Bronchoscopes suspected after infection outbreak
In California, nonsterile endoscopes found
Allegheny General Hospital in Pittsburgh has determined that the cause of an outbreak of pulmonary infections in 12 patients may be contaminated bronchoscopes that weren’t properly sanitized. Of the 12 patients, one patient died.
Based on its assessment, hospital officials contend the source of the increase in pseudomonas transmission discovered in 2002 is connected to the bronchoscopes and the possibility of defective equipment or failure of the bronchoscope sterilization technique.
The equipment used was a Steris System 1 Sterile Processing System, manufactured by Mentor, OH-based Steris. One accessory, a Steris Quick Connect Kit, was voluntarily recalled by the company in 2002 when it was determined that an incorrect adapter component might affect the sterilization process of scopes, according to the Food and Drug Administration (FDA). However, Allegheny General had not purchased the accessory and thus was not notified of the recall, according to a Steris spokesperson. The recall had no impact on any other accessories, the company emphasized.
In response to the Allegheny General outbreak, Steris told its customers in a letter that it conducted an investigation in October 2002 and determined that proper cleaning and disinfection procedures may not have been followed within the hospital. The FDA investigation is ongoing, according to an agency spokesperson.
In response to the outbreaks, the hospital took the following steps:
- All bronchoscopes were taken out of services, and new ones were purchased.
- An alternative sterilization process was implemented.
- The hospital contacted all former patients, or families of such patients, who underwent a bronchoscopy at the hospital between June 1, 2002, and Oct. 1, 2002.
- A hotline, (877) 226-6439, was established to help educate such patients about their risk of exposure to the bacteria and provide them with appointments for free diagnostic follow-up care at the hospital, if necessary.
- A question-and-answer sheet for patients and families was posted on the web site.
In other news, nonsterile endoscopes were found at two California hospitals and prompted national warnings from the manufacturer, Olympus America, to ensure proper sterilization is being conducted. No patient harm resulted at either hospital, according to the Sacramento-based California Healthcare Association.
Olympus America posted a safety notice on its web site (www.olympusamerica.com), which says that some customers inadvertently may be neglecting to reprocess the auxiliary water channels on certain 160 series Olympus endoscopes. An auxiliary water channel, also known as a water-jet, is found on the following Exera models: CF-Q160L, CF-Q160I, CF-Q160S, CF-Q160AL, CF-Q160AI, and GIF-2T160.
"This notice is to remind you that the auxiliary water channel must be reprocessed each time the endoscope is used," the company says. This step is necessary, even if the auxiliary water feature is not used during the procedure, Olympus America emphasizes.
Certain older model Olympus endoscopes also contain auxiliary water connections and must be regularly reprocessed, the company says. The auxiliary water inlet on these endoscopes is found on the control section of the endoscope, either immediately above the suction valve or just below the grip. (To see diagrams, go to www.olympusamerica.com/msg_section/msg_home.asp. Click on "Important Safety Notice.")
To obtain additional copies of reprocessing manuals for Olympus endoscopic equipment, call (800) 848-9024. For information on endoscopy educational programs sponsored by Olympus, go to www.olympusuniversity.com or call (800) 645-8100, ext. 6200.
Allegheny General Hospital in Pittsburgh has determined that the cause of an outbreak of pulmonary infections in 12 patients may be contaminated bronchoscopes that werent properly sanitized. Of the 12 patients, one patient died.
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