Now, let's welcome Jim Collins. Jim is the Endoscopy Accreditation Nurse for the Digestive Disease and Surgical Institute at the Cleveland Clinic. He serves on various ASG committees and has been active at the national and local levels of the Society of Gastroenterology Nurses and Associates for many years. Jim is the co-author of the Multi-Society Guideline on Reprocessing Flexible GI Endoscopes and Accessories. Thank you, Jim, for being here today. Take it away. All right. I do have a disclosure to make. I do have a financial relationship with Boston Scientific and Steris U.S. Endoscopy in the form of consulting as well as honorariums paid for educational sessions that I perform for them. So when we think of infection prevention and endoscopy, one thinks of infection prevention and endoscopy. They think of endoscope-associated infections first and foremost. However, as we have learned, endoscope-associated infections play such a small component of what goes on within the endoscopy unit in terms of infection prevention. As we've just learned, EAIs are low-frequency. There is often a long lag time between colonization and the appearance of the infection. We do have an adequate surveillance of outpatient procedures. Pathogens usually are the enteric flora within our own bodies, and the risk of some procedures might be lower than in other procedures which are performed. So when we look at the etiologies of infections when they do occur, we have found them to be related to irrigation tubings that have not been properly changed or are malfunctioning. Sometimes there's the absence of the check valve that's required on these tubings. With the supply chain shortages, we have had water bottles, reusable water bottles, reappear into the environments, and often these water bottles have not been properly high-level disinfected or sterilized. We see the improper reprocessing of endoscopic accessories, such as reusable biopsy forceps being high-level disinfected instead of sterilized, and we also have seen the reuse of single-use disposable appliances. Again mentioned, good hand hygiene practices. There has been documentation of contamination via hands of the caregivers, environmental concerns of improper room hygiene in between procedures, and as noted before, improperly handling of syringes and tubings, needles as single and multi-dose vials, and not prescribing to the appropriate use of personal protective equipment. My next three slides will share with you some findings from accreditation surveys, and as noted, we see that the infection control standards are often one of the most cited standards by surveyors. These are from the Joint Commission for the first six months of 2022, which noted that in ambulatory care centers that infection control standards was the leading standard which was cited. And we also find this true to be in hospitals as well in office-based surgical centers as well. So our surveyors, regardless of the accreditation agency they work for, are well-versed and become quite in-tuned into infection prevention within our endoscopy units. Looking at the specific standards, we look at performing high-level disinfection and sterilization of medical equipment. This namely involves the use of our reprocessing personnel and also how the endoscopes are reprocessed, so one of the major citations. Also we see that cleaning and performing low-level disinfection of medical devices, and this can be the before-mentioned glucometers that were found to be inadequately disinfected between patient use and often found to have residual bio-burden from previous uses when inspected by surveyors. That the facilities implements infection prevention and control activities while doing the following, storing medical equipment, storage of endoscopes, cabinets are one of the foremost areas which surveyors will take attention to. Looking at are the endoscope cabinets clean, are the endoscopes stored in a vertical fashion unless you have horizontal approved cabinets to ensure there's no puddles at the bottom of these cabinets. So again, making sure that we have safe environments for our endoscopes to be stored. Also looking at the correct use of personal protective equipments while we are performing the duties that we do through standard precautions. And also we see this is an environment of care standard related to personal protective equipment when we handle chemicals. So this can be a dual citation when we look at our reprocessing personnel due to the fact that they can cite both improper use of PPE during cleaning and disinfection of endoscopes as well as handling of the chemicals. So again, PPE being a paramount component in practice of infection prevention. So we're going to look at the process of cleaning an endoscope, which is typically a two semester, 10 credit course. So we'll cut it down into these 20 minutes that we do have. Endoscope reprocessing is very detailed and meticulous performance that needs to be done. It's basically made up of nine steps from pre-cleaning the endoscope at the point of use to storage of the endoscope. Each one of these nine steps has inherited areas where breakdowns can occur and often do occur. And when we look at the research that has been done, Corey Ofsted about 10 years ago went ahead and identified various areas within endoscope reprocessing where breakdowns occurred with majority being with incorrect brushing of the endoscope, as well as not brushing all the channels, incorrect bristle size, incorrect brush length have been noted, not appropriate drying the channels of the endoscopes between various processes of endoscope reprocessing, using sudsy water for the leak test, which can hide and camouflage any leaks that may be present on our endoscopes, skipping air purges between rinses and disinfection cycles, not properly flushing with an alcohol at the end of a recycling period, and also skipping the final drying and wipe down of an endoscope after it has been reprocessed. She's also found that there are a high number of human factors that aid within these reprocessing deficiencies in occurring. Three quarters of our reprocessing staff feel very pressured to work very quickly to meet demands of the department due to lack of inventory or just the number of endoscopes which need to be reprocessed. Nearly half complain of some sort of muscular pain that's associated with endoscope reprocessing, which led up to 30% of our staff to feel that this interfered with their performance in endoscope reprocessing, forcing a quarter of them to miss work from these type of injuries and interfering with their outside activities from work. Personal protective equipment, again, is the key of standard precautions. We need to ensure that we have the correct sizes for all our staff members, from extra small gloves to jumbo gowns, to ensure that all our staff are appropriately protected, to ensure that we have the right type of gowns for endoscope reprocessing, that the thin isolation gowns don't offer the fluid resistance that's required, as well as having the right type of gloves for our reprocessing techs, not having the standard exam gloves, but having high-wristed gloves to prevent any seepage of cleaning solutions into their hand compartments. Hand hygiene is a paramount of infection prevention, noted from the mid-1800s by Dr. Simmelweiss in Vienna, I believe. Hand washing to ensure that staff know the correct use of the popular alcohol hand sanitizers that are utilized today to dispense the correct amount and to rub their hands together for the right length of time. Also when to practice hand hygiene, and if they do wash their hands, if they're washing their hands for the correct amount of time. And when you do have your hand washing audits that are done, include all caregivers within your surveillance, and be sure to publicize this and let your caregivers know how well you're doing with the hand hygiene compliance. Now environmental hygiene, we want to ensure that we keep a clean and safe sanitary environment. Those EKG electrodes are allegedly patient-ready. I think I'd have reservations of using them. We want to ensure that when we clean our devices, again, low-level disinfection is often noted as a deficiency within disinfection practices. So we want to ensure that we are utilizing all equipment and cleaning them appropriately, and especially when we may have patients who present and need special precautions done, such as our C. diff patients that arrive, that when we're scheduling them and that we're utilizing the correct low-level disinfectant to handle durable medical goods. Know the wet times of the wipes that you are using, the disinfectant wipes, due to, again, supply chain shortages. We find that the wet time of these wipes vary greatly from a one-minute kill to a four-minute kill. So ensure the staff understand fully what the wet time is, that that's the wet time that the material has to be wet and in contact with the appliance being disinfected. Disinfection practices still, first and foremost, have to ensure that those single-dose vials truly are single-dose, that if multi-dose vials are utilized that they are utilized correctly, syringes and needles are utilized one time. And we want to create a culture of safety within our GI unit, and creating this culture of safety will increase the high reliability of our unit. Sound infection prevention plan to have the manufacturer's instructions for use readily accessible for staff to review, that they are up-to-date, that our safety data sheets, our SDS, are also up-to-date and readily accessible to all employees. And of course, our exposure control plan, in case there would be a blood or body fluid exposure, that all our staff have the personal protective equipment that is needed and the safe injection practices are followed. Meticulous endoscope reprocessing education is done, and that skill competency verification is done at least annually. You also would want to perform education competency verification whenever new procedures are put into place or new equipment has been purchased, or when there has been a breach that has been observed during reprocessing. You also want to ensure that you have appropriate space for reprocessing to be done, that the reprocessing follows a unidirectional flow from the contaminated area to the clean area, as was illustrated by our previous lecture, and that we also have adequate staff, and the staff have the time to process the endoscopes, which can be problematic when we have late procedures and also have procedures that occur on weekends. The SGE and the SG&A have infection control guidelines that are published and readily available for you to review to help create sound practices of infection control within your endoscopy units. Quality assurance issues, again, making sure that those reprocessing policies are up to date. MIFUs happen to change, they may change without notice. There was just a notice sent out by a manufacturer a few days ago on duodenoscope reprocessing that the manual is now 330-some pages long. So again, being able to review those processes and ensure that it's shared with the appropriate staff through regular education and competency scale verification. Also want to ensure that you have the traceability of your endoscopes through the entire high-level disinfection process, as well as being able to correlate that to patient use. Routine maintenance of our equipment has to be well documented. These are repairs of our endoscopes and also the maintenance that is done on other equipment we have, such as our AERs, our automated flushing devices. And now that scope storage has become more complex, many of these scope cabinets have filters that need to be changed on a routine schedule as well. So what do you do if an infection is suspected? Well, ASGE has a reprocessing failure guideline that can be implemented in case you have a suspected breach in reprocessing that led to EAI. That leads to the reporting of the event through institutional processes, as well as local authorities that are needed. Notification also lends guidelines towards the need for serological testing of patients and to help establish helplines for the patients to call in in counseling services. So what practice pearls may I lend to you is that endoscopy is truly a life-saving technology. And again, as we learned, infections are extremely rare. The bloodborne pathogens are easily eradicated by the high-level disinfectants that we utilize in today's cleaning of endoscopes and adherence to these established meticulous cleaning standards are crucial for our patient safety. I do have a couple questions that I'd like to share with you. While rounding one afternoon, you notice a disposable gowns that have been hung on the back of chairs in endoscopy procedure rooms. As the unit manager, you are aware that these gowns are to be, one, worn for the procedure and discarded when the gown is doffed, reused for the day's procedures due to supply chain interruptions, three, reused until the gown becomes visibly soiled. Oh, they did very well. Congratulations. They're worn for the procedure and discarded when doffed. That's very good. So since you did so well, should we try another? Okay. Number two, a new carer has joined the team in your endoscopy unit while wiping down a stretcher between patients' use with a disinfectant wipe. You notice the caregiver immediately placing fresh linen on the stretcher. You are aware that, one, manufacturer of the disinfectant wipes often exaggerate the wet time of these wipes. It is okay to proceed with placing fresh linen on the stretcher. The wet time must be observed to ensure disinfection of the stretcher surfaces, and three, the wet times must be observed when the surfaces of the stretcher are visibly soiled. Oh, again, very well. Number two is the correct answer. Isn't that something? Okay. What a smart audience we have. When orienting a new caregiver, infection prevention strategies in the endoscopy unit should include the following, sound hand hygiene practices, safe medication administration practices, meticulous endoscope reprocessing, sound environmental cleaning practices, five, all of the above. Excellent. It is acceptable practice to forego point-of-use treatment or pre-cleaning of an endoscope after a procedure if the manually cleaning process shall be carried out immediately post-procedure in the reprocessing room. Is this true or false? Yes, false is the answer. Pre-cleaning must always be done. And the last one, since there's five, while rounding in the reprocessing room, you note that the minimum effective concentration of the disinfectant solution is only documented as being performed daily. You are aware of, is okay to only monitor the MEC of the disinfectant solution at the beginning of the day. The MEC of the disinfectant solution must be performed when the first endoscope is disinfected and with the last endoscope disinfected for the day. MEC testing is to be performed and documented with each HLD cycle. The last, the number three is correct. So kudos to the audience and their excellent assessment of my questions. And that's all. That's all I have. Thank you for your attention. And I thank the course directors and ASGs for the ability to participate in this session. Here are the references I used for my presentation today, if you would like to go ahead and dig into those.

endoscopy

infection prevention

endoscope-associated infections

hand hygiene

personal protective equipment

reprocessing breakdowns