A DEEPER CLEAN Flexible endoscopes present some of the hardest reprocessing challenges, from transportation to manual cleaning.

From "superbug" outbreaks to low hand hygiene compliance rates, infection preventionists say there are plenty of cross-contamination threats that keep them up at night. We spoke to them about some of their current top concerns and what you can do to keep your facility free from infection.

— Kendal Gapinski

Meet Our Experts

Donna Nucci, RN, CIC, infection preventionist for Yale-New Haven (Conn.) Hospital and founder of Educated Nurses.

Marcia Patrick, RN, MSN, CIC, consultant and educator in infection prevention for the Association for Professionals in Infection Control and Epidemiology (APIC) in Tacoma, Wash.

Lori Groven, RN, BSN, MSPHN, CIC, infection preventionist at TRIA Orthopaedic Center in Bloomington, Minn.

Heather Hohenberger, BSN, RN, CIC, CNOR, CPHQ, quality improvement consultant, perioperative services at Indiana University Health.

MISSED SPOTS To ensure high-touch areas are cleaned between cases, TRIA Orthopaedic Center swabs and tests surfaces for ATP, a protein found in bioburden.

What are the biggest threats of cross-contamination?
Ms. Nucci: I'm particularly concerned about surface and environmental cross-contamination, especially when it comes to spores like C. diff., which are extremely difficult to kill. Apart from that, facilities also tend to have issues maintaining and handling dirty equipment, especially flexible endoscopes.

Ms. Patrick: It really depends on the facility. An endoscopy facility has different risks than standard surgery, where you're cutting through the skin. But when we look globally, hand hygiene compliance is a big one, as is disinfection of endoscopes, especially with the recent duodenoscope problems. Environmental cleaning and disinfection are also top concerns.

What can facilities do to improve their hand hygiene compliance?
Ms. Hohenberger: We have to come back to basics and make sure that we're consistently performing hand hygiene at all of the 5 moments (before touching a patient, before a procedure, after a procedure, after touching a patient and after touching a patient's surroundings), whether it's using soap and water or an alcohol hand rub. Hand hygiene is the No. 1 way to stop the spread of disease, whether it's in the hospital acute care or outpatient environment. It's a universal first line of defense.

Ms. Nucci: Time and time again, studies show that it's all about opportunity. You have to make things easy and error-proof for healthcare workers who are already being pulled in 7 different directions. I work with frontline staff and managers to walk around their unit and ask them where they need more hand hygiene opportunities.

Ms. Patrick: Some facilities also do "secret shopper" observations. But a lot of times, staff can easily identify what's going on. When I would do observations, some of them would catch on that I'm not just there to sit at the desk and hang out. Electric monitoring systems can help, but they come with an added cost. The best thing is to engrain it in the culture. If someone sees someone not complying, they should feel comfortable enough to urge him to wash his hands, or even take a bottle of alcohol-based rub and dispense it out.

Ms. Groven: We've had success with doing real-time observations and posting monthly results in our break room, broken down by department. But we also ask patients to get involved. We hand out forms that patients can fill out to say whether or not they saw their clinician washing their hands. When we only posted staff observation results, we would hear providers say that the scores weren't accurate since the employee couldn't see them washing their hands in the room. Well, the patient is in the room, and they now let us know whether or not they're complying.

PRE-CLEANING MADE EASY One of the simplest ways to prevent cross contamination during endoscopy procedures is to use single-use kits featuring a disposable brush, basin, lube bottle and sponge.

What are the most common mistakes facilities make during room turnover?
Ms. Groven: I worry about staff feeling rushed. Since we do orthopedics, sometimes the procedures are only 10 minutes long. We make sure turnovers are being done properly by constantly auditing and observing staff. We've recently started ATP testing on high-touch surfaces in the room, like the forced-air warmer cables, anesthesia cart and keyboards.

Ms. Nucci: C. diff. spores are an underestimated problem. They live on healthcare providers' hands and the environment, and you need soap and water to get them off. There are studies supporting the idea that a contaminated environment can lead to transmission of infection in a healthcare facility. One study's findings suggest that after a patient with C. diff. is discharged, the subsequent patient admitted to that same room has an increased risk of C. diff. Facilities need to standardize cleaning with a bleach-based product for these rooms, and ensure they have enough educated staff members to clean the rooms.

Ms. Hohenberger: One of the key foundations is making sure that the individuals doing the environmental cleaning are trained on how to do it properly and that they know their roles. If you have multiple people working in one room, sometimes things can get missed if roles are not clearly delegated. For example, you might want to have a policy that the anesthesia tech is in charge of cleaning the anesthesia cart, while another tech is always in charge of the back table and floor.

Would whole-room disinfection help in these instances?
Ms. Patrick: Some facilities, particularly hospitals that are seeing C. diff., MRSA and now CRE, have found that whole-room disinfection does help. I think the jury is still out on which one of the processes is optimal, but there seems to be some potential there. The downside, though, is cost and turnaround time. They can take several minutes to work, so they aren't practical for use in-between each case. Most seem to be using it after patients with a known infection or at night during terminal cleaning.

Ms. Nucci: We still need a considerable amount of testing and valid studies before good-old-fashioned cleaning is replaced. But, if I had to venture a guess, I believe we'll eventually get to a place where it will be standard to have UV lights or hydrogen peroxide sprayers built into the OR so you can just flip a switch and clean the entire room. I am hopeful the next 20 years will advance cleaning to a different level of efficacy.

GERM KILLER Good hand hygiene among staffers and doctors is the best defense against cross-contamination.

How can facilities beef up their central sterile departments?
Ms. Patrick: The biggest problem I see is not following the manufacturer's instructions for use (IFUs). You need to look at the sterilizer's instructions, the instrument manufacturer's directions and even the wrapper or container's IFUs. Sometimes they conflict. If that's the case, then you need to contact the manufacturers to choose the right process, though usually it's best to go with the one that's most stringent.

Training and certification of technicians can also help. I know I personally hate it when I go into a facility and the staffers or surgeons say, "I love when so-and-so is back in central sterile, he gets the job done in 10 minutes!" Then you go check the high-level disinfection solution and see that it requires a 12-minute dwell time. Often these techs have only a high school diploma, get on-the-job training and don't understand the complexity and need to follow each and every step, especially if a doctor is behind them screaming they need the scope.

Speaking of scopes, problems with flexible endoscope reprocessing have been all over the news recently. How can facilities reduce their risk?
Ms. Nucci: I regularly see several issues with endoscope reprocessing, and not just the manual cleaning issues that have been in the headlines. Staff should be pre-cleaning the scopes at the point of use and flushing them with an enzymatic solution before sending them to decontamination. You often see staff reusing basins or sponges to pre-clean, which risks cross-contamination. I instead advocate for single-use kits that contain everything you need for the procedure and pre-cleaning, like disposable sponges, basins, brushes and lube. You can make them yourself, or buy them pre-made.

Once pre-cleaned, there are sometimes problems handling the scopes. If the person who pre-cleans and transports it to decontamination isn't wearing the right PPE, her scrubs become contaminated. If she is also the one cleaning, reprocessing and storing the scope, now her contaminated scrubs have put that clean scope at risk. Best practice would be to advocate for a standard procedure for maintaining clean and dirty. One person can be in charge of pre-cleaning, decontaminating and placing the scope in the AER, all while wearing the recommended PPE. Then, a person not contaminated by the cleaning process maintains the newly reprocessed scope, getting it out of the AER and storing it.

Ms. Patrick: Endoscopes' design makes them inherently difficult to clean. If you can't see the surface, it's hard to know if it's clean. But there are options out there to help, like little scopes with a light source that let you look inside the scope's lumens or ATP cleaning verification tests. One thing some of the bigger hospitals are doing is culturing scopes more regularly. They aspirate sterile water through the scope and then send the sample to their lab for testing. Some do it for all scopes, while others may only do it for their complex scopes. You need to start by doing a risk assessment, and shape your process from there.

Ms. Hohenberger: It also helps to ensure that you have enough endoscopes to match your case volume. That allows techs enough time to reprocess them correctly.

Ms. Groven: We don't use flexible scopes at my current facility, but if we did, they would be my top concern. I don't envy anyone at facilities that do use them. OSM