Is it Time for Updated Infection Control Practices in Endoscopy?(Part 1)

Endoscopic procedures, like colonoscopy and upper GI endoscopy (EGD), are a valuable and life-saving screening and diagnostic tool performed by teams of medical professionals dedicated to providing the highest quality of patient care.  The evolution of these procedures has seen great advancements with high-definition endoscopes, automated scope reprocessors, and an ongoing commitment to patient education regarding the need for regular screenings for the early identification of colon cancer.  Nevertheless, with continuing reports highlighting infection control risks and weaknesses effecting endoscopy procedures at facilities across the country,  the infection prevention processes and practices employed during these commonly performed and life-saving procedures may be due for a facelift.

Given the nature of an endoscopic procedure there is, perhaps, no place in a healthcare facility where the generation and contact with enteric (GI) bacteria, viruses, and bloodborne pathogens is a more predictable, and repetitive, event.  How such risks are acknowledged and proactive prevention efforts implemented is a direct reflection of a facility’s “culture” of preventing known sources of infectious bacteria from being cross transmitted to the hospital environment where it can readily cross the path of other patients, staff, or even visitors.

Unlike surgical procedures, where an aseptic (or sterile) field is established and constantly observed, endoscopic procedures are historically practiced under “dirty” and “non-sterile” conditions where such aseptic principals and practices are not consistently applied.  Significant attention is rightfully focused on the cleaning and high-level disinfection of flexible endoscopes after use.  When properly performed and validated, this cleaning eradicates the bacteria and pathogens (as much as 1 trillion CFU/ml) that have contaminated the exterior surface and internal channels of a scope during the course of an endoscopy procedure.  Conversely, the way in which this same contamination and risk of cross-transmission recognized on the high-touch patient gurney, linens, and patient themselves is all too often overlooked.  This can result in trillions of potentially infectious bacteria and pathogens being carried out into the PACU, elevators and hallways on these surfaces as patients are moved from the procedure room.  In this case, the process flow of health care delivery represents a lapse in the containment and infection control processes as these gurneys, and the patients they carry, unknowingly become a vector for cross-transmission of infectious pathogens.  This risk is greatest in the period of time prior the point at which terminal cleaning is performed, though many GI bacteria can remain viable on environmental surfaces for months after exposure.

The prevention of cross-transmission of pathogens and risks of infection like those outlined above have gained an increased focus of guidelines and guidance from groups including the CDC (Centers for Disease Control and Prevention), APIC (Association of Professionals in Infection Control and Epidemiology), ASGE (American Society for Gastrointestinal Endoscopy), and AORN (Association of Perioperative Registered Nurses), not to mention the increased scrutiny of JC (Joint Commission) CMS (Centers for Medicare and Medicaid Services) surveyors, as well as HHS (Department of Health and Human Services) Prevention Focus Areas.  The CDC reports that endoscope related contamination is responsible for more healthcare-associated infection outbreaks than any other medical device.  Current ASGE Guidelines suggest the link between an endoscopy and an infection are also often attributed to inadequate aseptic techniques.  Most recently, updated guidelines from APIC extend the need for adequate containment and prevention efforts in procedural and outpatient surgery departments to reduce the ongoing transmission of MDRO and highly infectious pathogens, including C. difficile.

Important Next Steps for Infection Control:

So what can be done to eliminate HAI risks, like those outlined above, to ensure the ongoing safety of patients and facilities when performing procedures at high risk for generating or becoming sources for HAI causing bacteria and pathogens?

The answer can be surprisingly straightforward, and insightful.

Performing a Process Flow Risk Assessment (PFRA), like those recommended in CDC, Joint Commission, and APIC guidelines and recommendations, can identify weakness and opportunities for improvement in a number of critical categories, including infection control and patient safety.  This PFRA is not a series of check boxes that record a “spot check” of scope reprocessing logs or hand hygiene compliance on a quarterly or annual basis.  A comprehensive PFRA considers all aspects of care delivery on an individualized, departmental basis and serves as a working document for improving the safety, continuity, and often efficiency across the continuum of patient care.

A more detailed discussion of performing a PFRA will follow in Part 2 of this article.  However, a brief overview of essential components should consider the following:

  1. The PFRA should be initially performed at the departmental level, as they are best able to outline what they do on a day to day basis, and most often already have valuable ideas for improving their own processes.
  2. Once completed, the PFRA should be submitted to Infection Control and Risk Management for analysis and review.
  3. Collaboration among the departments (i.e. Endoscopy, Infection Control, Risk Management) identifies opportunities for confirming or improving existing processes to ensure patient safety and meet the infection control and risk management objectives within a facility.
  4. Any “gaps” or weakness in the identified process should be addressed and corrected
  5. The PFRA should be “stress tested” by walking a hypothetical patient (i.e. asymptomatic carrier, known MDRO carrier, etc) through the process from start to finish.
  6. The process of completing and evaluating a PFRA serves as a tool for both process improvement and any needs for ongoing review and education.
  7. Once completed, a PRFA serves as a foundation, or baseline, when considering future changes in process or procedure.

A comprehensive, facility-wide approach to infection control and improved patient safety should ideally consist of a series of integrated, individualized, departmental level PFRA assessments.  It is particularly critical to incorporate those high-risk departments or processes where bacteria, blood, or body fluids (OPIM) is frequently contacted or generated, where the type of care delivered poses risks for cross-transmission due to high mobility and traffic of patients and staff, or where contaminated (used) equipment or supplies are contacted or cleaned.

In endoscopy, you have all three present on a predictable and repetitive basis.  This comprehensive approach to infection prevention is critical to ensuring these procedures are performed in a hygienic environment of care using confidently sanitized and validated equipment.