Re-examine processes for cleaning bronchoscopes
CDC says infectious complications are occurring
The Centers for Disease Control and Preven-tion (CDC) in Atlanta is urging providers to re-examine their processes for cleaning bronchoscopes after the New York State Health Depart-ment found the transmission of respiratory infections at three unnamed facilities between 1996 and 1998 was due to inadequate cleaning of bronchoscopes.
The CDC estimates that 497,000 bronchoscopies were performed in 1996. "Although reported infectious complications caused by bronchoscopy are rare,1 the incidence is probably underestimated, with many episodes unrecognized or unreported," the CDC states.2
William A. Rutala, PhD, MPH, director of hospital epidemiology at the University of North Carolina (UNC) Hospitals and professor at UNC School of Medicine in Chapel Hill, says, "Use of contaminated scopes may also result in pseudoepidemics in which cultures obtained at the time of bronchoscopy represent colonization of the scope as opposed to colonization or infection of the patient. More than 35 outbreaks or pseudoepidemics have been reported through 1997." (For details on how bronchoscopes were implicated in two deadly TB outbreaks, see Same-Day Surgery, March 1998, p. 36.)
To reduce the opportunity for contaminated scopes, consider these suggestions from the CDC2 and other experts:
-Bronchoscope users should obtain and review model-specific reprocessing protocols from both bronchoscope and automated reprocessing system manufacturers. User education should include on-site training and observation during the setup of each bronchoscope model to clarify device- and model-specific differences in procedure.
"The CDC guidance in [reference 2] should be followed religiously to include model-specific reprocessing protocols." Rutala comments.
Jan Schultz, MSN, RN, president of Jan Schultz and Associates, agrees. "If you are buying a new device, make sure part of the purchasing specifications includes training on reprocessing," says Schultz, whose consulting service focuses on the reprocessing continuum.
Representatives from the manufacturer can be of great assistance, agrees Nancy Gondzur, RN, clinic manager of the Ambulatory Procedure Center at the University of Wisconsin Hospital and Clinic in Madison. "They come in and review equipment and go through the cleaning steps," Gondzur says.
The first step is manual cleaning of the scopes, she says. "It is different for different scopes and for different manufacturers."
The process is repeated for reprocessing equipment, she says. "We have a representative from the company actually walk us through hooking up the scope in the reprocessor. They offer little tips on how to do it a little smoother or easier, or they make sure you go through steps in a specific sequence."
- Connector systems should be clearly labeled (e.g., color coded) to ensure proper selection and use.
You can ask the manufacturer to label the connector systems before signing the contract. Or use colored tape to do it yourself, Schultz advises.
Gondzur says this step would make it easier for the person handling the reprocessing, "especially if you have a larger staff in which people float in and out."
At Gondzur’s facility, a decentralized central processing area has freed endoscopy nurses and staff from reprocessing responsibilities. "Nurses hated having to do all of that cleaning," she says. "The central processing staff is trained, and it’s very controlled. They’re competent and consistent."
- Quality-control procedures should be developed in each health care facility to include visual inspection of the bronchoscope, regular testing for bronchoscope integrity, maintenance, and surveillance for unusual clusters of organisms.
Leak test scopes after each use, Gondzur advises. "Look for leaks throughout the instrument, not just in the bending rubber [the flexible distal tip of the scope], but channel leaks in the main channel of the scope." Over time, biopsy forceps and metal reusable brushes can wear down the channel, which leads to leaks, she says. "You want to catch the leaks right away; otherwise, you can have water damage and a more expensive repair."
Manufacturers recommend that providers store scopes in a hanging position, she says. "Don’t leave them curled up in a cabinet or drawer. You’re not throwing things on top of them. You want to avoid trauma to the scope."
While most facilities perform visual inspections and regular leak-checking, few are performing surveillance for organisms, Schultz says. "For many same-day surgery programs, that’s difficult to do," she acknowledges. "However, it might be possible if copies of the lab results were sent not just to the patient’s chart, but to the infection control person for that facility."
- Ensure employees are performing disinfection/sterilization correctly.
Ensure your written policies and procedures are up to date, Schultz advises. "You use those as basis for teaching and demonstration and return demonstration by the employee," she says.
Bronchoscopes are complex, and new employees should be carefully supervised for the first couple of weeks that they are performing cleaning and sterilization, Schultz says. "Someone needs to be sure they’re following all the steps and that they know why the steps are important."
Conduct at least a yearly review of competency for all staff who are involved in reprocessing, she advises.
References
1. Martin MA, Reichelderfer M. APIC guidelines for infection prevention and control in flexible endoscopy. Am J Infect Control 1994; 22:19-38.
2. Centers for Disease Control and Prevention. MMW 1999; 48:557-560.
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