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3. Multi-resistant organism and Clostridium difficile infection (MDRO/CDI) module. Centers for Disease Control and Prevention website.
https://www.cdc.gov/nhsn/pdfs/pscmanual/ 12pscmdro_cdadcurrent.pdf. Accessed February 19, 2018.
4. Moehring RW, Lofgren ET, Anderson DJ. Impact of change to molecular testing for Clostridium difficile infection on healthcare facility associated incidence rates. Infect Control Hosp Epidemiol 2013;34:1055–1061.
5. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and chil- dren: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66:e1–e48.
6. Bartsch SM, Umscheid CA, Nachamkin I, Hamilton K, Lee BY. Comparing the economic and health benefits of different approaches to diagnosing Clostridium difficile infection. Clin Microbiol Infect 2015;21:1–9.
7. Updated guidance on the diagnosis and reporting of Clostridium difficile. United Kingdom National Health Service website. https://
www.gov.uk/government/uploads/system/uploads/attachment_data/ file/215135/dh_133016. pdf. AccessedMarch 13, 2018.
What Really Works for Scope Reprocessing?
To the Editor—Duodenoscopes used for endoscopic retrograde cholangio-pancreatography (ERCP) have complex designs that make reprocessing challenging. Infections have been linked to manual cleaning of the scope especially its forceps elevator. Other factors that contribute to infections include use of unsterile water and inappropriate storage of scopes.1,2 Despite duodenoscope reprocessing procedures exceeding manu- facturer’s recommendations, high-concern organisms such as
Klebsiella spp and Pseudomonas spp have been implicated in clinical infections.3,4,5 Media reports of high-concern organisms, such as carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum β-lactamase (ESBL) outbreaks linked to duodenoscopes, have heightened awareness regarding reproces- sing procedures.3,4 Infections from duodenoscopes have been linked to positive cultures isolated from urine, blood, abscesses, and stool.1,2 Mortality associated with contaminated duodeno- scopes is ~16% with all organisms and 56% with CRE.4 These mortality rates emphasize the need for optimal reprocessing practices. The World Health Organization emphasizes team- based collaborations, such as multidisciplinary teams (MDTs), to improve communication among healthcare workers. 6 Many studies have shown the benefits of MDTs in reducing nosoco- mial infections like bloodstream infections. 7–9 Multidisciplinary teams are effective at reducing infection rates through rapid identification of breakdowns in the process.7 We studied the impact of creating aMDT with clear roles and real-time huddles to optimize our scope-reprocessing practices. This retrospective study was conducted at a tertiary-care academic medical center with 401 beds. We aimed to evaluate the impact of an MDT with clear roles on the reprocessing of duodenoscopes. Reprocessing Olympus TJF-Q180V duodenoscopes along with surveillance cultures of the duo- denoscope tip (including forceps elevator) were evaluated during the baseline period (January 2016 through June 2016) and during our intervention period (September 2016 through July 2017). An MDT was created in July 2016 composed of representatives fromthe endoscopy center, the sterile processing department (SPD), the infection prevention department (IP), as well as hospital leadership. We utilized a responsibility assignment matrix (RAM) to outline responsibilities of team members (Table 1). The results of surveillance cultures were grouped based on risk to humans, as defined by Centers for
table 1. Responsibility Assignment Matrix (RAM) Implemented as a Part of Our Intervention GI
Team Process Name/Description
Identify positive culture and communicate with stakeholders; blast page with culture date, scope serial number; check e-mail within 15 minutes; and meet in 3 hours in infection prevention (IP) conference room.
Gather scope reprocessing documentation and bring copies to team huddle: reprocessing log, ATP testing log, patient log sheet, HLD printout, pick up log, culture collection log, ETO record system, ETO print out.
Identify patients involved and bring intraoperative documentation to team huddle. Determine risk to patients involved.
Determine whether patient communication is necessary.
After hours and weekends, CSPD member validates whether HLD requirements achieved and passed leak test and whether ETO cycle was completed with no errors. GI member gathers patient information. CSPD and GI members to email complete investigation to IP within 2 hours. IP member send out summary report within 1 hour.
CSPD Team
IP Team
Member Member Member II
R IR
R R I
I
R I
C
C R I
RR C
Hospital Leadership Team Member
I I I
R R I
NOTE. R, responsible; I, informed; C, consulted; GI, gastroenterology; CSPD, central sterile processing department; IP, infection prevention; ATP, adenosine triphosphate; HLD, high-level disinfection; ETO, ethylene oxide.
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