What needs to happen is that other researchers and other organizations also conduct research on this problem , because a small handful of studies doesn ’ t provide evidence that ’ s wide enough to write and issue a big guideline .
Guideline-issuing bodies can ’ t responsibly make new recommendations unless they have a significant body of evidence on which to base their guidance .”
often-ignored issue of ergonomics and body mechanics involved during processing tasks .
It ’ s an issue also noted by patient safety organization ECRI in its 2022 list of Top 10 Health Technology Hazards . A 2021 ECRI survey of healthcare workers who routinely perform duodenoscope reprocessing identified several significant patient and worker safety hazards including obstacles to effective reprocessing . Survey respondents cited time pressures and poor work environment ergonomics ( e . g ., work surfaces at an uncomfortable height ) as key concerns . ECRI specifically called out a higher risk of healthcare worker musculoskeletal injuries due to poor workspace ergonomics .
As Ofstead , et al . ( 2022 ) observe , “ Non-adjustable sinks cause significant discomfort for technicians of different heights and preclude them from leaning far enough into the sink to perform manual cleaning with instruments fully immersed in cleaning solution .”
The instructions for use ( IFUs ) are of little help in this issue , according to Ofstead who remarks , “ They don ’ t generally address workers ’ safety , and they don ’ t want to talk about minimizing splashes or droplets in ways that are particular and actionable ; generally , they don ’ t mention this issue at all . And so , there are guidelines and standards that would say , ‘ brush instruments underneath the surface of the water whenever possible ,’ and that ’ s absolutely a good idea , but it introduces other issues — if you lean over enough to fully immerse the instrument , you ’ re going to have ergonomics-related issues , as that ’ s an awkward task to perform if not at the right height .”
She continues , “ When you ’ re going to cover-brush instruments fully immersed , your hands and your arms are in the water . And when you ’ re in decontamination , you ’ re going to assume that that instrument is covered with patient tissue , blood , and other potentially infectious material , so the water must be assumed to be very highly contaminated . So now we ’ re going to plunge our hands into this water and we ’ re going to assume that the barrier protection of the gloves is going to provide ample protection for that , and it ’ s not true . Even with gloves with extended cuffs , it turns out that they ’ re not tall enough , and they fall down with vigorous physical activity . So , when you are brushing , scrubbing , rinsing , raising and lowering your hands and arms , the gloves fall down . Which is a result of not testing them in the real-world activity for which they are being used . We must return to considering carefully how PPE is used and ensure it ’ s offering the level of protection needed for the task .”
Ultimately , the researchers raise the question of how far droplets travel and whether they contain soil , bioburden , or viral pathogens , and note this is largely unknown .
“ Because of COVID , we ’ ve now come to recognize again the phenomenon of droplets falling and going everywhere ,” Ofstead says . “ What happened is that we began to accept things like reusing single-use PPE . That ’ s scary . So , COVID set the bar lower for infection control overall . And it almost institutionalized , or gave permission for not doing the right thing , I don ’ t know how we ’ re going to shift away from that . Institutions will continue to think , ‘ If personnel can wear that gown or that N95 again ,’ that gives them permission to continue cutting corners and think they got away with it . Even though we are starting to see a huge uptick in preventable healthcare-acquired infections like CLABSI , cutting corners is now accepted somehow . To me , that means we need to turn this around before we build a belief system in which this is okay to do . It ’ s not .”
The researchers suggest steps akin to the CDC ’ s hierarchy of controls for mitigating potential cross-contamination and protecting sterile processing personnel , such as training staff on recommended practices for reducing splash , maintaining a dirty-to-clean workflow , cleaning and disinfecting workspaces between reprocessing activities , as well as donning and doffing PPE correctly . But they emphasize , “ Environmental controls are clearly needed to reduce the risk . Possible solutions could be the use of hood-like systems with negative pressure ventilation and plexiglass barriers to physically prevent exposure to splashes ; new designs for sinks , faucets , and power sprayers ; and automated systems that perform some of the higher-risk activities .”
Ofstead acknowledges the significance of the challenges ahead . “ I know infection preventionists are understaffed and overwhelmed and they ’ re going to struggle to take leadership on this issue . And SPD leaders haven ’ t been able to get the resources they need , so I ’ m not sure where it will come from , but maybe we make some noise . We ’ re working on what we ’ re calling ‘ Splash 2.0 ,’ another study right now and I ’ m hoping that we ’ ll write a follow-up paper this spring . What needs to happen is that other researchers and other organizations also conduct research on this problem , because a small handful of studies doesn ’ t provide evidence that ’ s wide enough to write and issue a big guideline . Guideline-issuing bodies can ’ t responsibly make new recommendations unless they have a significant body of evidence on which to base their guidance . I think it is on members of industry and on those of us who are in a good position to do research , to document this problem . I also think it ’ s on industry to conduct research on the effectiveness of PPE ; in the meanwhile , if we can document this problem enough , I am confident we will no longer say droplets only go 3 feet .”
References :
Association for the Advancement of Medical Instrumentation ( AAMI ), American National Standards Institute ( ANSI ) ANSI / AAMI ST91 : Flexible and semi-rigid endoscope processing in health care facilities . AAMI , Arlington , Va . ( 2015 ), Pp . 1-70 . ECRI . Top 10 Health Technology Hazards for 2022 . Johnston ER , Habib-Bein N , Dueker JM , et al . Risk of bacterial exposure to the endoscopist ’ s face during endoscopy . Gastrointest Endosc , 89 ( 2019 ), Pp . 818-824 . Kaye MD . Herpetic conjunctivitis as an unusual occupational hazard ( endoscopists ’ eye ). Gastrointest Endosc , 21 ( 1974 ), Pp . 69-70 .
Van Wicklin SA , Conner R , Spry C . Guideline for processing flexible endoscopes . Guidelines for Perioperative Practice , Association of periOperative Registered Nurses ( AORN ), Denver , Co . ( 2017 ).