improving scope reprocessing 889
Disease Control and Prevention, as low- and high-concern bacteria.6 The reprocessing of duodenoscopes at our center starts with
bedside manual cleaning followed by repeat manual cleaning (within an hour) in the sterile processing department. To detect any residual biological material, adenosine triphosphate (ATP) testing is then performed on 5 spots of the duodenoscope: surface, 3 channels, and the elevator. If ATP levels are <100 relative light units (RLU), the duodenoscope undergoes high-level disinfection (HLD). If the duodenoscope fails ATP testing, the duodenoscope is recleaned following manu- facturer’s instructions and undergoes ATP retesting. AfterHLD with an automated endoscopic reprocesser, a total of 10 duodenoscopes undergo surveillance cultures every month. Duodenoscopes that are cultured are sent through HLD again. All duodenoscopes are then sterilized with ethylene oxide (ETO) prior to use. We have 24 scopes, and 92% of the scopes undergo surveillance cultures in a span of 4 months. Our monthly surveillance cultures represent efficacy of manual cleaning. During the baseline period (January 2016 through June
2016), scopes were cultured after 9.4% of the procedures (n=267). During the intervention period (September 2016 through July 2017), cultures were obtained after 20.3% of the procedures (n=492; P<.05). During our baseline period, 10 of 25 cultures were positive (40%). During the intervention period, 4 of 100 cultures were positive (4%; P<.05). We reduced our culture positivity by 36% by increasing the efficacy of our manual cleaning. Culture positivity is the ratio of positive cultures divided by number of scopes cultured. Compliance with the policy for obtaining cultures increased from 41.7% during the baseline period to 90.9% during the intervention period. Compliance was defined as a ratio of number of cultures obtained and number of cultures expected to be obtained during a defined period. Our compliance with the policy for obtaining cultures increased by 49.2%. Our compliance with the policy for manual cleaning within 1 hour of bedside cleaning increased from 38.5% (47 of 122 cultures) in the baseline period to 50.8% (375 of 738 cultures; P<.05) in the intervention period. Improvement in compliance with other steps in the process was not statistically significant. By establishing clear responsibilities with RAM(Table 1) and
emphasizing real-time huddles (when scope cultures are posi- tive), we reduced the rate of culture positivity significantly from 40% to 4%. We attribute our success to weekly meetings of MDT members from infection prevention and central sterile processing, which created a high level of engagement. We also developed a process of sending a notification (blast) page to all team members when a scope culture was positive.When a blast page was issued, all team players huddled within hours and conducted a root cause analysis. We used a shared database to track each endoscope fromthe time of use on the first patient to the subsequent patient. The data included in this database were added by different team members. An action plan was created,
and a communication was sent to everyone on the RAMwithin 24 hours of each meeting. This study has several limitations. It was a single-center experience, which reduces its generalizability. We did not have a control group, which reduces our confidence that these results were due to the intervention. We relied on capturing compliance based on documentation by personnel for most of the processes in our protocol, which allows for human error. In conclusion, by emphasizing principles of accountability
(RAM) and effective communication (real-time huddles), we were able to show improved efficacy of manual cleaning of endoscopes, which was indicated by reduction in the rate of culture positivity.
acknowledgments
We thank the central processing team and endoscopy center personnel for their contributions to this project. Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflict of interest relevant
to this article. Neha Nanda, MD;1,2
Preciosa Marasigan, RN;2 Stephanie Hall, MD;3 Evan Mosier, MD4
Affiliations: 1. Division of Infectious Diseases, Department of Medicine,
Keck School of Medicine, University of Southern California, Los Angeles, California; 2. Department of Healthcare Epidemiology and Infection Preven- tion, Keck School of Medicine, University of Southern California, Los Angeles, California; 3. Keck School of Medicine, University of Southern California, Los Angeles, California; 4. Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California. Address correspondence toNehaNanda,MD, Division of Infectious Disease,
Department of Medicine, Keck School of Medicine, University of Southern California, 1500 San Pablo, Los Angeles, CA 90030 (
neha.nanda@
med.usc.edu).
PREVIOUS PRESENTATION. This work was presented as “Impact of Multi- disciplinary Team on Duodenoscope Reprocessing to Minimize InfectionsWith High-Concern Organisms” at ID Week 2017 on October 4, 2017, in San Diego, California. Infect Control Hosp Epidemiol 2018;39:888–890 © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0024. DOI: 10.1017/ice.2018.98
references
1. KovalevaJ, Peters FT, van der Mei HC, Degener JE. Transmission of infection by flexible gastrointestinal endoscopy and broncho- scopy. Clin Microbiol Rev 2013;26:231–235.
2. MuscarellaLF. Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastro- intestinal endoscopy. World J Gastrointest Endosc 2014;6:457–474.
3. EpsteinL, Hunter JC, Arwady MA, Tsai V, et al. New Delhi metallo-β-lactamase–producing carbapenem-resistant Escher- ichia coli associated with exposure to duodenoscopes. JAMA 2014;312:1447–1455.
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