ECRI Lists "Cross Contamination from Flexible Endoscopes" in Top 3 Health Technology Hazards 2011

Patient cross contamination from the improper handling and reprocessing of flexible endoscopes is a serious issue today and was listed at #3 on ECRI’s list of Top Ten Health Technology Hazards for 2011.  In fact there is no such thing as a minor slip up when it comes to following endoscope reprocessing guidelines, the procedure was either followed or a step was missed.

While the actual risk of infection is estimated at 1 in 1.8 Million, it is the hospitals duty to contact all patients who were potentially exposed to the scope in question.  But that is exactly the question hospitals face when a potential “outbreak” occurs.

Lack of accessible data linking the endoscope and patient whom the the scope was used on has lead hospitals across the country to notify thousands of patients that they could potentially be infected with a disease such as hepatitis or HIV.

A few examples of reported outbreaks from the Pennsylvania Patient Safety Advisory’s article titled The Dirt on Flexible Endoscope Reprocessing can be seen below:

  • 2008 – 2010: Palomar Medical Center notified 3,400 patients that received endoscopic-related care  to return for tests for infectious diseases because the endoscopic equipment used in their care may not have been properly disinfected.
  • 2008 – 2009:  The Department of Veterans Affairs notified over 10,000 patients from three different hospitals that they were potentially exposed to blood born pathogens.
  • 2004:  The California Department of Health Services notified  5,000 patients they had been potentially been exposed to an infectious disease.

In 2004 the California Department of Health Services (DHS) on endoscope reprocessing established the following recommendations to aid investigation of endoscope sterility issues:

  • Maintain a log of the patient’s name, medical record number, date of procedure, specific procedure(s) performed, physician’s name performing the procedure(s), and endoscope type and model/serial number (or other unique identifier).
  • Identify each automated endoscope reprocessor(AER) used to process each endoscope (for multiple AERs) and the endoscope reprocessing cycles used on each endoscope. (Note that although the California DHS recommendations specify only AERs, the same recommendations can be applied to sterilizer units.) Not addressed in the California DHS recommendations is identification of endoscopes in the patient record.

Do these work flows seam feasible knowing the Operating Room environment?