoscopes. Protein and ATP levels exceeded benchmarks after manual cleaning for ≥20% of endoscopes. Borescope examinations identified numerous irregularities. CONCLUSIONS: Sampling multiple components, using two culture media, and extending incubation times detected more growth and prevented false negative results. These microbial culture methods along with biochemical tests and borescope examinations identified damaged and contaminated endoscopes.
Device-Associated Infection Prevention Session: DAIP-220 Presentation Number: 1203 Use of a Foley Insertion Gap Analysis to Reduce Incidence Rates of Catheter-Associated Urinary Tract Infections Dana Piatek, MSN, RN, CIC, Infection Prevention Coordinator, UPMC Horizon Background: During Fiscal Year 2015 a significant increase was observed in our Catheter Associated Urinary Tract Infection (CAUTI) incidence rate. Concerns were raised regarding staff insertion practices which prompted a Foley insertion gap analysis to determine the most common areas of error procedurally and in aseptic technique. By utilizing the results of the gap analysis to educate staff on proper insertion techniques we will reduce our incidence rate. Methods: Nurses from across our inpatient areas and surgical services area were observed during the gap analysis on August 24, 2015 for compliance with three areas: pre-insertion peri-care completion, aseptic insertion practices, and sequence of directions for use (DFU) procedural steps. The results of the analysis were shared with all nurses as part of their annual skills lab in addition to practical education regarding proper Foley insertion techniques. We measured CAUTI incidence rates during the baseline period of July 1, 2014 through June 30, 2015, prior to completion of the education sessions in November and December 2015, and post education sessions for a period of 10 months. Results: The gap analysis showed that pre-insertion peri-care was provided only 64% of the time. The aseptic insertion rate was non-aseptic 88% of the time. 100% variation in the sequence of DFU procedural steps for Foley Insertion was observed with 35% of the time participants either performed a step incorrectly or omitted one. CAUTI incidence decreased from 1.23 per 1,000 Device Days during the baseline period to 0.31 prior to completion of the education sessions and 0 post education for a 10 month period of observation. Conclusions: We found that use of a Foley insertion gap analysis was associated with a significant reduction in the incidence rates of CAUTIs within our hospital. The project also allowed for engagement of front line staff in establishing a sustainable improvement process.
Session: DAIP-221 Presentation Number: 1203 Catheter Associated Urinary Tract Infection (CAUTI) Targeted Assessment for Prevention (TAP) Effective Practices DeAnn E. Richards, RN, CIC, Infection Prevention Project Specalist, Lake Supeior Quality Innovation Network Background: TAP strategy is a data-driven approach provided by the Center for Disease Control and Prevention (CDC). This tool determines if current best practices is utilized and was completed
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017