1. ©2013 MFMER | slide-1

2. ©2013 MFMER | slide-2 INFECTION CONTROL AND PREVENTION IN ENDOSCOPY

3. ©2013 MFMER | slide-3 Introduction CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection.

4. ©2013 MFMER | slide-4 OBJECTIVES:  Discuss the role of healthcare workers and today’s challenges in infection control.  Discuss preventative measures taken in Ambulatory and Inpatient settings reduce infection  Demonstrate the role of proper hand hygiene in infection prevention

5. ©2013 MFMER | slide-5 OBJECTIVES CONT.  Explain the types of infections and risk associated with specific Endoscopic procedures.  Evaluate the increased risk of infection with possible variations in endoscope cleaning

6. ©2013 MFMER | slide-6 Discuss the role of healthcare workers and today’s challenges in infection control.  Hand Hygiene:  Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections.

7. ©2013 MFMER | slide-7  Disinfection of procedure room and all sites used for endoscopy:  To prevent cross-contamination in an endoscopic procedure room, most areas of the room should be designated as clean areas. Contaminated areas where accessories and specimens are handled should be separated from clean counter areas.

8. ©2013 MFMER | slide-8  Cont.  All contaminated areas must be cleaned and decontaminated between patients with an Environmental Protection Agency (EPA) registered, hospital-grade disinfectant appropriate for the specific microorganism (Rey et al., 2005; Rutala et al., 2008).

9. ©2013 MFMER | slide-9  HEALTHCARE WORKERS IN ENDOSCOPY SHOULD BE EDUCATED IN ALL OF THE FOLLOWING AREAS:  Reprocessing procedures for endoscopes and accessory equipment  Standard Precautions  Personal Protective Equipment  OSHA rules on occupational exposure to blood- borne pathogens

10. ©2013 MFMER | slide-10  Cont.  Mechanisms of disease transmission  Maintenance of safe work environment  Safe handling of high level disinfectants (SGNA 2010)

11. ©2013 MFMER | slide-11 Discuss the role of healthcare workers and today’s challenges in infection control.  Healthcare workers are the first line of defense against infection  They have the power to break the cycle or allow it to continue

12. ©2013 MFMER | slide-12  Cont.  Healthcare workers have an obligation to speak up if they see something that is not in line with proper protocol  No one should proceed in the face of uncertainty. Stop and resolve.

13. ©2013 MFMER | slide-13  Many patient care devices and items are designed to be used with one patient and often only one time. These items are considered disposable and must not be resterilized or reused. Read the manufacturer’s directions to be sure how a device is intended to be used. Healthcare workers should have extensive knowledge of such items and their recommendations

14. ©2013 MFMER | slide-14  Challenges  Fiscal restraint  Time  Increase in patient volume  Lack of proper education  Staffing shortages

15. ©2013 MFMER | slide-15 Demonstrate the role of proper hand hygiene in infection prevention Video: Hand Hygiene

16. ©2013 MFMER | slide-16 Explain the types of infections and risk associated with specific Endoscopic procedures.  Two endoscopic procedures with an increased risk of infection are:  MRSA post PEG placement  Post ERCP Infection

17. ©2013 MFMER | slide-17  MRSA POST PEG PLACEMENT  One study evaluated the risk of MRSA infection post PEG placement. They investigated the impact of known prior MRSA colonization on the incidence of symptomatic PEG site wound infection and mortality.

18. ©2013 MFMER | slide-18  RESULTS  A total of 83 patients underwent PEG placement; 23 (28%) of these patients had known MRSA colonization before PEG placement. Of these, 13 (57%) developed symptomatic MRSA infection of the PEG site. The remaining 60 patients (72%) had no known prior MRSA colonization.

19. ©2013 MFMER | slide-19  Results Cont.  In these patients, 9 (15%) developed symptomatic MRSA infection of the PEG site. The overall incidence of wound infection was 37% (31) of the total undergoing PEG placement, of whom 71% (22) had developed MRSA infection. The mortality of those with symptomatic MRSA infection of the PEG site was 9% (2/22), whereas the mortality from non- MRSA-infected PEGs was 20% (12/61).

20. ©2013 MFMER | slide-20  Results Cont.  The impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization of percutaneous endoscopic gastrostomy (PEG) sites on morbidity and mortality is uncertain.

21. ©2013 MFMER | slide-21  RESULTS CONT.  Patients with prior MRSA colonization had a significantly higher risk of developing symptomatic MRSA infection of the PEG site. However, there was still a significant risk (15%) of developing MRSA infection of the PEG site for patients with no known prior MRSA infection. MRSA infection of the PEG site did not affect mortality (Mainie I, Loughrey A, Watson J, Tham TC 2006).

22. ©2013 MFMER | slide-22  POST ERCP INFECTION  Infection is one of the most morbid complications of endoscopic retrograde cholangiopancreatography (ERCP) and among the most common causes of ERCP- related death.

23. ©2013 MFMER | slide-23  Cont.  Septic complications of ERCP include ascending cholangitis, liver abscess, acute cholecystitis, infected pancreatic pseudocyst, infection following perforation of a viscus

24. ©2013 MFMER | slide-24  Post ERCP infection cont.  In the 1980s, cross infection via contaminated endoscopes and ancillary ERCP equipment, such as cannulation catheters, was implicated in severe cases or outbreaks of septicemia from pseudomonas. (Motte,1991)

25. ©2013 MFMER | slide-25  Cont. Improvements have been made in endoscope reprocessing and handling of ERCP tools and equipment in the years since. A significant risk, however, still remains. (Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. Aug 2007;102(8):1781-8)

26. ©2013 MFMER | slide-26 Evaluate the increased risk of infection with possible variations in endoscope cleaning

27. ©2013 MFMER | slide-27  Endoscope Reprocessing  FLEXIBLE ENDOSCOPE REPROCESSING HAS BEEN SHOWN TO HAVE A NARROW MARGIN OF SAFETY. ANY SLIGHT DEVIATION FROM THE RECOMMENDED REPROCESSING PROTOCOL CAN LEAD TO THE SURVIVAL OF MICROORGANISMS AND AN INCREASED RISK OF INFECTION

28. ©2013 MFMER | slide-28  Cont.  Variations in manual cleaning can increase the risk of infection due to unacceptable amounts of bacteria left behind  Manufacturer recommendations are vitally important in the manual cleaning process

29. ©2013 MFMER | slide-29 A recent study conducted in 5 hospitals nationwide revealed that 3 of the 20 gastroscopes tested were shown to harbor unacceptable levels of bacteria. These results were presented at the APIC annual conference in June 2013. The results were broken down and categorized

30. ©2013 MFMER | slide-30 Instrument Failure Rate, % Duodenoscope (n = 30) 30 Gastroscope (n = 116) 24 Colonoscope (n = 129) 3 (Bommarito, 2013)

31. ©2013 MFMER | slide-31 How can we improve these results?  Patients are essentially waiting for these endoscopes to be disinfected and made ready for use. With an increase in patient volumes, a certain amount of stress has been added.  "It might be a good idea to look at ways to alleviate that time pressure so that the technicians have more time to reprocess that scope in a less stressful way”- Dr. Bommarito  Endoscope cleaning is very labor intensive. Technicians are sometimes on their feet consistently for an 8 hour period of time.

32. ©2013 MFMER | slide-32  Cont.  More data should be collected to evaluate the contamination level prior to manual cleaning.  Shortening the work shift or rotation of work stations may help alleviate this issue  If you have a scope that has a higher amount of contamination prior to disinfection, your disinfection process may be impaired. (Bommarito 2013)

33. ©2013 MFMER | slide-33 "The expectation that we would see no failures was perhaps a high benchmark, but clearly, we would like no endoscopes to fail a cleanliness rating," he said (Bommarito) here at the APIC (Association for Professionals in Infection Control) 2013 Annual Meeting

34. ©2013 MFMER | slide-34  Conclusion  Hold each other accountable  Take the time to do the right thing  Treat each patient as if they were your family member  Address issues as they happen  Be “in the know” when it comes to infection control practices. Education is the foundation for success..

35. ©2013 MFMER | slide-35 Q & A