Disinfection Research Articles

Comparison of agreement in asthmagen exposure assessments between rule-based automatic algorithms and a job exposure matrix in healthcare workers in Australia and Bhutan

Background:Assessment of occupational exposures is an integral component of population-based studies investigating the epidemiology of occupational diseases. However, all the available methods for exposure assessment have been developed, tested and used in high-income countries. Except for a few studies examining pesticide exposures, there is limited research on whether these methods are appropriate for assessing exposure in LMICs. The aim of this study is to compare a task-specific algorithm-based method (OccIDEAS) to a job-specific matrix method (OAsJEM) in the assessment of asthmagen exposures among healthcare workers in a high-income country and a low- and middle- income country (LMIC) to determine an appropriate assessment method for use in LMICs for future research.Methods:Data were obtained from a national cross-sectional survey of occupational asthmagens exposure in Australia and a cross-sectional survey of occupational chemical exposure among Bhutanese healthcare workers. Exposure was assessed using OccIDEAS and the OAsJEM. Prevalence of exposure to asthmagens and inter-rater agreement were calculated.Results:In Australia, the prevalence was higher for a majority of agents when assessed by OccIDEAS than by the OAsJEM (13 versus 3). OccIDEAS identified exposures to a greater number of agents (16 versus 7). The agreement as indicated by κ (Cohen’s Kappa coefficient) for six of the seven agents assessed was poor to fair (0.02 to 0.37). In Bhutan, the prevalence of exposure assessed by OccIDEAS was higher for four of the seven agents and κ was poor for all the four agents assessed (-0.06 to 0.13). The OAsJEM overestimated exposures to high-level disinfectants by assigning exposures to all participants from 10 (Bhutan) and 12 (Australia) ISCO-88 codes; whereas OccIDEAS assigned exposures to varying proportions of participants from these ISCO-codes.Conclusion:There was poor to fair agreement in the assessment of asthmagen exposure in healthcare workers between the two methods. The OAsJEM overestimated the prevalence of certain exposures. As compared to the OAsJEM, OccIDEAS appeared to be more appropriate for evaluating cross-country exposures to asthmagens in healthcare workers due to its inherent quality of assessing task-based determinants and its versatility in being adaptable for use in different countries with different exposure circumstances.

Single-use duodenoscopes are an efficient tool for emergency ERCP in real life.

Background Biliary tract emergencies are managed with endoscopic retrograde cholangiopancreatography (ERCP) using duodenoscopes, which are reusable devices that require high-level disinfection to minimize risk of cross-contamination. Recent reports about newly developed single-use duodenoscopes (SUDs) suggest equivalent performance with reusable duodenoscopes, but the effectiveness of SUDs in emergency ERCP has not yet been studied. Patients and methods We conducted a prospective case series of emergency ERCP procedures using SUDs (EXALT model D-Boston Scientific, United States) in a real-life, tertiary care setting without any possibility of using a back-up reusable duodenoscope. Results Twenty-one emergent ERCPs (acute cholangitis 48%, severe jaundice 38 %, others 14 %) were performed in 19 patients (mean age 49.5±15 years). Almost all procedures (20 of 21; 95 %) were technically and clinically successful, whereas selective cannulation failed in one case. Among the successful ERCPs, five (24 %) were achieved by a novice operator. The image was often considered skewed toward yellow tones (48 %), whereas stiffness and pushability for stent insertion were found suboptimal in 5 % of the procedures, without any impact on procedure success. Conclusions SUDs are effective and appropriate devices for emergent situations in real life even in non-expert hands and even if a regular duodenoscope is unavailable as a backup.

Splash generation and droplet dispersal in a well-designed, centralized high-level disinfection unit

Sterile processing personnel routinely decontaminate medical devices that are heavily soiled with blood, tissue, and secretions. Contamination may spread throughout processing areas, potentially exposing personnel and patient-ready devices, especially when there is insufficient separation between the dirty and clean areas. This study aimed to identify activities that generate splash, determine how far droplets travel during manual cleaning, characterize the impact of practices on splash generation, and assess effectiveness of personal protective equipment (PPE) at preventing splash exposure to technicians and visitors in the decontamination unit. Moisture-detection paper was affixed to PPE and environmental surfaces in a new processing department designed to optimize workflow and prevent cross-contamination. Droplet generation and dispersal were assessed during manual cleaning of a colonoscope and a transvaginal ultrasound probe. Splash was generated by most activities and droplets were detected up to 7.25 feet away. Transporting wet endoscopes dispersed droplets on a 15-foot path from the sink to the automated endoscope reprocessor. Extensive droplets were detected on PPE worn by technicians at the sink and observers 3-4 feet away. Manual cleaning of devices generated substantial splash, drenching technicians and the environment with droplets that traveled more than 7 feet. Engineering controls and better PPE are needed to reduce personnel exposure and risks associated with the potential dispersal of contaminated fluids throughout the facility.

Subacute Pulmonary Toxicity of Glutaraldehyde Aerosols in a Human In Vitro Airway Tissue Model.

Glutaraldehyde (GA) has been cleared by the Center for Devices and Radiological Health (CDRH) of the Food and Drug Administration (FDA) as a high-level disinfectant for disinfecting heat-sensitive medical equipment in hospitals and healthcare facilities. Inhalation exposure to GA is known to cause respiratory irritation and sensitization in animals and humans. To reproduce some of the known in vivo effects elicited by GA, we used a liquid aerosol exposure system and evaluated the tissue responses in a human in vitro airway epithelial tissue model. The cultures were treated at the air interface with various concentrations of GA aerosols on five consecutive days and changes in tissue function and structure were evaluated at select timepoints during the treatment phase and after a 7-day recovery period. Exposure to GA aerosols caused oxidative stress, inhibition of ciliary beating frequency, aberrant mucin production, and disturbance of cytokine and matrix metalloproteinase secretion, as well as morphological transformation. Some effects, such as those on goblet cells and ciliated cells, persisted following the 7-day recovery period. Of note, the functional and structural disturbances observed in GA-treated cultures resemble those found in ortho-phthaldehyde (OPA)-treated cultures. Furthermore, our in vitro findings on GA toxicity partially and qualitatively mimicked those reported in the animal and human survey studies. Taken together, observations from this study demonstrate that the human air-liquid-interface (ALI) airway tissue model, integrated with an in vitro exposure system that simulates human inhalation exposure, could be used for in vitro-based human hazard identification and the risk characterization of aerosolized chemicals.

Green Servitization in the Single-Use Medical Device Industry: How Device OEMs Create Supply Chain Circularity through Reprocessing

Establishing a circular supply chain for single-use medical devices would make a significant contribution to reduce health care-generated emissions. One way in which this can be accomplished is to apply the possibility of device recovery through high-level disinfection and sterilization (a process referred to as ‘reprocessing’). As increasing emphasis is being placed on reducing health care-generated emissions, several major OEMs of single-use medical devices have extended their business to reprocessing services, taking a green servitization orientation. The present paper examines the trend towards green servitization in the single-use medical device industry. It uses interviews with industry experts, complemented with information from secondary sources, to explore how the green servitization phenomenon is supporting the transition of the industry to a more sustainable economic model. The findings provide insights into the green servitization endeavors of device OEMs as regards services offered, strategic intents, dominant business models, use of collaborative relationships and capability requirements. The paper reveals that single-use device OEMs may have started to understand the perspective and the long-term market share gains of combining a service model and a manufacturing model, making reprocessing an integrated part of how they think about how to design, produce and deliver their products.

S1081 Evaluation of Abbreviated HLD Protocols for Duodenoscopes With Disposable Tips

Introduction: Recent observational studies suggest that duodenoscopes with disposable tips have lower rates of bacterial contamination compared to fully reusable duodenoscopes. However, it is unclear if the reprocessing of duodenoscopes with disposable tips can be abbreviated without compromising disinfection efficacy. We evaluated rates of duodenoscope bacterial growth after abbreviated disinfection protocols. Methods: We conducted a two-phase prospective observational study utilizing an abbreviated protocol for the disinfection of Pentax Medical ED34-i10T2 duodenoscopes with disposable tips. Phase 1 (P1), conducted from October 2021 to March 2022, used an abbreviated protocol of one manual wash (MW) prior to one cycle of high-level disinfection (HLD). Phase 2 (P2) was conducted from April to May 2022 and samples were obtained after two MWs and one HLD. Each duodenoscope was sampled in 4 locations per Figure. Samples were plated on routine medias for enteric pathogens including Clostridium difficile and Enterococcus spp. Antibiotic resistance was assessed via PCR for Vancomycin-resistant Enterococcus (VRE). One-sided Fisher’s exact test was done to identify differences in bacterial growth at each sample site in both phases. Contamination was defined by >100 CFU raw growth and >1 CFU C difficile and VRE. Results: P1: 46 duodenoscopes were sampled resulting in 184 sample events. 8 of 46 duodenoscopes had raw growth. 4 grew VRE. None grew C difficile. P2: 25 duodenoscopes were sampled resulting in 100 sample events. 2 of 25 duodenoscopes had raw growth. 4 grew VRE. None grew C difficile. P1 vs P2: There were no significant differences in total bacterial or VRE presence for all sample sites. For sites 2 and 3 in phase 2, the 95% confidence interval for the rate of contamination after two MW was 0.1% to 20.4%. This was higher than the CI limits for the rate of contamination in phase 1 (site 2 95% CI 0%, 7.7%; site 3 95% CI 0.1%, 11.5%). (Figure) Conclusion: In our study, one MW did not grow significantly more bacteria compared with two MW prior to HLD. This suggests that two MW may not be superior to one MW in achieving HLD in duodenoscopes with disposable tips. Duodenoscopes with disposable tips have lower bacterial contamination rates compared to prior FDA data1 on fully reusable duodenoscopes. Our data provide impetus for larger studies of abbreviated HLD protocols. (Table). 1 522 postmarket surveillance studies database: pilot phase (phase 1) of the Sampling and Culturing Study for Pentax. accessdata.fda.gov. 2020.Figure 1.: Sample locations: 1) The elevator tab, 2) instrument channel distal opening, 3) composite duodenoscope tip, and 4) the instrument channel. Samples 1-3 were collected with flocked swabs. The 4th was collected by flushing 25 mL of neutralizing buffer through the instrument channel, then scrubbing the channel with a brush, followed by another 25mL flush. The 50mL eluent was vacuum filtered through a 0.22-micron filter and plated on TSA. Duodenoscope serial numbers were recorded and one duodenoscope grew VRE in Phase 1 and Phase 2. Table 1. - Comparison of Contamination Rates by Sample Site in Phase 1 versus Phase 2 Phase 1 Phase 2 P1 vs. P2 (N=46) 95% CI (N=25) 95% CI p-value Raw Sample Presence ( >100 CFU) Site 1 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%) Site 2 0 (0%) 1 (4.0%) 0.35 (0%, 7.7%) (0.1%, 20.4%) Site 3 1 (2.2%) 1 (4.0%) 0.58 (0.1%, 11.5%) (0.1%, 20.4%) Site 4 7 (15.2%) 0 (0%) 1.00 (6.3%, 28.9%) (0%, 13.7%) Raw Sample Enterococcus Presence ( >1 CFU) Site 1 2 (4.3%) 1 (4.0%) 0.734 (0.5%, 14.8%) (0.1%, 20.4%) Site 2 2 (4.3%) 2 (8.0%) 0.441 (0.5%, 14.8%) (1.0%, 26.0%) Site 3 2 (4.3%) 2 (8.0%) 0.441 (0.5%, 14.8%) (1.0%, 26.0%) Site 4 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%) Raw Sample C. difficile Presence ( >1 CFU) Site 1 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%) Site 2 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%) Site 3 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%) Site 4 0 (0%) 0 (0%) -- (0%, 7.7%) (0%, 13.7%)

S1071 Assessment of Pathogenic Enteric Flora Contaminating Novel Duodenoscopes With Disposable Tips

Introduction: The FDA has advised that endoscopy units use duodenoscopes with disposable components to minimize the risk of duodenoscope-associated infections. Data are emerging on the effectiveness of disposable tips in preventing contamination of the duodenoscope with high-risk organisms. We hypothesize that disposable tips will not eliminate high-risk bacterial contamination. Methods: We conducted a prospective observational study from October 2021 to March 2022 to speciate and quantify the bacterial contamination rate of 46 Pentax Medical ED34-i10T2 duodenoscopes with disposable tips. After disposal of the tip, the duodenoscope was cultured after one manual wash (MW) and one cycle of high-level disinfection (HLD) in an automated endoscope re-processor, and then again after two MW and an additional cycle of HLD. Each duodenoscope was sampled in 4 locations after the first MW-HLD cycle and the second: 1) elevator tab, 2) instrument channel distal opening, 3) composite duodenoscope tip, 4) instrument channel (Figure). Bacterial pathogenicity was classified by the FDA 1 as high-concern (any CFU) and low/moderate-concern organisms ( >100 CFU). Clostridium difficile and Enterococcus faecalis were classified as high-concern organisms. We compared contamination rates to historical data from the FDA surveillance study of Pentax reusable duodenoscopes that demonstrated contamination rates of 6.0% high-concern organisms and 8.2% low/moderate-concern organisms. Results: 46 Duodenoscopes were sampled resulting in 368 sample events. After one MW-HLD cycle, 8 of 46 duodenoscopes remained contaminated with any organism. After the full HLD, 5 of 46 duodenoscopes remained contaminated with any organism. Low/moderate concern organisms were isolated in 2.7% of samples (95% CI 0.9%, 6.2%). High concern organisms were isolated in 0% of samples (95% CI 0%, 2.0%). (Table) Conclusion: Compared to historical FDA data from reusable Pentax duodenoscopes, the rate of low/moderate-concern organism contamination of duodenoscopes with disposable tips was lower, and the confidence interval excluded the historical rate. The rate and confidence interval limits for high-concern organism contamination in our study were also lower than FDA data1. Our results suggest that disposable tips decrease but do not eliminate duodenoscope bacterial contamination. 1 522 postmarket surveillance studies database: pilot phase (phase 1) of the Sampling and Culturing Study for Pentax. accessdata.fda.gov. 2020.Figure 1.: Each duodenoscope was sampled in 4 locations: 1) elevator tab, 2) instrument channel distal opening, 3) composite duodenoscope tip, 4) instrument channel. Samples 1-3 were collected with flocked swabs. Swabs were plated on routine medias for relevant enteric pathogens. The 4th was collected by flushing 25mL of neutralizing buffer through the elevator channel, then scrubbing the channel with a brush, followed by another 25mL flush. The 50mL eluent was vacuum filtered through a 0.22-micron filter and plated on TSA. Antibiotic resistance was assessed via PCR. CFU and proportion of contaminated scopes were compared between MW-HLD cycles. Table 1. - Descriptive Table comparing sample rates to historical FDA reported rates of contamination Outcome Historical Rate Summarized Rate across all Sites (95% CI) Raw sample total low-concern organism >100 CFU presence 8.2% 2.7% (0.9%, 6.2%) Raw sample total high-concern organism (Enterococcus and C difficile) >1 CFU presence 6.0% 0% (0%, 2.0%)

S606 High Rates of Clostridioides difficile Colonization Among Patients Undergoing Gastrointestinal Endoscopy

Introduction: Endoscopy is an essential part of medical care for both diagnostic and therapeutic indications. Gastro-intestinal endoscopy (GIE) can also provide a window into individuals’ microbiome. Clostridiodes difficile infection (CD) is a common healthcare associated infection (HAI) that causes significant morbidity and mortality. The aim of our study is to evaluate the presence of CD in patients undergoing GIE for cancer screening or other indications. Methods: A prospective non-randomized study was performed between December 2021 and April 2022 at GIE suite at an academic medical center. The study included 115 individuals who underwent GIE for screening and other medical reasons (110 outpatients and 5 inpatients). Electronic health records were reviewed for procedure-related information as well previous infection or colonized with CD and resistant bacteria within the past 2 years. A water sample was obtained from the GIE used immediately after use and after processing and high-level disinfection. An environmental culture was used for CD detection. Results: The study had 74 (64%) females and 41 (36%) males with mean age of 57 with a standard deviation of 13 years. The procedures were done by 12 physicians with an average time for the procedure of 37 with a standard deviation of 20 minutes. Only 1 patient was diagnosed with CD previously. However, environmental CD culture was positive in 28 (24%) patients. Post disinfection samples were all negative for CD. The majority of the patients had no multidrug resistant organisms 3 (2.6%). Colonoscopies were predominantly performed for colon cancer screening 104 patients (90%). Conclusion: Colonoscopic examination revealed high prevalence of within the community. Endoscope processing was effective in eliminating CD from the GIE. Hospital associated CD infection could be originating from a community source. Colonized hospitalized patients are at high risk for developing CD disease especially after antibiotic use.

No relation between adenosine triphosphate after manual cleaning and presence of microorganisms on endoscopes after automated high-level disinfection.

Background and study aims Adenosine triphosphate (ATP) tests are increasingly used to detect biological material; however, their reliability to detect bacterial contamination in endoscopes is not proven. We investigated the predictive value of ATP tests after manual cleaning for presence or absence of microorganisms as shown by culture after automated high-level disinfection (HLD) in duodenoscopes and linear echoendoscopes (DLEs). Patients and methods After manual cleaning, ATP tests were performed on swab samples taken from the detachable cap and forceps elevator, and on flush samples of the DLE working channels. These results were compared to the growth of any microorganisms in cultures acquired after automated HLD. ATP tests with > 200 relative light units (RLU) were considered positive. Receiver operator characteristic (ROC) curves were used to compare the RLU levels with microbial presence in cultures. Results In total, 903 procedures were performed involving 26 distinct DLEs. Depending on sample site, 20.8 % (cap) to 63.8 % (channel brush) of the ATP negative samples were accompanied by positive post-HLD cultures. 54.4 % of the cap samples with a positive culture (growth of any kind of microorganism) and 91.8 % of the channel samples with a positive culture had a negative ATP test after manual cleaning. ROC curves per sample site, DLE type and microorganism type all had area under the curves below 0.6. Conclusions In our study, ATP tests performed after manual cleaning could not predict presence or absence of microorganisms after automated HLD as shown by culture. More than half of the positive cultures were preceded by a negative ATP test.

Бактерицидна ефективність, фенольний коефіцієнт і білковий індекс дезінфікуючого засобу Біолайд за впливу на Escherichia coli

Goal. To study the bactericidal activity, and bacteriostatic properties, to select the most optimal bactericidal effective concentrations of the new disinfectant (DI) Biolaid for its effect against the test culture of Escherichia coli ATSS 25922 in different time exposures, and to determine its phenolic coefficient and protein index. Methods. Microscopic, cultural, biochemical, statistical. Results. The results of the research on the properties of the new DI Biolaid are presented, the main components of which are components that after a certain time break down into safe water, oxygen, and lactic acid. The bactericidal efficiency was experimentally investigated of the working solutions 0.1; 0.2; 0.25; 0.5; 1.5; 4, and 10% concentrations and optimal concentrations of Biolaid working solutions were selected according to their influence during 10, 20, 30, and 60 minutes. A test was conducted to identify the bacteriostatic properties of DI Biolaid, and the analysis of the results of which proved their absence. The results of experiments on the study of the phenolic coefficient are presented, which indicate the greater efficiency of DI Biolaid compared to the standard phenol solution. The indicators of the protein index of DI Biolaid were established, which indicated a decrease in the effectiveness of this agent due to protein contamination. Conclusions. It was found that 0.25% and higher concentrations of the working solutions of the new DI Biolaid provided complete neutralization of the test culture E. coli ATSS 25922 after exposure for 30 minutes, and 0.1% and higher concentrations after exposure for 60 minutes without the manifestation of bacteriostatic properties. The phenol coefficient of the new DI Biolaid was 7.95 times higher than the bactericidal activity of the standard phenol solutions. Protein contamination can reduce the bactericidal efficiency of the new DI Biolaid by 2.07 times.

Management Alternatives of Aquifer Storage, Distribution, and Simulation in Conjunctive Use

Aquifers are ubiquitous, and their water is easy to obtain with low extraction costs. On many occasions, these characteristics lead to overexploitation due to important water level declines, reduction of river base flows, enhanced seawater intrusion, and wetland affection. The forecasted increase in water demands and global warming will impact the future availability of water resources. Conjunctive use of surface and subsurface waters can help in mitigating these impacts. There are two main conjunctive use strategies: artificial recharge (AR) and alternate conjunctive use (ACU). AR stores waters that are not to be used directly in aquifers. ACU utilizes groundwater in dry periods, while surface waters are preferred in wet ones; this allows the increase of water supply with lower dam storage, economic gains, and environmental advantages. Efficient conjunctive use can prevent soil salinization and waterlogging problems in semiarid countries due to excessive recharge from irrigation return flows or other origins. Groundwater is a neglected and generally misused resource to maintain environmental conditions. When considering the solution to a water resources problem, groundwater should always be part of the design as an alternative or a complementary resource. Aquifers have large inertia, and changes in their volumes are only noticeable after years of observations. Unfortunately, groundwater observation networks are much poorer than surface ones, something that should be changed if groundwater is to come to the rescue in these times of climate change. Human and material resources should be made available to monitor, control, analyze, and forecast groundwater.

High-level disinfection evaluation in the ambulatory setting

High level disinfection (HLD) is a complex process, requiring appropriate materials and highly trained personnel. An investigation of the HLD process was performed at an outpatient urology practice upon notification of expired chemical test strips being utilized. Infection Prevention (IP) identified various breaches in the reprocessing of flexible cystoscopes and transrectal prostate biopsy probes. Contributing factors identified were gaps in staff training, availability of all necessary supplies and staff supervision.

Implementation of a High-level Disinfection Audit Program to Standardize Processes and Improve Compliance at an Academic Health System

Background Reducing the transmission of pathogens from medical devices continues to be a focus of the healthcare industry. High-level disinfection (HLD) is one method frequently employed to eliminate disease-causing microorganisms. HLD is a complex process that requires meticulous cleaning and attention to numerous details such as temperature, concentration of disinfectant, and exposure time among others. Staff must be properly trained and competent to ensure the process is being performed correctly. During a review of processes, it was noted that practices were inconsistent between like departments. Therefore, an audit program was developed and implemented to improve consistency, ensure best practices, and provide support to department staff. Methods A detailed review of industry recommendations, regulatory standards, and manufacturer's instructions for use was used to facilitate and inform the development of auditing tools. Audits focused on key departments such as Endoscopy, Transesophageal Echocardiogram (TEE), Ultrasound (US), as well as areas using liquid high-level disinfectants (LHLD). A compliance-based audit schedule was designed to ensure routine monitoring of processes. Audit findings were labeled as general or critical, with each requiring action plan development and follow-up from department leadership. Results The audit program has proven beneficial in highlighting deviations in practice, enhancing communication, and allowing the team to address real or perceived barriers. Pre-audit compliance averaged 87.7% (US), 88.1% (TEE), 91.2% (Endoscopy), and 94.5% (LHLD). Six months post implementation, overall compliance had increased to an average of 95.2% (US), 94.4% (TEE), 96.8% (Endoscopy), and 96% (LHLD) respectively. Conclusions Implementation of a routine audit program with actionable follow-up increased overall compliance for departments utilizing high-level disinfection while providing a tool for sustainability. An audit program is beneficial to ensure safe patient care by staying current and compliant on HLD standards, recommendations, and best practices. Reducing the transmission of pathogens from medical devices continues to be a focus of the healthcare industry. High-level disinfection (HLD) is one method frequently employed to eliminate disease-causing microorganisms. HLD is a complex process that requires meticulous cleaning and attention to numerous details such as temperature, concentration of disinfectant, and exposure time among others. Staff must be properly trained and competent to ensure the process is being performed correctly. During a review of processes, it was noted that practices were inconsistent between like departments. Therefore, an audit program was developed and implemented to improve consistency, ensure best practices, and provide support to department staff. A detailed review of industry recommendations, regulatory standards, and manufacturer's instructions for use was used to facilitate and inform the development of auditing tools. Audits focused on key departments such as Endoscopy, Transesophageal Echocardiogram (TEE), Ultrasound (US), as well as areas using liquid high-level disinfectants (LHLD). A compliance-based audit schedule was designed to ensure routine monitoring of processes. Audit findings were labeled as general or critical, with each requiring action plan development and follow-up from department leadership. The audit program has proven beneficial in highlighting deviations in practice, enhancing communication, and allowing the team to address real or perceived barriers. Pre-audit compliance averaged 87.7% (US), 88.1% (TEE), 91.2% (Endoscopy), and 94.5% (LHLD). Six months post implementation, overall compliance had increased to an average of 95.2% (US), 94.4% (TEE), 96.8% (Endoscopy), and 96% (LHLD) respectively. Implementation of a routine audit program with actionable follow-up increased overall compliance for departments utilizing high-level disinfection while providing a tool for sustainability. An audit program is beneficial to ensure safe patient care by staying current and compliant on HLD standards, recommendations, and best practices.

A Risk Assessment Approach to Categorize High-Level Disinfection Gaps Across the Healthcare Enterprise

<h3>Background</h3> Endoscope reprocessing is a multi-step process and gaps can impact the efficacy of the disinfection process. An increase in breaches with high-level disinfection (HLD) processes was reported to infection prevention. Upon further investigation, it was realized the number of departments performing HLD had increased, the types of devices reprocessed increased, and procedural variation existed, sometimes within the same department. A lack of defined quality assurance, process improvement (QAPI) existed whereby, the burden of this problem across the organization was not realized. <h3>Methods</h3> An organizational risk assessment and inventory of devices were convened. The risk assessment tool was designed utilizing a hazard vulnerability approach (HVA) with a scoring methodology. The criterion used was based on manufacturer guidelines, regulatory requirements, and recognized industry experts. Hospital-based Infection Preventionists (IP) convened a team to complete the risk assessment. The senior IP and epidemiology team collated the information with a detailed report presented to the corporate level quality and safety committee. <h3>Results</h3> One hundred forty-two locations were performing HLD, encompassing 22 service lines and at least 10 different types of devices. Examples of locations included speech therapy, women's health, and urology. Primary risks identified by the HVA included inappropriate transport of devices, lack of environmental controls, and gaps in the pre-treatment of devices at the point of care. Secondary risks included gaps in leadership with HLD oversite, variation in policies, disposal of waste, and documentation, primarily gaps in logs. Device-specific audit tools were created with a monthly HLD audit cadence that is now included within the infection prevention program plan and QAPI. <h3>Conclusions</h3> This risk-based and HVA illustrated the scale and risks of this decentralized procedure and processes. Tight controls such as standard audit tools with a focused infection prevention QAPI process to report monthly compliance or gaps thereof are needed for these complex disinfection protocols.

The Road to High Level Disinfection and Sterilization Competency in Ambulatory Clinics

Background In 2020, our organization added an infection prevention role for approximately 250 affiliated ambulatory clinics. A rounding assessment tool was developed and initiated. During this initial rounding, it was discovered that several locations were not performing High Level Disinfection on endocavity ultrasound probes, and those that were performing the HLD, were not following manufacturer's guidelines. Upon further investigation, similar findings were discovered for both HLD of endoscopes as well as sterilization using tabletop autoclaves. There was no official training or competency program in place for any of these processes in the ambulatory clinics. Methods First, a gap analysis was performed. Data was collected on the current processes and a complete device inventory was created. A cluster analysis was performed and revealed the infection rate among potentially affected patients over the last 3 years to be within the expected range. A 3rd party infection control consultant was brought in to validate and verify our proposed plan of creating new processes, educating staff, and developing a sustainable competency program. Results Broken processes were immediately halted and corrected. Three competency programs were developed and implemented for HLD and Sterilization, which included online modules, webinars, hands-on training (for endoscopes), and a competency check-off. This involved 175 staff members in almost 50 clinics across the state and only one IP. New logs were created and distributed to the practices as well as supply lists of necessary items to maintain compliance. Conclusions At the time of this abstract, 64% of staff had completed the competency training and were checked-off. Those who are unable to complete it by the deadline, will be unable to perform that skill. This will be a required annual competency moving forward. In 2020, our organization added an infection prevention role for approximately 250 affiliated ambulatory clinics. A rounding assessment tool was developed and initiated. During this initial rounding, it was discovered that several locations were not performing High Level Disinfection on endocavity ultrasound probes, and those that were performing the HLD, were not following manufacturer's guidelines. Upon further investigation, similar findings were discovered for both HLD of endoscopes as well as sterilization using tabletop autoclaves. There was no official training or competency program in place for any of these processes in the ambulatory clinics. First, a gap analysis was performed. Data was collected on the current processes and a complete device inventory was created. A cluster analysis was performed and revealed the infection rate among potentially affected patients over the last 3 years to be within the expected range. A 3rd party infection control consultant was brought in to validate and verify our proposed plan of creating new processes, educating staff, and developing a sustainable competency program. Broken processes were immediately halted and corrected. Three competency programs were developed and implemented for HLD and Sterilization, which included online modules, webinars, hands-on training (for endoscopes), and a competency check-off. This involved 175 staff members in almost 50 clinics across the state and only one IP. New logs were created and distributed to the practices as well as supply lists of necessary items to maintain compliance. At the time of this abstract, 64% of staff had completed the competency training and were checked-off. Those who are unable to complete it by the deadline, will be unable to perform that skill. This will be a required annual competency moving forward.

The Road to Excellence: Paving the Way to Construct a Successful Infection Prevention Program in a Complex Healthcare Network

BackgroundOur healthcare system is a level I trauma center with 25 clinics and over 1 million patient encounters per year. The Infection Prevention team of 9 has oversight of all infection prevention activities. A mock survey was completed to prepare the system for a Joint Commission survey. Results from the mock survey identified gaps within the infection prevention program and called attention to the need to implement best practices. During this time, the infection prevention team was experiencing challenges related to the COVID-19 pandemic and high staff turnover.MethodsMock survey findings were categorized into 8 buckets: Infection prevention program, dust and environmental cleaning, expiration dates, manufacturer's instructions for use, low level disinfection, probes, scopes, and storage of supplies. Infection Preventionists were assigned to service lines and buckets to facilitate interdepartmental collaboration and create solutions to address findings. Routine tracers completed by the infection prevention team provided a means to measure compliance over time.ResultsThe mock survey was conducted in November 2020 and the Joint Commission survey was completed in November 2021. In just 12 months, there was a 98% reduction in the number of findings attributed to the Infection Control chapter - 168 mock survey findings in 2020 was reduced to 2 survey findings in 2021. In 2020, 127 findings were considered high risk and 33 were considered an immediate threat to health and safety. There were 0 findings in 2021 that were considered high risk or an immediate threat to health and safety.ConclusionsImplementation of a robust infection prevention program is essential to the success of the healthcare system. Key elements that contribute to a high-quality program include standardization of best practices, designating team members to become consultants for service lines, increasing interaction and visibility with staff members, and implementing committees to discuss opportunities for improvement and monitor initiatives.

What Is the Impact of a Comprehensive Educational Program on Sterilization Processes in the Outpatient Physician Office Setting

<h3>Background</h3> Invasive procedures are routinely done in the outpatient physician office setting. Outpatient physician offices are often licensed for business occupancy and are not required to have accreditation, which limits health care regulatory requirements and mandated reporting. Furthermore, physician office staff often do not have the training or background education for proper instrument reprocessing. A potential risk of performing invasive procedures in the outpatient physician office setting include improperly sterilized or disinfected equipment and instruments, and the transmission of infectious pathogens to patients. The objective of this study was to improve sterilization processes and compliance with Center for Disease Control recommendations. <h3>Methods</h3> We conducted a pilot study at 13 outpatient physician offices that perform reprocessing of surgical instruments and equipment over the course of 1 year. A comprehensive tracer audit tool was developed to assess the level of compliance with Center for Disease Control (CDC) recommendations for sterilization and high-level disinfection in the outpatient physician office setting. A list of approved reprocessing supplies was created to standardize the process. Medical assistants and licensed vocational nurses who were responsible for performing sterilization received comprehensive education from a sterile processing educator. Their reprocessing skills were validated during a follow up visit that included a competency. <h3>Results</h3> Sterilization practices were improved as a result of this study and were demonstrated by competency validation and improved compliance scores on the trace audits at all 13 offices. <h3>Conclusions</h3> This study found that a comprehensive education program did improve compliance on sterilization processes in the outpatient physician offices which was demonstrated as by competency validation and increased compliance scores on the tracer audits at all offices. The improved sterilization processes have reduced the risk of infection and exposure to infectious pathogens in addition to reducing risk for the organization.

Management of a Candida Auris Patient Across Two Healthcare Systems

BackgroundContaining Candida auris (C. auris) has proven to be especially challenging during the COVID-19 pandemic given the enormous constraints on Infection Prevention (IP) departments. Knowledge of the organism, appropriate identification methods, and infection prevention strategies are key to reducing the risk of transmission. Many IP departments have been unable to develop or maintain comprehensive admission screening protocols and have limited best practices available for managing C. auris patients in the acute care setting. We describe the first case of C. auris in the acute care setting in the state of Minnesota and outline the infection prevention strategies used by the two systems that provided care to this patient.MethodsUpon receipt of a preliminary positive C. auris result at Hospital One, the patient was placed into contact precautions. All patients that were identified as exposed were screened. A comprehensive infection prevention strategy was implemented in collaboration with the state health department and Hospital Two. The plan included transmission-based precautions, hand hygiene compliance, environmental cleaning and disinfection, and staff and patient education.ResultsA total of 48 patients were screened for C. auris at Hospital One and no additional positive results were identified. The patient was transferred to Hospital Two for progressive care needs and required an extensive hospital stay post-surgery. No additional screening was recommended by the state health department. Practical prevention strategies for high level disinfection and sterilization, environmental cleaning, patient transport and ambulation, and procedural protocols were developed. No additional C. auris colonization nor clinical isolates have been identified to date.ConclusionsThis case highlighted the importance of inter-facility communication and the need for an established screening protocol for C. auris to identify cases in a timely manner. The robust infection prevention strategies implemented by the two systems resulted in no known transmission to other patients or staff.

Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared with duodenoscopes with fixed distal caps: a randomized trial

Newly designed duodenoscopes with disposable distal caps have been developed for better cleaning and preprocessing to reduce the risk of bacterial contamination (BC). We compared BC and organic residue of duodenoscopes with disposable distal caps and duodenoscopes with fixed distal caps after manual cleaning and high-level disinfection (HLD). Four hundred duodenoscopes were randomized into group A (fixed distal caps, n= 200) and group B (disposable distal caps, n= 200). After manual cleaning, samples from the elevator were submitted for culture. An adenosine triphosphate (ATP) test was performed for organic residue evaluation. Based on our previous data, ATP< 40 relative light units (RLUs) had 100% sensitivity with 100% negative predictive value to confirm no BC after reprocessing. After manual cleaning, group A had a higher BC rate (14% vs 7%, P= .02), a higher proportion of duodenoscopes with ATP≥ 40 RLUs (73.5% vs 57%, P= .001), and a higher mean of ATP level (226.6 vs 82.0 RLUs, P< .001) compared with group B. After HLD, the proportion of potential BC (ATP≥ 40 RLUs) in group A was 2.7 times higher than group B (4% vs 1.5%, P= .13). Mean ATP level after HLD in the 2 groups was significantly lower than before the HLD procedure (group A, 24.2 vs 226.6 RLUs [P< .001]; group B, 20.4 vs 82.0 RLUs [P< .001], respectively). After manual cleaning, duodenoscopes with disposable distal caps had significantly lower BC and organic residue than duodenoscopes with fixed distal caps. Only a few duodenoscopes from each group did not pass the ATP threshold after HLD.

Knowledge Level on Infection Control among Romanian Undergraduate and Postgraduate Dental Students.

Background and Objectives: Infection control practices in dentistry should be continuously evaluated. The aim of the present study was to assess the knowledge of dental students from Iași, Romania about infection control in the dental office. Materials and Methods: Dental students and resident dentists attending the “Grigore T. Popa” University of Medicine and Pharmacy in Iași were randomly selected in accordance with ethical guidelines, and a cross-sectional, questionnaire-based online study was conducted. The questionnaire included 21 items about infection control in dentistry. A descriptive statistical analysis was performed, and the chi-square test was used for data comparison, with a cutoff point of 0.05 for statistical significance. Results: The study sample included 150 subjects (75.3% female and 24.7% male) with a mean age of 25.71 ± 4.54 years. Mode of infection transmission was known by 74% of the subjects, and 76% were aware of standard precautions, with significant differences by the year of study (p = 0.012, r = 0.002). A percentage of 20% of subjects knew the means of transmission of the hepatitis B virus (HBV) (p = 0.032, r = 0.166). Most of the subjects were not vaccinated against HBV (p = 0.002, r = −0.274). Notions of high-level disinfection and sterilization were confused by 19.5% of the subjects. Only 22% of the subjects knew the correct processing of handpieces (p = 0.048, r = −0.071). The sources of information were diverse for 64.66% of the respondents, while 31.33% of them used courses and seminars only. Conclusions: There is a need for improvement in the level of knowledge on infection control for both dental students and residents.