Biofilms: Cities of SlimeBiofilms: Cities of SlimeHow to Keep Them Out of the How to Keep Them Out of the

Operative and Endoscopy Operative and Endoscopy SuitesSuites

Carolyn Fiutem, MT(ASCP), Carolyn Fiutem, MT(ASCP), CICCIC

May 10, 2011May 10, 2011

Objectives:Objectives:

The attendee will be able to define The attendee will be able to define biofilmbiofilm

The attendee will be able to list at The attendee will be able to list at least three health risks of the least three health risks of the presence of biofilm to the patientpresence of biofilm to the patient

The attendee will be able to The attendee will be able to describe at least three appropriate describe at least three appropriate Infection Prevention practices for Infection Prevention practices for instrument reprocessing that aid in instrument reprocessing that aid in the prevention of infection to the the prevention of infection to the patientpatient

Organism “Life Styles”Organism “Life Styles”

• Microorganisms have the Microorganisms have the ability to live in two forms:ability to live in two forms: Planktonic (free-floating)Planktonic (free-floating) Biofilm (attached/sessile)Biofilm (attached/sessile) 4 microbial reservoirs:4 microbial reservoirs:

GI tractGI tract GU tractGU tract MouthMouth SkinSkin

• Germ Theory = One Germ Theory = One organism - One disease organism - One disease (“I” Theory)(“I” Theory)

• Defined by Louis Pasteur Defined by Louis Pasteur and used Koch’s Postulatesand used Koch’s Postulates

• Multispecies Multispecies Community Theory – Community Theory – cells living in a defined cells living in a defined 3-dimensional, 3-dimensional, interactive, interactive, interdependent interdependent community (“We” community (“We” Theory)Theory)

• Eli Metchnikoff in the Eli Metchnikoff in the 1850s1850s

• Organism survival – 3.4 Organism survival – 3.4 billion years ago was billion years ago was based on biofilmbased on biofilm

• Found in fossilsFound in fossils

Biofilm:Biofilm:

An aggregate of An aggregate of microorganisms that microorganisms that attach to each other attach to each other and/or a surfaceand/or a surface

Frequently embedded in a Frequently embedded in a self-produced matrix of self-produced matrix of extracellular polymeric extracellular polymeric substance (EPS) – slimesubstance (EPS) – slime

Cause an estimated 1M Cause an estimated 1M HAIs/year in the U.S.HAIs/year in the U.S.

Can be seen hours to Can be seen hours to weeks to months post-weeks to months post-procedurallyprocedurally

Biofilms are highly Biofilms are highly organized…organized…

Initially, organic material forms a conditioning film on the surface.

• Individual cells populate the surface

• EPS produced and attachment becomes irreversible

• Biofilm architecture develops

• Architecture matures; competition replaced by cooperation

• Single cells (seeds) are released

Characteristics of Characteristics of Biofilm Communities:Biofilm Communities:

• Cell-to-cell communication:Cell-to-cell communication: Quorum Sensing – Quorum Sensing –

between gram negative between gram negative organismsorganisms

Pheromones – between Pheromones – between gram positive organismsgram positive organisms

Cross-talk – signaling Cross-talk – signaling methodology that methodology that crosses between species crosses between species

• Described as a kelp bed in Described as a kelp bed in the ocean or lava-likethe ocean or lava-like

• Multi-species compositionMulti-species composition

• Dynamic environment – Dynamic environment – not all of biofilm in same not all of biofilm in same stage of developmentstage of development

• Optimally organized to Optimally organized to make use of available make use of available nutrientsnutrients

• Numerous Numerous microenvironments, with microenvironments, with pH diverse micro-pH diverse micro-communitiescommunities

• Wide range of enzymatic Wide range of enzymatic activitiesactivities

• Properties of solids Properties of solids (elasticity) and liquids (elasticity) and liquids (viscosity)(viscosity)

Biofilm Biofilm MigrationMigration

http://www.scielo.br/img/revistas/bjid/v12n6/a16tab01.jpg

Biofilm growing in Biofilm growing in dental water line…dental water line…

http://www.aquatechnology.net/biofilm2.jpg

Biofilm and IV Biofilm and IV catheters…catheters…

www.ivteam.com/.../uploads/2008/05/biofilm.jpg Marcia Ryder – Smith & Nephew

Scanning electron micrographs of Pseudomonas aeruginosa biofilm formation. A. Attachment to a surface. B. Attachment followed by phenotypic changes in the cell wall to induce production of adhesins. C. Further production of extrapolymer substances (alginate) embed the reproducing cells for microcolony and biofilm formation. Images from the CDC Public Health Image Library (http://phil.cdc.gov/Phil/home.asp

A. Catheter section treated with a stain for extrapolymer saccharide (EPS) produced by the attached bacteria. B. The same catheter section stained for DNA. C. An overlay of A and B, with the EPS- and DNA-stained biofilm showing the dispersal of cells within the EPS.

www.medscape.com/viewarticle/508109_2

www.executivehm.com/.../

Biofilms Causing Non-Union and Device Failure

ryortho.com/biologics.php?news=277_Biofilms-C...

www.technologyreview.com/Biotech/17150/

Streptococcus pneumoniae was one of a number of organisms cultured from the ear of a child with chronic otitis media…

SEM Micrograph of a Biofilm formed by Bacterial Colony on Silicon Substrate

www.bacteria-world.com/biofilms.html

The photograph to the right shows the initial formation of a complex biofilm. A colony of bacteria is starting to form in several areas on the surface of the device. The bacteria are the very small spherical structures. In some areas, the bacteria are clustering together, and an emerging adhesive matrix is developing around the groups of bacteria. Making this a very interesting picture is the fact that a number of much larger Leucocytes (White Blood Cells) have detected the bacterial infection, and have also attached to the surface, and appear to be forming their own biofilm in response to the bacteria.

www.bacteria-world.com/biofilms.html

Exudate on an implant…Exudate on an implant…

Staphylococcus

Polymicrobial

Polymicrobial gnrs

Candida albicans

Mycobacterium fortuitum…

www.biomedcentral.com/1471-2180/8/184

www.biomedcentral.com/1471-2180/8/184

Confocal laser scanning microscopy (CLSM)

Mycobacterium smegmatis

Clinical consequences Clinical consequences of biofilm:of biofilm:

Planned staging for Planned staging for release (metastasis) to release (metastasis) to distal sitesdistal sites

Increased resistance Increased resistance (5000 times or more) (5000 times or more) to physiologic to physiologic antibiotic antibiotic concentrationsconcentrations

Neutralization of host Neutralization of host defense mechanisms, defense mechanisms, including phagocytosisincluding phagocytosis

Prolonged/Prolonged/complicated, complicated, expensive treatmentsexpensive treatments

<10% grow in the <10% grow in the laboratorylaboratory

Enhanced exchange Enhanced exchange of genetic material, of genetic material, leading to multi-leading to multi-drug resistance or drug resistance or increased virulenceincreased virulence

Increased number Increased number of organisms per of organisms per unit areaunit area

Increased occlusion Increased occlusion and reduced flowand reduced flow

New strategies for treatment New strategies for treatment not focusing on elimination of not focusing on elimination of

biofilm:biofilm:

Reinforcement of good Reinforcement of good biofilms, i.e. “smart probiotics” biofilms, i.e. “smart probiotics” or replacement therapy (stool or replacement therapy (stool enemas)enemas)

Selective use of energy Selective use of energy sonication and chemical sonication and chemical therapy to reduce the primary therapy to reduce the primary infecting burdeninfecting burden

Smart Surfaces:Smart Surfaces:

• As early as 2001, As early as 2001, preventing and preventing and controlling controlling disease related disease related to biofilms to biofilms figured in 2 of 7 figured in 2 of 7 healthcare healthcare challengeschallenges

• MetalsMetals SilverSilver CopperCopper

• AntibioticsAntibiotics– Minocycline-RifampinMinocycline-Rifampin– Vancomycin +/- heparinVancomycin +/- heparin– TriclosanTriclosan

• Anti-infective Anti-infective Biomaterials/PolyBiomaterials/Polymersmers– CHGCHG– CHG-Silver-sulfadiazineCHG-Silver-sulfadiazine– Irgasan®Irgasan®– Hydrophilic Hydromer®- Hydrophilic Hydromer®-

CoatingCoating

Prevention is Prevention is better than better than

cure…cure…

Definitions…Definitions…

Manufacturer’s instructions are imperative Manufacturer’s instructions are imperative to achieve desired effect and not damage to achieve desired effect and not damage the object or instrumentthe object or instrument

Cleaning – the removal of foreign material Cleaning – the removal of foreign material from objectsfrom objects Detergents, enzymes, mechanicalDetergents, enzymes, mechanical

Disinfection - the destruction of pathogenic Disinfection - the destruction of pathogenic and other kinds of microorganisms by and other kinds of microorganisms by physical or chemical meansphysical or chemical means Know intended use and scope of activityKnow intended use and scope of activity

Sterilization – destroy all microorganisms on Sterilization – destroy all microorganisms on the surface of an article or in a fluid to the surface of an article or in a fluid to prevent disease transmission associated prevent disease transmission associated with the use of the article or fluidwith the use of the article or fluid Know intended use and scope of activityKnow intended use and scope of activity

Spaulding Classification:Spaulding Classification:

Critical Critical – objects that – objects that enter sterile tissue or enter sterile tissue or the vascular system the vascular system Requires sterilizationRequires sterilization Confer a high risk for Confer a high risk for

infection if infection if contaminatedcontaminated

Surgical instruments, Surgical instruments, cardiac/urinary cardiac/urinary catheters, implants, catheters, implants, ultrasound probes used ultrasound probes used in sterile body cavitiesin sterile body cavities

Spaulding Classification:Spaulding Classification:

Semi-criticalSemi-critical – contact – contact mucous membranes or mucous membranes or non-intact skin non-intact skin RT/anesthesia RT/anesthesia

equipment, cystoscopes, equipment, cystoscopes, laryngoscope blades, laryngoscope blades, some endoscopessome endoscopes

Requires high level Requires high level disinfectiondisinfection

Should be free of Should be free of bacteria but a small bacteria but a small amount is acceptableamount is acceptable

Spaulding Classification:Spaulding Classification:

Non-criticalNon-critical – contact – contact intact skin but not intact skin but not mucous membranesmucous membranes Requires low level Requires low level

disinfectiondisinfection Noncritical patient care Noncritical patient care

items, i.e., blood items, i.e., blood pressure cuffs, bedpans, pressure cuffs, bedpans, crutchescrutches

Noncritical Noncritical environmental surfaces, environmental surfaces, i.e., bedrails, bedside i.e., bedrails, bedside tables, patient furnituretables, patient furniture

Risk and Prevention…Risk and Prevention…

Patient Characteristics:Patient Characteristics: DiabetesDiabetes Nicotine useNicotine use Steroid useSteroid use MalnutritionMalnutrition Prolonged pre-op hospital stayProlonged pre-op hospital stay Pre-op nares colonizationPre-op nares colonization Perioperative transfusionPerioperative transfusion

Risk and Prevention…Risk and Prevention…

Preoperative Issues:Preoperative Issues: Pre-op antiseptic showerPre-op antiseptic shower Pre-op hair removal – never in the Pre-op hair removal – never in the

OROR Patient skin prep in the ORPatient skin prep in the OR Pre-op hand/forearm antisepsisPre-op hand/forearm antisepsis Management of infected/colonized Management of infected/colonized

surgical personnelsurgical personnel Antimicrobial prophylaxis – choice Antimicrobial prophylaxis – choice

& timing& timing

Risk and Prevention…Risk and Prevention…

Intra-op Issues:Intra-op Issues: OR environment – OR environment –

Disinfection/SterilizationDisinfection/Sterilization Surgical attire and drapesSurgical attire and drapes Asepsis and surgical techniqueAsepsis and surgical technique

Dependant on the procedure, not Dependant on the procedure, not where the procedure is performedwhere the procedure is performed

Post-op Issues:Post-op Issues: Incision careIncision care Discharge planningDischarge planning

Standard Precautions…Standard Precautions…

Hand hygiene – surgical scrubHand hygiene – surgical scrub GownGown GlovesGloves Face/Eye ProtectionFace/Eye Protection Do not leave restricted area with Do not leave restricted area with

procedure PPE on – OSHA issueprocedure PPE on – OSHA issue Clean environment between casesClean environment between cases Disinfectant contact timeDisinfectant contact time Disinfectant organism Disinfectant organism

effectivenesseffectiveness

Factors affecting the Factors affecting the efficacy of disinfection and efficacy of disinfection and

sterilization…sterilization… Number and location of microorganismsNumber and location of microorganisms Innate resistance of microorganismsInnate resistance of microorganisms Concentration and potency of Concentration and potency of

disinfectantsdisinfectants Physical and chemical factorsPhysical and chemical factors Organic and inorganic matterOrganic and inorganic matter Duration of exposureDuration of exposure BiofilmsBiofilms

no products are EPA-registered or FDA cleared no products are EPA-registered or FDA cleared for degrading or reducing numbers of bacteria for degrading or reducing numbers of bacteria in biofilmsin biofilms

Scope Reprocessing Scope Reprocessing Challenges…Challenges…

• More healthcare-associated More healthcare-associated outbreaks have been linked to outbreaks have been linked to contaminated endoscopes contaminated endoscopes than any other medical devicethan any other medical device

• Inherent complexities of the Inherent complexities of the instrument:instrument: Long, narrow lumensLong, narrow lumens Flexible jointsFlexible joints Multiple channelsMultiple channels Openings/PortsOpenings/Ports ValvesValves CapsCaps Accessory equipment to Accessory equipment to

biopsy, brush, or cut tissuebiopsy, brush, or cut tissue

• Reprocessing requires:Reprocessing requires:– Meticulous cleaning of Meticulous cleaning of

curves/turns, thin curves/turns, thin lumens, “nooks and lumens, “nooks and crannies”crannies”

– High-level High-level disinfection/sterilizationdisinfection/sterilization

– Not cross-contaminatingNot cross-contaminating– Bronchoscopes: 64,000 Bronchoscopes: 64,000

colonies/ml of bacteria colonies/ml of bacteria post-procedurepost-procedure

– Follow manufacturers Follow manufacturers instructions for instructions for instrumentation and instrumentation and chemical usedchemical used

– AERs – automate and AERs – automate and standardizestandardize

Disinfection strategies vary widelyDisinfection strategies vary widely Per FDA, manufacturers must include at least one Per FDA, manufacturers must include at least one

validated cleaning and disinfection/sterilization validated cleaning and disinfection/sterilization protocol in the labeling for their devicesprotocol in the labeling for their devices

Tonometers – HSV, HIV, Adenovirus (epidemic Tonometers – HSV, HIV, Adenovirus (epidemic keratoconjuntivitis)keratoconjuntivitis)

Mucous membrane instruments – HIV, HBV, HSV, Mucous membrane instruments – HIV, HBV, HSV, HPV, TBHPV, TB

Cleaning is the key first step – Don’t allow organic Cleaning is the key first step – Don’t allow organic debris to dry on the instruments!debris to dry on the instruments!

Tonometers, Cryosurgical Tonometers, Cryosurgical Instruments, Endocavitary Instruments, Endocavitary

Probes…Probes…

Sterilizing Practices…Sterilizing Practices…

• Delivery of sterile products depends on:Delivery of sterile products depends on:• Unit designUnit design• DecontaminationDecontamination• Disassembling and packagingDisassembling and packaging• Loading the sterilizerLoading the sterilizer• MonitoringMonitoring• Sterilant quality and quantitySterilant quality and quantity• Appropriateness of the cycleAppropriateness of the cycle• Effectiveness of the sterilization Effectiveness of the sterilization

processprocess• Other aspects of device reprocessingOther aspects of device reprocessing

Sterilization Practices…Sterilization Practices…

Cycle verification – before useCycle verification – before use Physical facilitiesPhysical facilities CleaningCleaning PackagingPackaging LoadingLoading Storage – event-related expirationStorage – event-related expiration Monitoring – all steps, all monitorsMonitoring – all steps, all monitors Patient safety is the only thing Patient safety is the only thing

that matters!that matters!

Causes of endoscopy-Causes of endoscopy-associated infections are associated infections are

multi-factorial…multi-factorial… Defective equipmentDefective equipment Inability to access elevator channels during cleaning Inability to access elevator channels during cleaning

and disinfection processesand disinfection processes Inadequate cleaning and disinfection of endoscopes Inadequate cleaning and disinfection of endoscopes

between patientsbetween patients Contaminated water rinsesContaminated water rinses Contaminated automatic endoscopic reprocessorsContaminated automatic endoscopic reprocessors Biofilm formation in endoscopes or automated Biofilm formation in endoscopes or automated

reprocessorsreprocessors Inadequate cleaning and sterilization of endoscopic Inadequate cleaning and sterilization of endoscopic

accessoriesaccessories Contaminated multidose vials, needles or syringesContaminated multidose vials, needles or syringes

Documented outbreaks…Documented outbreaks…

Hepatitis B and CHepatitis B and C Pseudomonas after ERCP and other scope proceduresPseudomonas after ERCP and other scope procedures TrichosporonTrichosporon Helicobacter pyloriHelicobacter pylori Serratia marcescensSerratia marcescens Burkholderia pseudomalleiBurkholderia pseudomallei Mycobacteria tuberculosisMycobacteria tuberculosis Mycobacterium avium-intracellulareMycobacterium avium-intracellulare Multi-drug Resistant gram negative rods and M. tbMulti-drug Resistant gram negative rods and M. tb Mycobacterium cheloniMycobacterium cheloni Clostridium difficileClostridium difficile Gastrointestinal virusesGastrointestinal viruses

Used to visualize the interior of a hollow Used to visualize the interior of a hollow organ or body spaceorgan or body space

Since 1800s – rigid tubes containing a Since 1800s – rigid tubes containing a series of lenses and mirrors, using series of lenses and mirrors, using natural lightnatural light

1950s – Neoendoscopic era – introduction 1950s – Neoendoscopic era – introduction and application of fiber opticsand application of fiber optics

Allowed the development of flexible Allowed the development of flexible instrumentsinstruments

Allowed for the use of this technology in Allowed for the use of this technology in multiple settings: multiple settings: HospitalsHospitals Ambulatory CentersAmbulatory Centers Private PracticesPrivate Practices

Endoscopes:Endoscopes:

Preventing Cross-contamination in Endoscope ProcessingPreventing Cross-contamination in Endoscope Processing (FDA Nov. 2009) (FDA Nov. 2009)Guidelines for Reprocessing Flexible Gastrointestinal EndoscopesGuidelines for Reprocessing Flexible Gastrointestinal Endoscopes *(July *(July

2003)2003)Guidelines for Disinfection and Sterilization in Healthcare FacilitiesGuidelines for Disinfection and Sterilization in Healthcare Facilities (CDC (CDC

Nov. 2008)Nov. 2008)*Guidelines endorsed by:*Guidelines endorsed by:

SHEA (Society for Healthcare Epidemiology in SHEA (Society for Healthcare Epidemiology in America)America)

ASGE (American Society for Gastrointestinal ASGE (American Society for Gastrointestinal Endoscopy)Endoscopy)

American Gastroenterological AssociationAmerican Gastroenterological Association American Society of Colon and Rectal SurgeonsAmerican Society of Colon and Rectal Surgeons Society of American Gastrointestinal Endoscopic Society of American Gastrointestinal Endoscopic

SurgeonsSurgeons Society of Gastroenterology Nurses and AssociatesSociety of Gastroenterology Nurses and Associates AORN (Association of Perioperative Registered AORN (Association of Perioperative Registered

Nurses)Nurses) Federal Ambulatory Surgery AssociationFederal Ambulatory Surgery Association The Joint CommissionThe Joint Commission APIC (Association for Professional in Infection Control APIC (Association for Professional in Infection Control

and Epidemiology)and Epidemiology)

Administrative Aspects:Administrative Aspects:

Establish an institutional program and procedures for Establish an institutional program and procedures for monitoring adherence to the program.monitoring adherence to the program. Comprehensive QA and Safety Program for all aspectsComprehensive QA and Safety Program for all aspects

ID all staff and departmentsID all staff and departments Set-up, break-down, and reprocessing procedures – Set-up, break-down, and reprocessing procedures –

every type of scopeevery type of scope ID all scopes, accessories, and reprocessing ID all scopes, accessories, and reprocessing

equipmentequipment Establish and document training/retraining Establish and document training/retraining

programsprograms Procedures/responsibilities for tracking useful lifeProcedures/responsibilities for tracking useful life Assure scopes and AERs are compatibleAssure scopes and AERs are compatible Review, update, disseminate proceduresReview, update, disseminate procedures

Administrative aspects…Administrative aspects…

Establish SOPs for preparing Establish SOPs for preparing scopes for patient contactscopes for patient contact Must not conflict with Must not conflict with

manufacturers manufacturers instructionsinstructions

Have correct versions of Have correct versions of instructionsinstructions

Written device-specific Written device-specific instructions for all scope instructions for all scope models and AERs usedmodels and AERs used

Review written Review written reprocessing instructions reprocessing instructions from AER manufacturer – from AER manufacturer – apply to your scopes and apply to your scopes and implemented correctlyimplemented correctly

Administrative Aspects…Administrative Aspects…

Comprehensive QC ProgramComprehensive QC Program Visual inspections and testingVisual inspections and testing Manufacturer recommended Manufacturer recommended

PM programPM program Process monitorsProcess monitors Records of scope useRecords of scope use Method for detecting clusters Method for detecting clusters

of infectionsof infections Document trainingDocument training Document repairsDocument repairs Document Document

introduction/withdrawal of introduction/withdrawal of useuse

Administrative aspects…Administrative aspects…

Train, retrain, and establish a chain of accountabilityTrain, retrain, and establish a chain of accountability Provide and document comprehensive and intensive Provide and document comprehensive and intensive

training BEFORE beginning duties; should include:training BEFORE beginning duties; should include: Proper procedures, equipment connections and Proper procedures, equipment connections and

which items are single use or reprocessedwhich items are single use or reprocessed Hands-on training for each scope and AER usedHands-on training for each scope and AER used Additional training and documentation when new Additional training and documentation when new

scope or AER implementedscope or AER implemented Frequent reminders not to deviateFrequent reminders not to deviate

– Re-evaluate and document competency at periodic Re-evaluate and document competency at periodic intervalsintervals

Technical aspects…Technical aspects…

Read and follow operating manual and instructions for Read and follow operating manual and instructions for useuse Clean, disinfect/sterilize, assembleClean, disinfect/sterilize, assemble Follow manufacturer’s instructions for procedures and Follow manufacturer’s instructions for procedures and

productsproducts Can scope go in AER? i.e., elevator-wire-channel of Can scope go in AER? i.e., elevator-wire-channel of

most duodenoscopes cannot be accessed by AERsmost duodenoscopes cannot be accessed by AERs Compare instructions from scope manufacture and Compare instructions from scope manufacture and

AER manufacturer – resolve any conflicting infoAER manufacturer – resolve any conflicting info Educated on biological and chemical hazardsEducated on biological and chemical hazards PPE requiredPPE required Mechanism to determine if scope is clean or Mechanism to determine if scope is clean or

contaminatedcontaminated

Technical Aspects…Technical Aspects…

Manually clean scopes BEFORE disinfection/sterilizationManually clean scopes BEFORE disinfection/sterilization Critical regardless of whether AER utilized or manually Critical regardless of whether AER utilized or manually

reprocessedreprocessed Staff must understand importance of initial manual Staff must understand importance of initial manual

cleaningcleaning Wipe and flush IMMEDIATELY following procedureWipe and flush IMMEDIATELY following procedure Leak tests – done before immersionLeak tests – done before immersion Disconnect/disassemble scope components as far as possibleDisconnect/disassemble scope components as far as possible Enzymatic cleaner – discard after each use; not antimicrobialEnzymatic cleaner – discard after each use; not antimicrobial Remove debris/residuals – must be meticulous and include Remove debris/residuals – must be meticulous and include

valves, channels, connectors, detachable parts – Flush and valves, channels, connectors, detachable parts – Flush and Brush; can use ultrasonic cleanersBrush; can use ultrasonic cleaners

Visual inspectionsVisual inspections

Technical aspects…Technical aspects…

High Level Disinfection – most flexible endoscopesHigh Level Disinfection – most flexible endoscopes Utilize product cleared by the FDAUtilize product cleared by the FDA Exposure Time and TemperatureExposure Time and Temperature Compatible with the scopeCompatible with the scope Completely immerse scope and componentsCompletely immerse scope and components AER must be capable of reprocessing scope and AER must be capable of reprocessing scope and

componentscomponents Attach all channel connectorsAttach all channel connectors Cannot interrupt cycleCannot interrupt cycle Active Infection Prevention staff – clusters, FDA Active Infection Prevention staff – clusters, FDA

advisories, manufacturer alerts, scientific advisories, manufacturer alerts, scientific literature (AER deficiencies that lead to infection)literature (AER deficiencies that lead to infection)

Technical aspects…Technical aspects…

Final drying step, if not listed as a precaution or Final drying step, if not listed as a precaution or contraindication in the manufacturer’s instructionscontraindication in the manufacturer’s instructions

Flush channels with sterile or filtered waterFlush channels with sterile or filtered water Discard rinse waterDiscard rinse water Flush channels with 70-90% ethyl or isopropyl alcoholFlush channels with 70-90% ethyl or isopropyl alcohol Air dry using forced airAir dry using forced air Reduces possibility of recontamination by water-borne Reduces possibility of recontamination by water-borne

organisms and reduces risk of biofilmorganisms and reduces risk of biofilm Hang scope is vertical position to facilitate dryingHang scope is vertical position to facilitate drying Stored so that scope is protectedStored so that scope is protected Water bottle & connecting tubing – high level Water bottle & connecting tubing – high level

disinfection or sterilization daily; should only be filled disinfection or sterilization daily; should only be filled with sterile waterwith sterile water

Technical aspects…Technical aspects…

EnvironmentEnvironment Storage cabinets should be ventilatedStorage cabinets should be ventilated Room should be:Room should be:

Negative pressure to outside the roomNegative pressure to outside the room Minimum 2 air exchanges of outdoor air per hourMinimum 2 air exchanges of outdoor air per hour Endoscopy rooms should have 6 complete air Endoscopy rooms should have 6 complete air

exchanges per hourexchanges per hour Bronchoscopy rooms should have 12 complete air Bronchoscopy rooms should have 12 complete air

exchanges per hourexchanges per hour Air should not be recirculated by means of room unitsAir should not be recirculated by means of room units Relative humidity should be 30-60%Relative humidity should be 30-60% Temperature should be 68-73°FTemperature should be 68-73°F

Technical aspects…Technical aspects…

Patients with symptoms of infections Patients with symptoms of infections transmitted via airborne droplet transmitted via airborne droplet nuclei…nuclei… Test must be absolutely necessaryTest must be absolutely necessary Perform only in room with following parameters:Perform only in room with following parameters:

Negative pressureNegative pressure 12 air exchanges per hour and direct exhaust to the 12 air exchanges per hour and direct exhaust to the

outdoors more than 25 feet from an air intake or filters outdoors more than 25 feet from an air intake or filters through a HEPA filterthrough a HEPA filter

Staff wear N-95 respirators or PAPRsStaff wear N-95 respirators or PAPRs Maintain airborne precautions after procedureMaintain airborne precautions after procedure Do not reuse room until sufficient air exchanges have Do not reuse room until sufficient air exchanges have

taken placetaken place

Technical aspects…Technical aspects…

Reprocessing Area/RoomReprocessing Area/Room Should be a separate areaShould be a separate area Adequate space for reprocessingAdequate space for reprocessing Appropriate air flow – negative air pressureAppropriate air flow – negative air pressure Ventilation – 10 air exchanges per hour; appropriate Ventilation – 10 air exchanges per hour; appropriate

to the chemicals utilizedto the chemicals utilized Not recirculated via room unitNot recirculated via room unit Appropriate workflow pattern – dirty to cleanAppropriate workflow pattern – dirty to clean Must minimize opportunity for cross contaminationMust minimize opportunity for cross contamination Storage facilities separate from processing facilitiesStorage facilities separate from processing facilities

Emerging pathogens Emerging pathogens and future and future

challenges…challenges… CryptosporidiumCryptosporidium Helicobacter pyloriHelicobacter pylori E. coli 0157:H7E. coli 0157:H7 RotavirusRotavirus HPV (Human Papilloma Virus)HPV (Human Papilloma Virus) NorovirusNorovirus SARSSARS Creutzfeld-Jacob Disease (CJD)Creutzfeld-Jacob Disease (CJD) Antibiotic Resistant Bacteria – Antibiotic Resistant Bacteria –

resistant to disinfectantsresistant to disinfectants

Resources…Resources…

AORN – Association of periOperative AORN – Association of periOperative Registered NursesRegistered Nurses

AAMI – Association for the Advancement of AAMI – Association for the Advancement of Medical InstrumentationMedical Instrumentation

CDC – Centers for Disease Control and CDC – Centers for Disease Control and PreventionPrevention

APIC – Association for Professionals in APIC – Association for Professionals in Infection ControlInfection Control

FDA – Food and Drug AdministrationFDA – Food and Drug Administration EPA – Environmental Protection AgencyEPA – Environmental Protection Agency SHEA – Society for Healthcare Epidemiology SHEA – Society for Healthcare Epidemiology

in Americain America ASGE – American Society for Gastrointestinal ASGE – American Society for Gastrointestinal

EndoscopyEndoscopy

Thank you and…Thank you and…