Optimize GI infection control: Best strategies, protocols & new technology

Three gastroenterologists discuss best practices for infection control at their endoscopy centers and hospitals, and how they're able to stay at the forefront of providing quality patient care.

Q: How do you ensure infection control at your GI practice?

Pankaj Vashi, MD, Medical Director, Gastroenterology/Nutrition and Metabolic Support at Cancer Treatment Centers of America® (CTCA) at Midwestern Regional Medical Center: Cancer Treatment Centers of America® (CTCA) at Midwestern Regional Medical Center (Midwestern) takes hospital acquired conditions very seriously. As an organization, we treat patients with the most advanced and complex cancers who are often immunocompromised and more susceptible to infections.

We incorporate many levels of protective steps to address hospital-acquired conditions within our facility placing patient safety at the top of our priority list. CDC and Joint Commission-recommended evidence based practices are in place, and our team of highly trained quality professionals regularly reviews our processes, procedures and outcomes, continuously looking for areas to improve. This commitment to quality is demonstrated by our continued achievement of a Five-Star quality summary score for patient experience — the highest possible rating — by Centers for Medicare & Medicaid Services (CMS).

Rahul Pannala, MD, Mayo Clinic, Rochester, Minn.: There are several infection control measures that we undertake in gastroenterology at our institution. After each procedure, the endoscope is placed on a cinch pad in its own bin so that cross contamination between endoscopes is prevented. In addition, enzymatic cleaning is performed at the bedside immediately after use and then endoscopes are subjected to manual cleaning and high-level disinfection as per manufacturer recommendations.

For duodenoscopes, we undertake additional measures given the recent concerns with CRE. All patients undergoing procedures where a duodenoscope is used are tested for CRE and the duodenoscope is sequestered until a result is available. Duodenoscopes used in patients who are colonized with CRE are chemically sterilized using ethylene oxide after standard reprocessing. All other duodenoscopes are processed through two cycles of manual cleaning plus two cycles of high level disinfection.

In addition, with a grant from the American Society of Gastrointestinal Endoscopy (ASGE), we are evaluating the role of point of care testing using a rapid Carba-R (Cepheid Inc) test which gives a rapid assessment of CRE colonization status of the patient. We are also evaluating the utility of this assay in testing duodenoscopes. We believe that this would lead to a more efficient strategy of identifying endoscopes that may need chemical sterilization as opposed to high level disinfection.

Q: What infection control measures do you follow?

Brett Bernstein, MD, AGAF, FASGE, Director of Clinical Integration for Gastroenterology and Endoscopy, Mount Sinai Health System; Clinical Associate Professor, Icahn School of Medicine at Mount Sinai: The process of ensuring infection control is a complex one that involves multiple stakeholders. First and foremost is the establishment and maintenance of a culture of safety, mindfulness and hyper vigilance. Infections need to be considered a zero tolerance event by all staff. Our endoscopy program is responsible for the oversight of over 80,000 procedures annually across four ambulatory surgery centers and seven hospital campuses.

Standardization of process with special attention to the precleaning and cleaning of equipment prior to high level disinfection is ensured by continually examining, reviewing and amending our infection control policies in real-time as information continues to change almost monthly. Performing competency assessments at more frequent intervals for our technical staff (i.e. every three months) ensures that they utilize the most up-to-date protocols.

PV: For the safety of our patients requiring GI support, it is very important to have strict infection control measures for all procedures and the equipment we use i.e., endoscopes. We adhere to the following protocols:

• Use approved sterilizing processor, which needs to be tested frequently for contamination.
• Have separate dirty and clean scope rooms.
• Employ well-trained scope cleaner technicians who undergo regular in services for quality assurance.
• Take random cultures from scopes every month. This is especially important with ERCP scopes, which are most susceptible to contamination.
• Undergo routine checks by infectious control department.
• Led by a strong leadership team that understands the importance of safety and owns the quality measures.

CTCA® at Midwestern was recently awarded Leapfrog's Top Hospital recognition, which is widely acknowledged as one of the most prestigious distinctions any hospital can achieve in the United States. According to The Leapfrog Group, "Top Hospitals have lower infection rates, better outcomes, decreased length of stay and fewer readmissions.” By achieving Top Hospital status, CTCA at Midwestern has proven it prioritizes the safety of its patients, is committed to transparency and provides exemplary care for patients and their families.

Further, it is helpful to understand that CTCA at Midwestern is licensed as an acute care facility, although we are a cancer specialty hospital. A number of cancer hospitals are exempt from any program reporting, mandatory or voluntary. We are very proud of not only our commitment to transparency and focus upon continuous measurement and improvement, but also seeking those accreditations and certifications with standards that focus upon the unique needs of the oncology patient. In addition to The Joint Commission accreditation, CTCA at Midwestern has achieved such strenuous certifications as those by the American College of Surgeons Commission on Cancer and the American Society for Clinical Oncology Quality Oncology Practice Initiative.

Q: What new technologies are you using to stay on top of infection control?

BB: We have gone beyond the basic requirements through implementing a commercial bioburden assay (3M Cleantrace) that utilizes bioluminescent testing of scopes after manual cleaning to ensure adequacy prior to high level disinfection. In addition we are excited to begin launching a remote video auditing program at Eastside Endoscopy, one of our ambulatory centers. We have engaged Arrowsight, a company that has been instrumental in improving food safety in the meat and poultry industry to install cameras in our scope processing areas where technicians will be monitored for accuracy and completeness of the cleaning process based on OEM and FDA recommendations.

Any break in protocol would lead to our lead technician, nurse manager and myself receiving a text and email alerting us to this and allow the scope to be taken out of service and technician given appropriate in servicing. We believe this is potentially groundbreaking as simple competency testing cannot accomplish what real-time auditing such as this can.

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