The Pulse | Friday, June 15, 2018

Greater Risk of Infection Than Thought for Colonoscopy and Endoscopies

In early June, the Gut journal published a study from Johns Hopkins, indicating the rates of infection after colonoscopies and upper-GI endoscopies performed at U.S. outpatient and ambulatory surgery centers are 100 times higher than previously understood. The study showed that bacterial infections such as E. coli and Klebsiella can affect anywhere from one to three in 1,000 patients, depending on the procedure. Previously, infection rates were believed to be 1 in 1 million. You can read more about the study’s findings in an article from Health Day. 

While this news is concerning, SGNA reminds its members to do everything they can to follow SGNA guidelines and stay in the know when it comes to infection prevention. Below are insights and thoughts on what you can do from SGNA President-Elect, Catherine Bauer, MSN MBA CGRN CFER, and Betty McGinty, MS HSA BS RN CGRN, High Level Disinfection Safety and Quality Director at Northside Hospital in Atlanta.

We Cannot Cut Corners
From Cathy Bauer, MSN MBA CGRN CFER SGNA President-Elect, Director of Endoscopy/Bronchoscopy and Motility at University of Virginia Medical Center

Over the last few years, there have been concentrated efforts on cleaning and reprocessing ERCP and EUS scopes because of the recent outbreaks of infections related to the difficulty of cleaning these scopes. This study reminds us of the importance of cleaning each and every scope to the best of our ability each time. We cannot cut corners, no matter which scope we are cleaning. The importance of developing and following standard work for all scopes based on the manufacturers’ information for use (IFU) is the first step in making sure the staff is trained to do the reprocessing correctly. Frequent validation of these skills can also play an important role in patient safety.

This study also points out the need for post-procedure checks on our patients. This can be done via phone calls or written surveys. The sooner the center hears about an adverse event, the better the outcomes for the patient and real-time coaching for the staff can be done.

 Reprocessing Vigilance and Consistent Follow-Ups
From Betty McGinty, MS HSA BS RN CGRN, High-Level Disinfection Safety and Quality Director at Northside Hospital in Atlanta

This news comes on the heels of recently published studies in the American Journal of Infection Control (4-18-18), where researchers found that post-reprocessed endoscopes evaluated at three hospitals revealed evidence of organic contamination in 22 percent, microbial growth in 71 percent, and retained moisture in 49 percent. The study noted that reprocessing failed about half the time, involving all types of flexible endoscopes, regardless of one of the hospital’s very good practices. 

My takeaways from this were: a need to ensure reprocessing vigilance, to verify cleanliness prior to high-level disinfection and to spot-check endoscopes post-reprocessing for disinfection effectiveness, presence of moisture, and damage to endoscopes. It reminded me that high-level disinfection does not kill all spores and that much effort needs to be applied to manually clean the scopes.

This news also highlights under-reporting that occurs regarding post-endoscopy infections that occur following colonoscopy and esophagogastroduodenoscopy performed at ambulatory surgery centers. I agree that this is a population that has perhaps not been studied regarding outcome data. It is important to know about such outcomes as infections so that improvement opportunities may be realized and patient care may be improved.

The suggestions made by the authors regarding consideration of choice of facility for procedure, as well as the timing of procedures following hospitalization, in efforts to prevent infection in vulnerable patient populations, may become practices of providers. GI nurses and associates may find themselves in patient advocate roles in assisting patients to understand the rationale. They may also find themselves in patient education roles, reassuring patients that the ASC staff follow infection prevention practices in an effort to keep them safe. This includes hand washing, low-level disinfection of non-critical equipment, high-level disinfection of semi-critical equipment and so on.

I think it is important to note that this information has already made it to publications such as Health Day that will be readily available to the general public, so there is a good chance patients and potential patients will have concerns.

I am concerned about the lack of reported infections post-procedure. There needs to be outpatient surveillance for outcomes and procedural environments need to continue, as they offer less cost and are generally are better for patients than hospital environments when it comes to infection exposures.

What can GI professionals do? Pay attention to all infection prevention practices. That includes hand hygiene, low-level disinfection, PPE, treating single-use devices as such, following reprocessing protocols, high-level disinfection and sterilization. The must also screen patients (pre-procedure phone calls), including infection history, recent hospitalizations, recent endoscopic procedures. Follow up phone calls must be performed to identify early signs/symptoms of infections, and a second follow up should be considered to further identify outcomes. Lastly, become an Infection Prevention Champion.