Outbreaks of GI “Superbugs” Underscore the Need for Enhanced Infection Control Processes in Endoscopy

Do you consider endoscopic GI procedures as “Low Risk” for contact with infectious bacteria or bloodborne pathogens?  If so, it may be time to revisit this misleading and potentially dangerous perception.

Earlier this month, the FDA warned healthcare facilities about multiple reported failures in the effectiveness of reprocessing procedures used on certain endoscopes that had become contaminated with the “nightmare superbug” CRE (carbapenem-resistant Enterobacteriaceae).  This is one of a growing number of bacteria originating from the GI tract that have developed an increasing resistance to even the most powerful of antibiotics.  Publicized reports confirm that more than 100 infections and 28 deaths have been linked to the cross-transmission of CRE in endoscopic settings from unsuspected bacteria that had eluded standard cleaning and disinfection.  A sentinel event like this serves as a stark reminder that the GI tract serves as the ultimate origin of many of the most prevalent and infectious bacteria known today (including C. difficile, VRE, and CRE), and there is no place within a hospital or healthcare facility where encountering these same GI-borne bacteria and pathogens is as predictable, and their spread therefore preventable, as within an endoscopy setting.  Given the very nature and course of the procedures performed, there exists a dangerous disconnect between the inherent risks of generating infectious bacteria and the continuity of infection control processes employed to contain these during procedures. All too often these risks have been minimized, flying under the radar of infection control processes as they have been historically (and misleadingly) written off as “dirty” or “non-sterile” procedures.

Eliminating “Gaps” in Endoscopy Infection Control

The thorough reprocessing and safe handling of flexible endoscopes is, without question, the most important (and common sense) component of ensuring the hygiene of equipment and supplies used in GI endoscopy.  However, it is also critical to assure that the infection control and prevention processes implemented throughout the sequence of events that comprise these procedures sufficiently recognize and address the predictable risks of contamination and cross-transmission from the bacteria, bloodborne pathogens, secretions, and OPIM (other potentially infectious materials) generated through direct contact with the mucosal linings and fluids of the GI tract.

In accordance with these risks, the ASGE “Guidelines for safety in the gastrointestinal endoscopy unit,” (American Society for Gastrointestinal Endoscopy, 2014) highlight the need for the identification and elimination of any infection control “gaps” along the continuum of endoscopy care, recognizing that such gaps or failures jeopardize patient safety.  Expanding well beyond standard scope reprocessing and hand hygiene recommendations, these guidelines call for the development and implementation of a comprehensive infection prevention plan to address the risks of contact and cross-transmission of infectious GI pathogens throughout the course of an endoscopy procedure.  This includes a thorough evaluation of the complex activities and interactions that take place from the initial pre-op stage, contact with surfaces and equipment touched or contaminated during the procedure, and movement patterns that can facilitate cross-transmission extending all the way through recovery and discharge.

 Unique Infection Control Needs in GI Endoscopy

When evaluating infection prevention processes along the continuum of care in GI endoscopy, one of the most commonly overlooked (and preventable) risks of introducing infectious bacteria and pathogens into the hospital or patient care environment is inherent to the traffic patterns and procedure flow within an endoscopy department.  To illustrate, consider that in an aseptic (sterile) O.R. surgical environment, a patient is transferred to a fixed surgical table and a defined “field” established to differentiate “clean” from potentially contaminated surfaces and equipment.  Any tool or supply entering the field is sterile, and significant attention is paid to activities within the operating room to avoid infections that can be caused from pathogens being transmitted from the environment to the patient.

In contrast, GI endoscopy procedures are, by definition and practice, non-sterile procedures as they are performed on existing anatomic portals.  However, this designation does not accurately reflect that these also involve extensive contact with mucous membranes already known to be heavily colonized with a persons microflora, or naturally existing bacteria.  During an endoscopic GI procedure, exposed linens, handrails, stretcher frames, mattresses  and even the patient’s skin are readily subjected to contamination with bacteria and pathogens through incidental contact with the exterior scope surface, frequent contact with gloved hands, and the secretions and droplets generated.  Movement patterns within the environment of an endoscopy suite are also not as standardized, with biopsy snares and supplies, for instance, often being moved in and out of the immediate procedure area between uses. 

Unlike most surgical processes, an endoscopy patient remains on the same stretcher from pre-op through discharge.  They are moved in and out of the endoscopy room on the very surface where their procedure was just performed, transported for recovery, and even returned to a patient care unit, all on the same stretcher and all prior to necessary and appropriate steps to prevent risks of pathogen exposure and cross transmission from being passed on to other patients, staff, and the rest of hospital environment.  Unless adequate handling and containment measures are instituted, pathogen risks (the very same ones that necessitate the diligent handling, transport, and high level disinfection of the scopes themselves) are left totally unaddressed and readily carried out of the procedure room on an ongoing and repetitive basis.

Uncontained Bacteria:  A Facility-Wide Risk

Basis principals in epidemiology and infection control confirm that a latent bacteria in one person can be the infection causing pathogen to someone else.  One patient can unknowingly be a carrier of a highly virulent or resistant bacteria or pathogen without showing signs or symptoms, though these can all too quickly become the causative agent for a complicated or life threatening infection in another.  Therefore, any predictable contact or encounter with blood or any body fluid that can contain infectious pathogens must be addressed at the first point of contact.  It is also well established that cross-transmission of  infectious pathogens begins as soon as a bacterial source achieves mobility via high touch surfaces in a hospital environment.  Within an endoscopic setting, this transmission is set in motion as the stretcher and patient first exit the procedure room headed for recovery.  In PACU or recovery, contact with the recently contaminated stretcher and patient occurs incidentally and repetitively during interactions with staff (who do not typically wear PPE), family members, or others present.  These risk pathogens are readily spread throughout the immediate care area, hallways, and even inpatient units as these patients are transported back to their room on these same contaminated and highly mobile patient care surfaces.  Potentially infectious source pathogens have now found their unwitting “vectors” for extensive and ongoing cross-transmission, with risks increased exponentially as this virtually unchecked cycle is repeated over and over again throughout the day.

To further compound inadequately addressed risks, consider for a moment the effectiveness of the routine “terminal cleaning” of endoscopy stretchers, which generally takes place after a patient has been transported to their inpatient room or discharged as an outpatient.  This cleaning task, often performed by non-clinical personnel with limited knowledge of its recent “history”, is often almost naively relied upon as the single-step rationale for finally addressing the contamination present on these surfaces that has occurred during use.  In terms of preventing cross-transmission, this can be too little and too late, as the cycle has already been set in motion and bacteria doesn’t exactly wait around for cleaning and disinfection.  If the meticulous and well defined endoscope reprocessing protocols (where bacteria within the small inside channels and “elevators” in these devices are submerged and flushed with high level disinfectants for 20 minutes or longer) have been found to be insufficient in many cases, how effective is the cursory cleaning an endoscopy stretcher undergoes after discharge?  When mattress and frame surfaces exposed to contamination during a procedure are eventually cleaned and disinfected, commonly missed or difficult to reach areas can harbor infectious bacteria and pathogens for up to 30 months.  The nooks, crannies, and crevices of the frame itself, and even underside of the stretcher mattress are just a few of the surfaces that can be virtually impossible to ensure adequate disinfection while still meeting the efficiency and turn-time needs in a busy endoscopy unit.  The ultimate goal should be to minimize contact and exposure risks for these surfaces during use, preventing as much contamination as possible at this first point of contact.

The Need for Enteric Contact Precautions in GI Endoscopy

These facts alone support the need to take steps to eliminate these all too common gaps in the containment and prevention processes in GI endoscopy.  By first identifying the contact and transmission risks that occur, facilities can implement the necessary measures to proactively protect these surfaces from exposure to contamination and contain them at their initial point of contact within the endoscopy suite.  Fortunately, this process is not as elusive or daunting as it may initially seem.  Current APIC (Association of Professionals in Infection Control and Epidemiology) guidelines recommend the application of disposable protective barriers on surfaces likely to become contaminated during endoscopic procedures to prevent the risks of environmental cross transmission of infectious GI bacteria, including C. difficile.  CDC guidelines have long recommended the use of disposable protective barriers on high touch surfaces that are likely to become contaminated with infectious bacteria and pathogens, touched frequently with dirty or gloved hands, or difficult to immediately clean.  In GI endoscopy, you have all three of these conditions during each and every procedure, with exposure hazards ranging from bloodborne pathogens and enteric viruses to the most prevalent of infectious bacteria.  Enhanced enteric contact precautions should, at a minimum, be implemented and observed in order to contain these risks within the procedure room or endoscopy suite.  The end goal should be to eliminate any opportunities for uncontained bacteria or pathogens to escape the confines of the endoscopy procedure room, in a similar manner to isolation precautions and practices that are instituted to limit cross-transmission risks in other patient care areas.

The need for identification and increased awareness of these high risk pathogens in endoscopic settings, and the implementation of appropriate containment strategies, is an intrinsic component of an effective infection control process.  Basic principles of epidemiology and infection control confirm that preventing an initial source of potentially infectious bacteria or pathogens at the first point of encounter is the most effective means of interrupting the cycle of contamination and cross-transmission that can otherwise lead to infections.  Current guidelines, along with a healthy dose of common sense, indicate that this is particularly applicable in endoscopic GI settings, where contact with the known “home” of highly infectious enteric bacteria and pathogens is both a certain and predictable event.  Infection control “gaps” along the continuum open the door to begin the cycle of cross-transmission that can lead to dangerous and deadly infections.

Preventing Infections is Everyone’s Responsibility

After all, where else in a hospital or healthcare setting would contact with prevalent enteric pathogens occur so predictably and repetitively, yet still not have adequate safeguards in place to prevent them being readily carried out and moved throughout the facility?  Endoscopic GI procedures provide a valuable and potentially lifesaving diagnostic and treatment tool for the patients served.  In meeting this vast array of patient needs, it is critical to remember that it is the inherent responsibility of each and every healthcare provider to ensure that appropriate infection prevention processes are in place and adhered to in order to protect the health and safety of not only their own patients and staff, but everyone else in their facility and health care community.

 About the Author:  Tom Szymczak, PT is a board licensed Physical Therapist with more than 20 years of experience in safety and process analysis, infection and injury prevention, exposure reduction, workplace safety, and healthcare education. He currently serves as a safety consultant, author, educator and speaker specializing in infection prevention, work flow process analysis, exposure reduction, and biomechanical/workplace safety. Tom is the founder and president of Vortek Surgical, a specialty device company dedicated to providing effective products and strategies for improving healthcare delivery and safety, including the ENDODRAPE Endoscopy Containment Systems and EPS-30 line of endoscopy positioners.  For more information, please contact Tom directly at tom@vorteksurgical.com.


 A Simple, Cost Effective Solution to a

Common Endoscopy Infection Control Gap

     The ENDODRAPE® Endoscopy Containment Systems from Vortek Surgical provide a simple to use, cost effective solution to efficiently and effectively containing pathogens and OPIM, protecting stretcher surfaces and linens from contact and contamination during GI endoscopy procedures.

Similar to the PPE worn by endoscopy personnel, the ENDODRAPE® systems efficiently establish the recommended protective barrier to prevent contamination of high touch surfaces during the procedure, consistently providing effective containment within the procedure room.  Preventative containment of bacteria and pathogens at the initial point of contact eliminates risks of these becoming moving vectors for cross-transmission as stretchers and patients are transported from the procedure room into PACU/recovery, or moved through other patient care areas through facility hallways and elevators.

The ENDODRAPE® systems are comprised of a comprehensive barrier that is quickly deployed prior to the start of a procedure.  This barrier establishes a “Zone of Protection,” shielding the patient, linens, and stretcher surfaces from contamination during an endoscopic GI procedure.

Specifically designed for use in GI endoscopy, the ENDODRAPE® systems also incorporate a number of procedure enhancing components, including a modifiable scope guard to effectively assist in maintaining the scope on the stretcher throughout the procedure (and protect expensive endoscopes from unnecessary wear and damage), integrated pockets to facilitate and standardize the safe management of snares and biopsy forceps, and readily accessible gauze sponges.

Upon completion of the procedure, the ENDODRAPE® is quickly removed and disposed of, along with any contamination, disposable supplies and accessories.  The implementation of the ENDODRAPE® establishes a functional protective barrier in an integrated self-contained system that promotes procedural process flow and equipment protection.

For additional information regarding the benefits of implementing the ENDODRAPE® Containment Systems, or to view our educational video about enhancing infection control in GI endoscopy, please visit www.endodrape.com or contact Vortek Surgical at (888) VORTEK-1.