Infection Prevention

Reports emerged six years ago about fatal outbreaks of antibiotic-resistant bacteria in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). In response, the CDC provided guidance on how to set up an Interim Duodenoscope Surveillance Protocol (IDSP), which involves culturing the scopes for residual pathogens. We adapted the protocol to fit our facility's capabilities and came up with a program to ensure these difficult-to-clean devices are properly cared for and closely monitored. Here are its key elements:

• Inventory management. Develop a method for tracking scopes, and a quarantine process for scopes awaiting culture results. Have staff log the model of the scope and the date it was cleaned, quarantined and cultured. Staff should also note who performed the culture, the date of reprocessing after the culture and the date of quarantine pending return of the culture. Finally, the date the cultures were returned, whether they were deemed acceptable or unacceptable and who released the scope from quarantine should all be recorded. Knowing who was involved during the process and at which step will allow you to identify those who may need further training.

You should also develop a premature release and tracking protocol for emergency use. Thanks to our logs, we could easily track scopes prematurely removed from quarantine. For example, cultures for scopes used on Monday morning and cultured that afternoon aren't back until Wednesday or Thursday. But if an emergency case requires use of that scope on Tuesday, and the cultures taken Monday subsequently come back "unacceptable," we'd easily be able to inform both the Monday patient and the Tuesday emergency patient of possible exposure. Fortunately, we've never had an instance where a scope pulled out of quarantine came back "unacceptable."

• Categorize pathogens. In a paper I recently coauthored (osmag.net/UMe9Md), we identified "high concerning" contaminants as yeast, Staph aureus, enterococci, and gram-negative enteric bacilli. "Low concerning" organisms were coagulase-negative staphylococci, micrococci, and gram-positive rods.

Very low numbers of low concerning organisms are considered "acceptable." Remember, you're not sterilizing scopes. You're high-level disinfecting them, so you can't expect a totally negative culture. Unacceptable culture results require scope recleaning, reculturing and a return to quarantine pending results of the second culture.

• Make the job easier. You can't expect staff members to remember each step of the more than 40 involved in scope reprocessing. To help make the difficult task of cleaning scopes a bit easier, I created a laminated placard — comprise of three legal-sized pieces of paper — listing all of the required steps, along with how-to pictures. They're readily available, in-the-moment visual aids for staff to reference. You should also implement skill validation sessions and educational in-services to ensure staff understand and follow proper reprocessing protocols.
• Keep adapting. The cleaning brush our scope vendor recommended had a wire loop at the distal end that was very close in size to the diameter of the elevator channel on our pediatric duodenoscope, and we were concerned about causing damage by trying to force the brush into the channel.

We were forced to choose between the manufacturer-recommended brush or continuing to use cytology brushes because they come sterile and are smaller in diameter. We chose the latter. It was the best option we had.

While deciding between the brush options, we made another discovery. A new proceduralist wanted to use endoscopic ultrasound scopes, but the elevator mechanism in some models was similarly designed to that in our duodenoscopes, making them more challenging to clean. We therefore applied our duodenoscope culturing process to the endoscopic ultrasound scope. That was a proactive step on our part.

We've never had any trouble with infections from duodenoscopes — most likely because we're constantly refining our cleaning processes based on the latest data and guidelines, as well as our own experiences. OSM