A CRITICAL EVALUATION OF INFECTION CONTROL PRACTICE
Endoscopy is one procedure which can present infection risks to the client. The quality of care provided in endoscopy is gradually decreasing and thus there is an increasing incidence of infections in clients after undergoing endoscopy. The nurses are at the front line in the prevention and control of endoscopy-related infection.
This paper aims to examine the current practices of the hospital where I work in the procedure of endoscopy and the role of the nurses. It also aims to provide recommendations after researching into the current conditions and infection control procedures.
Nosocomial infections (NIs) are hospital-born infections and now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to intensive care units (ICUs) (, 2004). Infection after endoscopy is one example.
Endoscopy means looking inside and refers to looking inside the human body for medical reasons. It is a minimally invasive diagnostic medical procedure used to evaluate the interior surfaces of an organ by inserting a small scope in the body, often but not necessarily through a natural body opening. Through the scope, one is able to see lesions.
Being able to examine internal organs through the use of endoscopy has been a major advance in the prevention, detection and treatment of gastrointestinal diseases and disorders, such as ulcers, cancer, and internal bleeding.
Endoscopy is performed immediately if there are “alarm” markers including anemia, GI bleeding, anorexia, early satiety, recurrent vomiting, dysphagia, jaundice, palpable mass, guaiacpositive stool, or weight loss. Because the diagnostic yield for organic pathology with endoscopy is 60 percent in patients over age 60, these patients should also receive early endoscopy, preferably within four to six weeks of presentation, if symptoms have occurred for the first time (, 2000).
In my current place of employment, there is an increasing number of hospital infections brought by the procedure of endoscopy. Major reasons for transmission of infections in endoscopy were improper cleaning and disinfection procedures, contamination of endoscopes by automatic washers and inability to decontaminate endoscopes despite use of standard disinfection techniques, because of the complex channel and valve systems (, 1993).
Salmonella species and Pseudomonas aeruginosa were repeatedly identified as causes of infections transmitted by gastrointestinal endoscopy, and Mycobacterium tuberculosis, atypical mycobacteria and P. aeruginosa were the most common causes of infections transmitted by bronchoscopy. One case of hepatitis B virus transmission via gastrointestinal endoscopy was also documented (, 1993).
The primary goal of any infection control program is to reduce infection risk for patients, employees and others. Infection control shares this goal with those involved in reprocessing of patient care equipment and medical devices. Properly prepared equipment or medical devices are essential for reducing infection risk. Outbreaks related to contaminated equipment have been associated with process failures as a result of inadequate training, failure to follow manufacturer's recommendations or to implement recommended practices (, 2003).
The nurse’s role is to assess the client’s defense mechanisms, susceptibility, and knowledge of infections. Clients have to be aware of infections since this is about their health. Client will then assume self-care using proper infection control techniques. The client is less aware than the nurse of factors that promote the spread of infection or the ways to prevent its transmission (, 2004).
A review of disease history with the client and family may reveal an exposure to a communicable disease which can increase chances of getting infection. A thorough review of the client’s clinical condition may detect signs and symptoms of actual infection or risk for infection.
An analysis of laboratory findings provides information about a client’s defense against infection. By knowing the factors that promote susceptibility or risk for infection, the nurse is better able to plan preventive therapy that includes aseptic techniques. By recognizing early signs and symptoms of infection, the nurse can alert others on the health care team to the potential need for therapy and initiate supportive nursing measures.
A review of physical assessment findings and the client’s medical condition reveals the status of normal defense mechanisms against infection. Many factors influence the client’s susceptibility to infection. These factors include age, nutritional status, stress, disease process, and medical therapy (, 2004). The nurse has to gather information about each factor through the client’s and family’s history.
A client with infection may have a variety of health problems. The nurse assesses ways that the infection affects the client’s and family’s health needs. These may be physical, psychological, social, or economical.
The client at risk for infection must understand the measures needed to reduce or prevent microorganism growth and spread. Providing clients or family members the opportunity to discuss infection-control measures or to demonstrate procedures will reveal their ability to comply with therapy. The nurse may determine that clients will require new information or that previously instructed information needs reinforcement.
Though infectious complications of flexible bronchoscopy are considered to be relatively rare, endoscopes, including bronchoscopes, are the medical devices most commonly linked to nosocomial outbreaks ( 2004). A recent, large, highly publicized outbreak of Pseudomonas aeruginosa associated with bronchoscopes has prompted a reexamination of the procedures used to clean these delicate and complicated instruments. Though the cause of that outbreak was attributed to bronchoscope contamination because of a manufacturing defect, there are numerous examples in the literature of bronchoscopy-associated infections and pseudoinfections caused by faulty reprocessing procedures (, 2004).
There are several risk factors for disease transmission following endoscopy. A significant risk associated with cross-infection due to any pathogenic microorganism following an endoscopic procedure is inadequate cleaning and high-level disinfection of the endoscope. In each reported case of disease transmission via an endoscope or biopsy forceps, a critical breach in the recommended reprocessing protocol was identified (, 2002).
Treating all patients the same and as if each were a potential carrier of anthrax (or any other pathogenic microorganism) makes sense and is a crucial component of standard precautions, a set of principles designed to protect surgical staff from infection. By also exercising some of the practices of aseptic technique, such as more frequent hand washing, routine cleaning of environmental surfaces using an appropriate disinfectant and wearing gloves, the links of the chain required for infection are broken.
Although there is only limited specific instrument reprocessing instructions that address the prevention of anthrax cross-infection, strict adherence to well-established endoscope reprocessing guidelines appears to be sufficient in the prevention of the transmission of B. anthracis from one patient to another (i.e., cross-infection) during bronchoscopy and gastrointestinal (GI) endoscopy ( 2002).
The flexible and rigid bronchoscopes traverse the nasopharynx or orropharynx and carry with them the indigenous microbial flora to distal regions and may thus inoculate the tracheobronchial tree and possibly the pulmonary parenchyma. The three potential consequences of this event include: 1. onset of new infection in the tracheobronchial tree or lung parenchyma or, if the patient has preexisting infection, further spread of infection locally or to extrapulmonary sites; 2. spread of infection from one patient to another via the bronchoscope, if the methods of disinfection and sterilization are inadequate; and 3. pseudoinfection due to cross-contamination of the bronchoscope, resulting in isolation of organisms from the bronchoscopic specimens of a patient who is clinically not infected.
Review of the literature indicates that the last-mentioned consequence is more commonly encountered in clinical practice. The occurrence of pseudoinfection inevitably leads to costly and time-consuming procedures to guarantee that the patients are not infected. Rigorous adherence to sterilization and disinfection procedures and a commonsense approach to protecting the uninfected patients and bronchoscopy personnel from infected patients and instruments will prevent the risk of propagating infection through the brochoscope. This can be accomplished by establishing a set of policies regarding disinfection, sterilization, and protection of uninfected patients, as well as the bronchoscopist and paramedical personnel involved in bronchoscopy (1993).
Theoretically, bronchoscopy has the potential to transmit infection from the tracheobronchial tree to distant organs. It may intuitively appear that bronchoscopic procedures pose a great risk of producing this complication because the instrument traverses the oropharyngeal area and carries the indigenous microorganisms to the distal tracheobronchial tree and pulmonary parenchyma. Hypothetically, again, this mode of spread may result in two types of "true" infections. First, the transmission of microbes from oropharyngeal areas to the tracheobronchial tree or lung parenchyma may result in tracheobronchitis or pneumonia. Second, the preexisting pulmonary infection may spread locally or by hematogenous mode to nonpulmonary sites. Conceivably, the latter is a serious complication of bronchoscopy. These are examples of the bronchoscope propagating infection from one anatomic region to another in the same patient (, 1993).
Another potential complication is the bronchoscopic spread of infection from an infected patient to an uninfected patient. In this scenario, there are two avenues to propagate the infection. First, the bronchoscope is exposed to the infectious agent and, assuming that the method of sterilization or disinfection used in ineffective and the same bronchoscope is employed in another patient, the infecting organisms are transmitted to the uninfected patient, who then develops clinical infection. This is an example of a "true infection" transmitted by the bronchoscope from one person to another ( 1993).
Second, the bronchoscope is exposed to an infectious organism and, in spite of sterilization and disinfection, the infectious agents are incompletely eliminated from the instrument. When the same bronchoscope is used in an uninfected patient, the bronchoscopically obtained secretions reveal the presence of organisms derived from the first patient. This is an example of a "pseudoinfection. Also known as cross-contamination, the psuedoinfection does not cause clinical illness. When bronchoscopic samples from several patients document the presence of the same organism as a result of cross-contamination, the term "pseudoepidemic" is used. Until the pseudoepidemic is recognized as such, it creates an alarming clinical situation and sets in motion steps to exclude infection in uninfected patients ( 1993).
(III) Recommended Practice
Any facility in which gastrointestinal endoscopy is performed must have an effective quality assurance program in place to ensure that endoscopes are reprocessed properly. Quality assurance programs for endoscopy must include the supervision, training, and annual competency review of all staff involved in the process, systems that assure availability of appropriate equipment and supplies at all times, and strict procedures for reporting possible problems.
Healthcare workers responsible for endoscope reprocessing are recommended to review the basic principles of infection control, standard precautions and aseptic technique. Also, these healthcare workers are encouraged to review the operator's manuals of each of their facility's different models of bronchoscopes and GI endoscopes to become better acquainted with the internal design of each and to establish whether any require special reprocessing procedures. Ensuring that each of the endoscope's surfaces, particularly its internal channels, are accounted for and are being thoroughly cleaned and high-level disinfected by reprocessing personnel after each use is crucial to prevent nosocomial infection.
Endoscopes and their accessories should be cleaned and processed according to the manufacturers' specific instructions. Flexible endoscopes, by virtue of the body cavities in which they are used, acquire high levels of microbial contamination during each use. ( 2003) More health care associated infection outbreaks have been associated with contaminated endoscopes than with any other medical device. ( 2003) Use of proper protocols reduces the risk for adverse patient outcomes, prevents damage to the lenses and fiber-optic components of the instruments, and helps prevent delays by avoiding unnecessary malfunction.
Endoscopes, endoscopic accessories, and related equipment should be disassembled and cleaned manually, using mechanical friction when possible. Endoscopes and related equipment are considered contaminated after use. Immediate cleaning reduces the formation of thick masses of cells and extracellular materials known as biofilms (2003). Biofilms are microbial masses that attach to surfaces that are immersed in liquids. After they have formed, sterilizing/disinfecting agents must penetrate the agent-resisting biofilms before killing microorganisms within the biofilms. Immediate decontamination is necessary to protect patients and personnel and to prevent transmission of potentially infectious microorganisms. Flexible endoscopes that have crevices, joints, and internal channels may be more difficult to clean and sterilize or disinfect than rigid instruments that have flat surfaces. Removing gross soil from narrow internal channels and lumens may be difficult.
Endoscopes should be sterilized or disinfected according to recommended practices for sterilization in perioperative practice settings. Policies and procedures for cleaning and processing endoscopes, endoscope accessories, and related equipment should be developed, reviewed regularly, revised as necessary, and readily available in the practice setting.
Use of the appropriate mode of cleaning and disinfecting the bronchoscope is mandatory to prevent true infections and pseudoinfections. The agents currently recommended for chemical disinfection of the flexible bronchoscopy include 2 percent glutaraldehyde solution and ethylene oxide. If the former agent is used, the instrument should be immersed in it for 20 to 30 min. If the latter is used, at least a 90-min exposure to ethylene oxide followed by nearly 10 h of aeration time is recommended for sterilization. These procedures must be preceded by adequate mechanical cleaning. Chemical disinfection with alkaline glutaraldehyde solution warmed to 25°C with an exposure time of 45 min is 100 percent effective in killing M tuberculosis. This efficacy drops to 99.8 percent if the exposure time is reduced to 10 min. An exposure time of 45 min is recommended for disinfecting the flexible bronchoscope and accessories that cannot be treated by steam autoclave. The solution should be tested daily with a glutaraldehyde monitor strip to ensure a constant pH. Unless the tests show unacceptable pH, the solution is changed every 14 days. An exposure time of 10 min is sufficient to kill vegetative organisms and the HIV.
Infection control policies in bronchoscopy practice should comply with the following guidelines: (1) Infection control precautions should apply to all patients, whether deemed infectious or not. (2) All equipment used should be dismantled and thoroughly washed in an appropriate neutral detergent immediately after use to remove respiratory secretions and to reduce contamination; an ultrasonic cleaner may be used prior to the disinfecting process so that the debris can be removed from the bronchoscopic accessories if manual cleaning fails. (3)"Clean" and "infected" areas should be strictly maintained in the bronchoscopy suite, so that contaminated instruments are separated from sterile and clean equipment. (4) Medical personnel in contact with each patient should wear simple barrier clothing, masks, gloves, and goggles routinely. (5) Heavily contaminated bronchoscopes should be disinfected for at least 20 min (30 to 40 min for M tuberculosis and 4 to 6 hr for M avium-intracellulare) in alkaline glutaraldehyde (2 percent) after cleaning. (6) Bronchoscopy specimens for studies should be handled appropriately. (7) Used disposable material should be discarded properly. (8) Bronchoscopists and paramedical personnel actively involved in bronchoscopy should be vaccinated against hepatitis B virus (, 1993).
The reprocessing of endoscopes is an integral component of the overall endoscopy experience. This process should be continually monitored by the healthcare professionals, especially the nurses, so that the cleaning and disinfection of flexible endoscopic instruments will be maintained for the safety of any client at any time. It is important for the public to be reassured that there is such an on-going effort.
Such audit would be done by both government health offices and by the hospital administration as well. This audit would allow the department in my place of work to standardize the information given to patients who are to undergo endoscopy. This has helped to ensure safe practice as all nurses now give standard advice to all patients regarding endoscopy. The use of audit will also serve to enhance practice as can be seen by the results.
In general, central sterile processing is the core department responsible for the majority of items reprocessed. The primary function of a central processing department is to provide services ensuring that reusable medical devices and equipment are cleaned, disinfected or sterilized appropriately prior to use. The primary function of the receivers of these services, i.e. clinical departments, is to provide diagnostic, empiric or therapeutic interventions. In many hospitals, clinical departments like the operating room, endoscopy, anesthesia, respiratory care and radiology are also responsible for high level disinfection and sterilization procedures. No matter where items are reprocessed, there are universal procedures that should be followed to ensure that medical devices are safe and ready for use (, 2003).
Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in client care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care ( 2001).
Local and national agencies, along with the national department concerned on health, should send inspectors to the hospital and surgery centers to observe staff and question them about how they clean, reprocess and maintain equipment used in endoscopy. This should be done to all hospitals including my place of employment. They should also check the credentials of physicians or nurses performing endoscopies and require that any accidents or infections be reported.
The staff in the hospital should also hold monthly meetings and assessment of infection control procedures. Also, there should be a monthly check up of the equipments used in endoscopy and ensure that they aren’t at all likely to cause infections in patients. Education should also be provided to nurses and policies and guidelines on the use of the endoscope and in minimizing infection should take place in the hospital.
These recommended practices and other recommendations are intended as an achievable recommendation representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.
Patient safety should be the number one concern before, during and after each procedure in any hospital. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. In my area of work, the principles of general preventive measures such as the implementation of standard and isolation precautions should be reviewed. Isolation precautions are used to help prevent spread of infection. These are procedures that include separating the patient from an environment so that the risk of infection will be lessened. This could be done in the hospital in order to reduce the incidence of infections from endoscopy procedures.
The success of the nurse who practices infection-control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the client’s response, such as absence of fever or development of wound drainage, with expected outcomes determines the success of nursing interventions.
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