Anecdotal evidence suggests that while most intensivists agree that cross-contamination linked to bronchoscopes exists, many also think it isn’t an issue in their institutions. We recently discussed this dichotomy with Dr. Atul Mehta and asked about steps institutions can take to educate clinicians about proper prevention measures.
Q: “We can’t imagine anyone not knowing about the potential for bronchoscope cross-contamination. Does everyone assume it just happens to the other guy?”
Dr. Mehta: “Actually, very few people know that bronchoscopes can spread infection. Only about 10% of physicians even know that every bronchoscope comes with a manual. And only half of that amount ever actually read the manual.” (He refers us to a paper entitled “The high price of bronchoscopy” ).
“But if you don’t read the manual, you don’t know the exact procedure of how to clean the bronchoscope.”
Q: “That’s alarming.”
Dr. Mehta: “If you were to make rounds with doctors in hospitals, you will quickly learn that they believe that cleaning the bronchoscope is the domain of nurses, assistants, respiratory therapists or bronchoscope technicians. Especially in community hospitals, the majority of doctors simply do not know how to clean the bronchoscope.
“In our teaching program, we train the fellows how to clean the bronchoscope in the first two weeks of the rotation. But in private institutions, there are no teaching programs.
“Physicians simply aren’t aware that there is the potential of causing cross-contamination with scopes. As a result, a doctor might use a scope, leave it on the table (without cleaning it) and in comes the next doctor who reuses it.”
[We notice two large charts in the bronchoscope cleaning area.]
Dr. Mehta: “If those posters are not there, the person cleaning the bronchoscope may not be performing all of the required steps. The only way the problem can really be solved is through education.”
Q: “And smaller institutions?”
Dr. Mehta: “When smaller hospitals cannot employ a full-time bronchoscopist, one will travel from institution to institution. If he or she continually puts the scope in the same bag, that’s the worst thing to do.”
Q: “Is biofilm a particular problem?”
Dr. Mehta (nods): “Sixty percent of all hospital infections are caused by biofilm. It’s less likely that biofilm will form in the endoscopes if it is mechanically cleaned. But if you don’t actually brush the device and you just put the scope in the automatic processor, chancers are that the biofilm will still be there.”
Q: “Critical care doctors use endoscopes less frequently than bronchoscopists. Might they not think that contamination such as the recent case of CRE is an endoscopy issue and not relevant to the ICU? And is it?”
Dr. Mehta: “Since CRE can occur anywhere, it isn’t just an ICU or endoscopy bug.”
[We asked for detail about how bronchoscopes spread disease.]
Dr. Mehta: “What is different about CRE is that the patient won’t show infection for eight days, at which point the bronchoscopy is forgotten. Very few labs actually take the time to follow-up on potential infections.
“Ideally, you would culture every scope once every month, but nobody does that.”
Q: “is it true that some hospitals clean different scopes in the same processor?”
Dr. Mehta: “Yes, many smaller institutions typically clean bronchoscopes, endoscopes and colonoscopies in the same processor. However, there may not be a proper connector for every instrument, which leads to inadequate cleaning.”
Q; “CMS recently published a checklist for endoscopes. If there’s a conflict between what the scope manufacturer says to do, and what the reprocessor says to do, you’ll need to come up with a solutions. Do you have any resources to solve that problem?”
Dr. Mehta: “This is one of the bigger issues in proper scope care. There are typically two posters provided with cleaning instructions. However, if the posters are not hanging where I clean the scope, there is no way I know how to properly clean it. But the scope should be cleaned immediately after the procedure. Biofilm (presentation) is very subtle—it can, for example, even be hidden in the filter of an automatic processor.”
Dr. Atul Mehta, Professor of Medicine at Lerner College of Medicine, is a staff physician at the Cleveland Clinic’s Department of Pulmonary Medicine of Respiratory Institute. He also holds the first Buoncore Family Endowed Chair in Lung Transplantation. Dr. Mehta is founder and president of the American Association for Bronchology, and Senior Editor of the Journal of Bronchology and Interventional Pulmonology.
This article was originally published in An Intensivist’s Handbook, September 2016, by Ambu, Inc.