THIS WEEK'S ARTICLES
10 Steps to a Clean, Disinfected Endoscope
To ensure these devices safe for reuse, don't cut corners.
The proper cleaning and disinfection of flexible endoscopes is a difficult, detailed task that includes dozens of steps. These complex devices can present serious health risks to patients when improperly cleaned. If it's been a while since you've assessed your scope care protocols and techniques, here are some key points to review.
- Preclean at the bedside. Procedural staff should follow instructions for use (IFU) to remove bioburden and prevent buildup of biofilm. Don't give this aspect short shrift, because scopes that aren't properly cleaned can't be properly high-level disinfected. "Fortunately, bedside kits for cleaning endoscopes immediately after they've been used are readily available," notes Casey Czarnowski, BA, CRCST, CSPDT, CIS, CER, sterile processing educator at Stanford (Calif.) Health Care. "They include a small plastic basin, a packet of powdered soap and a syringe."
- Prepare for safe transport. Place contaminated scopes into a closed bag or a sealed rigid container for transport to the reprocessing area.
- Test for leaks. Hook scopes up to an automated leak tester, which can detect damage to external surfaces and internal channels. The sooner you catch and repair these tiny imperfections, the better you can address them not just for patient safety, but also to extend the lives of the scopes. "Don't rush through this step," advises Joyce Mackler, RN, MSN, CASC, nurse manager at Seaford (Del.) Endoscopy Center. "Observe scopes in clean water for at least 30 seconds while angulating the bending sections in all directions."
- Time is of the essence. Don't let scopes sit for more than an hour before manual cleaning. "Delays can lead to bioburden remaining on or in the scope, which increases cross-contamination and infection risks," says Jorge Tavera, CGTS, a reprocessing tech at PIH Health Downey (Calif.) Hospital. Adds Mr. Czarnowski, "Scope manufacturers have recently instituted delayed-processing protocols that not all scope owners know about." Those protocols usually call for an extended soaking period before high-level disinfection if scopes sit for more than an hour after procedures before manual cleaning begins.
- Manually clean. Brush the scope's internal channels with properly sized brushes, then connect the scope to a machine that flushes the channels with enzymatic soap for one minute. Brush again, then reconnect to the flushing machine, this time flushing the channels with clean water. Wipe down the outside of the scope with clean water.
- Visually inspect. Check the outside of the scope with a 10x magnifying glass to inspect for residual soil. Always inspect the tip of the scope, where bacteria often hide, notes Mr. Tavera. Use a borescope to examine internal channels.
- Load the washing machine. Place properly cleaned scopes into an automated endoscope reprocessor (AER), following the device manufacturer's IFUs to determine the proper dilution of the detergent. If scopes aren't clean, more manual brushing and flushing is necessary.
- Rinse and dry. At the end of the AER cycle, thoroughly rinse scopes with clean water and use a lint-free cloth to wipe down their exteriors. Dry the inside of scopes by pushing forced air through the channels. "Always air dry or blow dry scopes before storing them," says Mr. Tavera.
- Properly store. At the very least, have a cabinet designated for this function. Hang your scopes vertically, which promotes drying and prevents recontamination. Specialized scope storage cabinets offer built-in fans and HEPA filters to enhance the drying process.
- Document the entire process. If an infection occurs, it'll be much easier to trace a scope to a case if you track usage. "Tag each scope with the month and day it was last used and cleaned," says Mr. Tavera.
Overall, never oversimplify scope reprocessing. "Don't skip any of the steps, and don't go through the motions," says Mr. Tavera.
Standardizing Your Skin Prepping Practices
Paring down products and monitoring compliance protects patients and cuts costs.
The larger your roster of doctors and nurses, the more unwieldy and error-prone your skin preparation practices can become in the absence of strict protocols. With a process like skin prepping, rampant variation can exist in everything from training to solutions to application technique.
Pare down the number of skin prep solutions your facility uses, recommends Khaled J. Saleh, MD, MPH, MHCM, FRCS(C), CPD, the CEO of Saleh Medical Innovations Consulting and Sphere Orthopaedics & Regenerative Health,. Dr. Saleh teamed with facility administrators to review the clinical and business cases for prepping product by having surgeons list the Strengths, Weaknesses, Opportunities and Threats (SWOT) associated with their preps of choice.
"Surgeons are driven by numbers and data," says Jesse Hixson, MSN, RN, CNOR, director of nursing at Allegheny Health Network in Monroeville, Pa. "Show them the current cost per case and what the cost per case is likely to be after the changes to the prepping protocols are made."
Limiting your choices of prepping solutions will cut down on variations in application requirements, but auditing staff for compliance with your skin prep protocols remains vital. "You have to keep entering ORs and conducting blind audits," says Mr. Hixson. "If you're not constantly critiquing staff, they get lax in their practice."
When auditing staff, watch if they follow these basic skin prepping practices:
- Proper application. Staff should have a clear understanding of how each prepping solution needs to be applied. For example, when they perform a chlorhexidine gluconate (CHG) prep, they should start at the incision site, work out in concentric circles and never reverse direction back to the incision site. "Explain to them that moving from a dirty to clean area can contaminate the area around the incision," says Mr. Hixson.
- Proper coverage. Never assume the same number of CHG application sticks will adequately cover the area around the surgical site for every patient. Patient assessment prior to prepping should focus on the size of the extremities. You don't want nurses to try to stretch the contents of a single applicator instead of reaching for another one. "Prepping a former football player for a shoulder arthroscopy will require more solution than what's needed for a 70-year-old woman," says Mr. Hixson.
- Avoid shortcuts. Don't allow hurried staff to lean on seemingly harmless workarounds that could jeopardize patient safety. For example, if nurses prepping the abdomen reach across patients instead of walking around the table, their scrubs could contaminate prep sites.
Mr. Hixson says proper and effective skin prepping is ultimately about eliminating variables, streamlining the process wherever possible and getting everybody on the same page to maintain a laser-focus on proper patient care.
Key Advantages of OR Turnover Kits
Reducing room turnover time, improving efficiency and decreasing the risk of cross-contamination.
Hospitals in today's environment are looking for ways to reduce cross-contamination, improve efficiency and minimize lost revenue. These critical issues converge when evaluating a facility's operating room turnover process.
One element of financial concern is the lost revenue associated with operating room turnover time. Every minute spent cleaning and turning over a room in between procedures is time the OR is not generating revenue. This lost revenue can become costly to the healthcare facility over time.
While often difficult to quantify, the cost of an "OR minute" is generally made up of fixed costs such as equipment and utilities as well as variable costs such as supplies and wages. While studies vary in their estimate of the cost per minute for OR time, figures indicate that the cost per minute ranges from $29 per minute for low complexity to a high of $80 per minute for high complexity procedures.1 In today's competitive environment, significant potential revenue can no longer be overlooked.
As facilities explore potential options to improve turnover times, many have implemented the use of room turnover kits. These kits have shown to shorten turnover times when used in combination with an organized process of assigning staff specific tasks in the process of room turnover. Defining and assigning tasks to specific staff members can have a significant impact on decreasing turnover times while streamlining the entire process.
While some facilities choose to stock multiple items separately, many find that single-use kits are ideal for reducing turnover time. Custom, pre-assembled kits include all the items needed to turn over the room quickly and efficiently, including disposable linens, patient safety straps, mop heads, replacement waste bags and fluid solidifier. These items help reduce turnover time and potentially add thousands of dollars in revenue over time.
Another advantage of turnover kits is consistency in cleaning practices, a critical element in decreasing the risk of HAIs and SSIs. Operating rooms are challenged to maintain sterile, clean environments. Handling multiple patients with varying procedures in a single day requires consistent processes and practices to ensure that each patient is provided with the safest environment possible. Impervious, disposable linens found in turnover kits can protect the OR table from contamination by limiting exposure to excess fluids. Additionally, antimicrobial, disposable linens can also protect the patient from harmful bacteria and viruses that may be harbored in the cracks and crevices of the OR mattress.
Ansell's unique STAT-PAC O.R. Turnover Kits feature the only disposable linens with antimicrobial protection against bacterial migration and strike-through contamination. STAT-BLOC™ Linens are 99.9% effective against E.coli, MRSA and CRE and now show efficacy against COVID-19.2 In a time when the fight against cross-contamination is critical, these disposable, antimicrobial linens are an infection prevention tool that every healthcare facility should have on hand.
1. Macario, A. "What does one minute of operating room time cost" Journal of Clinical Anesthesia. 2010 22, 233-236
2. Data on file. Visit www.ansell.com/stat-bloc
COVID-19 Might Not Stick on Surfaces
Researchers don't detect the coronavirus on high-touch areas next to COVID-19 hospital units.
Just how long does the coronavirus stay infectious on surfaces? New research suggests it's not for very long.
The study, performed last May in a Spanish hospital, examined the bacterial load of high-touch surfaces located in public areas next to COVID-19 units. Researchers collected 92 samples which were obtained from 46 different high-touch surfaces: 36 sites next to COVID-19 units and 10 in public elevators. The sites were sampled four hours after routine cleaning with 1,000 ppm sodium hypochlorite, with two samples obtained at each site.
Despite finding high bacterial loads indicative of recent high touch, researchers found no indication of the coronavirus on any of the surfaces. The finding is even more eye-opening due to the characteristics of the building in which the study was performed. Everyone entering or leaving the COVID-19 units had to pass through the areas studied, which included bathrooms, hallways, coffee machines, wall phones, railings, elevator buttons and waste areas.
The researchers conclude, "Our data indicate that environmental contamination with SARS-CoV-2 in public areas in the vicinity of COVID-19 hospitalization units does not seem to be of great magnitude."
Before you alter your enhanced surface disinfection protocols, however, the researchers noted several caveats, and say the subject merits further, wider study. "Our results are probably affected by the exceptional circumstances adopted by the hospital during the pandemic period," they write. "As no visitors were permitted, the contamination of surfaces was probably much lower than that during the normal functioning of the hospital." They also note that masking was mandatory in the facility, and say the findings "support the hypothesis that compliance with infection prevention practices of health care workers assisting COVID-19 patients was appropriate, especially universal masking and hand hygiene adherence."
Experts come together in a 'moment in time' study to determine what providers still need to know and do about the virus.
The Society for Healthcare Epidemiology of America (SHEA) last month announced that 40 experts in epidemiology and infectious diseases have teamed up to define critical areas of study needed to inform clinical practice, policy and prevention strategies for COVID-19 and future pandemics.
The new research agenda identifies crucial gaps in understanding of the epidemiology, transmission and consequences of COVID-19 and other viral diseases.
Among the most pressing matters, according to the group:
- Understanding the spread of the virus through asymptomatic and pre-symptomatic patients infected with COVID-19;
- Determining how risk factors impact the severity of the disease;
- Understanding long-term cardiometabolic, respiratory, neurological and psychological impacts of the virus;
- Developing tools to identify outbreaks more rapidly in healthcare settings so that early interventions can curtail outbreaks;
- Improving the understanding of personal protective equipment (PPE), including socio-behavioral reasons for not following PPE guidance, as well as the continued need for PPE during and after the pandemic.
As the one-year mark of the pandemic approaches, knowledge and understanding about COVID-19 has grown, but as these study recommendations show, so much more remains unknown, and the situation remains extremely fluid. The authors note their agenda, while a significant tool for shaping the scientific process, represents expert opinion at "a moment in time during the worst days of the COVID-19 pandemic," and that "priorities may shift as the pandemic evolves and as vaccines and other therapeutics become available."