Special Edition on Sterile Processing Imperatives Special Edition- Sterile Processing Imperatives | Page 21

harbored high-concern organisms or actionable levels of microbial growth (>100 CFU). Mold and Gram-negative bacteria were detected, including S. maltophilia, Sphin- gomonas phyllosphaerae, and Escherichia coli/Shigella. At one hospital, high protein levels were detected in seven of eight bronchoscopes, indicating manual cleaning failed to remove soil. Visual inspections using magnification and borescopes identified residue or defects in 100 percent of bronchoscopes.” Ofstead and her team found that audits evaluating per- sonal protective equipment use and reprocessing guideline adherence (e.g., point-of-care pre-cleaning; leak testing; manual cleaning; visual inspection; cleaning verification; high-level disinfection; rinsing; drying; storage; transport and handling) identified breaches in all five hospitals. They explain, “Technicians in two hospitals (Sites 1, 5) performed most reprocessing steps correctly, but bronchoscopes at both sites harbored S. maltophilia due to contaminated rinse water. In three hospitals (Sites 2-4), nearly all steps were performed incorrectly or skipped entirely. In light of these breaches and observations that most bronchoscopes were damaged and contaminated, a recommendation was made that procedures in two hospitals be halted until strict protocols could be implemented and personnel retrained. In addition, it was recommended that badly damaged bronchoscopes be removed from service and replaced with single-use, sterile bronchoscopes or new reusable bronchoscopes constructed with sterilizable materials.” “It is possible that contaminated bronchoscopes could infect COVID-19 patients with other infectious diseases,” says Cori L. Ofstead, MSPH. “It’s also possible that contaminated devices could expose healthcare workers to the virus when they are cleaning and disinfecting them between patients. Given what we’ve learned about the overall level of bronchoscope contamination, we urgently need to know whether healthcare personnel are getting exposed to the virus or other pathogens on bronchoscopes due to the lack of PPE and other supplies.” The authors note that sterile, disposable bronchoscopes would “substantially reduce the risks” to patients and hospital staff, and also point out that disposable devices are recommended by the American Association for Bronchology and Interventional Pulmonology. In addition, many tests for COVID-19 result in false negatives, while a bronchoscopy is the most accurate way to confirm that a patient has the virus, Ofstead notes. As Ofstead and Hopkins, et al. (2020) observe, “There is currently an urgent need to reduce the number of patients requiring hospitalization or intensive care, in part because of shortages of ventilators and personal protective equipment. Given the high bronchoscope contamination rates found during routine use in previous studies, we must now consider the possibility of bronchoscopy-associated transmission of COVID-19 or other pathogens that could cause secondary infections. Theoretically, high-level disinfection should elim- inate these risks when bronchoscopes are well-maintained and reprocessed according to manufacturer instructions and professional guidelines. However, even during normal patient loads, practices are frequently substandard, and pathogens are commonly present on patient-ready endo- scopes. The presence of gastrointestinal pathogens found in bronchoscopes and BAL samples suggests the possibility of cross-contamination caused by intermingling bronchoscopes and gastrointestinal endoscopes during reprocessing. This hypothesis is supported by findings at one hospital where protein and bioburden levels on brand-new bronchoscopes increased significantly following manual cleaning prior to any clinical use.” The researchers add, “Reprocessing effectiveness has not been evaluated in epidemic settings and research is needed to confirm that COVID-19, influenza viruses, and other pathogens are eliminated in these settings. The use of sterile, disposable bronchoscopes would substantially reduce the risks for patients and reprocessing personnel, and this approach has been recommended by the American Association for Bronchology and “It is Interventional Pulmonology. However, possible that single-use bronchoscopes are not contaminated universally available and may not be sufficient for advanced bronchoscopy. bronchoscopes When reusable bronchoscopes must could infect be used, they should be segregated from gastrointestinal endoscopes COVID-19 and sterilized rather than relying on patients high-level disinfection. We urgently recommend further research assessing with other potential contamination of reusable infectious bronchoscopes with viral, bacterial, and diseases.” fungal pathogens. Laboratory methods should include bacterial/fungal cultures — Cori L. and molecular assays (e.g., real-time Ofstead, MSPH PCR) for respiratory viruses, including COVID-19. To optimize the accuracy of results, samples should be taken from multiple components using a friction-based technique (e.g., flush-brush-flush for sampling ports and channels). Laboratories should utilize methods that foster growth of microbes that are viable but not easily culturable (e.g., using neutralizers to counteract residual reprocessing chemicals that could suppress growth, concentrating samples, and incubating for at least five to seven days or six to eight weeks when culturing for Mycobacteria). Due to the relative insensitivity of viral culture and potential safety concerns related to cultivating COVID-19, molecular testing (i.e., targeted real-time PCR and multiplex respiratory panels) could be considered to assess for contamination with viral pathogens.” “No patient should suffer from preventable nosocomial infections due to bronchoscopy,” Ofstead says. “Using bronchoscopes that have physical defects and harbor viruses, bacteria, or fungi puts vulnerable patients at risk and could have adverse effects on public health. Institutions are obligated to protect both patients and reprocessing personnel and ensure bronchoscope reprocessing practices adhere to guidelines and manufacturer instructions.” Reference: Ofstead CL, Hopkins KM and Binnicker MJ. Potential impact of contam- inated bronchoscopes on novel coronavirus disease (COVID-19) patients. Infect Control Hosp Epidemiol. 2020 Apr 2:1-10. www.healthcarehygienemagazine.com • Sterile Processing Imperatives 2020 21