“10 veterans test positive for hepatitis after colonoscopies” – USA Today
A headline such as the one above appearing in a 2009 USA Today article is a major loss for everyone involved. Unfortunately the trend of recent endoscope infection scares is on the rise after hospitals in Escondido, California and Hennepin County, MN had to publicly notify thousands of patients that they may have been exposed to a virus such as hepatitis or HIV.
What started as a failure to follow proper HLD reprocessing guidelines quickly turned into an operational and public relations nightmare for the hospitals. Because of manual documentation, tracking and reprocessing workflows which produce scattered and innacurate data needed to identify the exact patients exposed to the endoscope, the organizations were required to provide blood tests for each patient who may have been at risk.
Whats so difficult about cleaning a flexible endoscope?
- To begin with there are many steps in the process as can be seen in the flexible endoscope cleaning and disinfection guide assembled by the SGNA , leading to a greater risk for one to be missed or intentionally skipped.
- Second, there is very little accountability created by current endoscope storage and High Level Disinfection (HLD) processes within GI labs. Scopes can be found hanging in unlocked cabinets while clinicians manually document the steps they have completed.
- Lastly there are no checks and balances built into the workflow to insure that scopes which have not been properly cleaned cant be used in a procedure.
The Solution: Red Alerts and a movement to “Complete Endoscope Use Cycle Management”
While providing barcode based tracking systems or locking down the endoscope storage room can help improve your current process, the goal now is to use one system to track every scope from the time its removed from the cabinet through the case, into each stage of reprocessing and finally back into the cabinet itself. The ability to gather all of this data in one place allows Mobile Aspects iRIScope solution to keep each scope under surveillance and know whether a potentially infected endoscope was returned as cleaned.
The secured storage unit will then light up red as seen in this featured video while simultaneously pushing out an alert to the GI Lab supervisor. This mitigates the risk of having an improperly disinfected scope be returned to a cabinet (where it can compromise other scopes) and then used in another procedure. Because we can effectively trace the use of that scope back to the exact patient it was used on, as well as the staff member responsible for it there is no longer the need to scare thousands of people who had recently been tested.
Have you reviewed your endoscope disinfecting processes recently?