Cori L. Ofstead

Influenza vaccination among registered nurses: Information receipt, knowledge, and decision-making at an institution with a multifaceted educational program

OBJECTIVE To evaluate the receipt of information and knowledge about influenza and vaccination, as well as influenza vaccination status and reasons for declining vaccination, among registered nurses. DESIGN Cross-sectional survey of registered nurses (RNs). SETTING A large tertiary medical center with a long-standing, multifaceted influenza vaccination program and relatively high vaccination rates among employees overall (76.5%). PARTICIPANTS Randomly selected group of 990 RNs employed as inpatient staff nurses at the institution. RESULTS The survey was completed by 513 (51.8%) of 990 RNs. Most RNs (86.7%) had received an influenza vaccination in the past, and 331 (64.5%) intended to receive vaccination during the 2005-2006 influenza season. More than 90% of RNs acknowledged exposure to educational bulletins, and most had received information about influenza severity (383 [74.7%]), transmission (398 [77.6%]), vaccine safety (416 [81.1%]), and the time and location of free vaccination (460 [89.7%]). A majority (436 [85.0%]) felt they had received all the information they needed to make good decisions about vaccination. However, only 49 RNs (9.6%) gave correct answers to more than 85% of the knowledge questions on the survey. The reasons most frequently reported for declining vaccination were doubts about the risk of influenza and the need for vaccination, concerns about vaccine effectiveness and side effects, and dislike of injections. CONCLUSIONS RNs exposed to a longstanding, multifaceted educational program had received information about influenza vaccination, but misconceptions were common and only 331 (64.5%) intended to receive vaccination. Strategies other than educational interventions are needed to increase influenza vaccination rates and thereby to ensure healthcare worker and patient safety.

Endoscope reprocessing methods: a prospective study on the impact of human factors and automation.

The main cause of endoscopy-associated infections is failure to adhere to reprocessing guidelines. More information about factors impacting compliance is needed to support the development of effective interventions. The purpose of this multisite, observational study was to evaluate reprocessing practices, employee perceptions, and occupational health issues. Data were collected utilizing interviews, surveys, and direct observation. Written reprocessing policies and procedures were in place at all five sites, and employees affirmed the importance of most recommended steps. Nevertheless, observers documented guideline adherence, with only 1.4% of endoscopes reprocessed using manual cleaning methods with automated high-level disinfection versus 75.4% of those reprocessed using an automated endoscope cleaner and reprocessor. The majority reported health problems (i.e., pain, decreased flexibility, numbness, or tingling). Physical discomfort was associated with time spent reprocessing (p = .041). Discomfort diminished after installation of automated endoscope cleaners and reprocessors (p = .001). Enhanced training and accountability, combined with increased automation, may ensure guideline adherence and patient safety while improving employee satisfaction and health.

Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines

BACKGROUND Pathogens have been transmitted via flexible endoscopes that were reportedly reprocessed in accordance with guidelines. METHODS Researchers observed reprocessing activities to ensure guideline compliance in a large gastrointestinal endoscopy unit. Contamination was assessed immediately after bedside cleaning, manual cleaning, high-level disinfection, and overnight storage via visual inspection, aerobic cultures, and tests for adenosine triphosphate (ATP), protein, carbohydrate, and hemoglobin. RESULTS All colonoscopes and gastroscopes were reprocessed in accordance with guidelines during the study. Researchers collected and tested samples during 60 encounters with 15 endoscopes. Viable microbes were recovered from bedside-cleaned (92%), manually cleaned (46%), high-level disinfected (64%), and stored (9%) endoscopes. Rapid indicator tests detected contamination (protein, carbohydrate, hemoglobin, or ATP) above benchmarks on bedside-cleaned (100%), manually cleaned (92%), high-level disinfected (73%), and stored (82%) endoscopes. Visible residue was never observed on endoscopes, but it was often seen on materials used to sample endoscopes. Seven endoscopes underwent additional reprocessing in response to positive rapid indicators. Control endoscope channels were free of biologic residue and viable microbes. CONCLUSION Despite reprocessing in accordance with US guidelines, viable microbes and biologic debris persisted on clinically used gastrointestinal endoscopes, suggesting current reprocessing guidelines are not sufficient to ensure successful decontamination.

Reported gastrointestinal endoscope reprocessing lapses: The tip of the iceberg

BACKGROUND Most cases of microbial transmission to patients via contaminated endoscopes have resulted from nonadherence to reprocessing guidelines. We evaluated the occurrence, features, and implications of reprocessing lapses to gauge the nature and breadth of the problem in the context of widely available and accepted practice guidelines. METHODS We examined peer-reviewed and non-peer-reviewed literature to identify lapses reported in North America during 2005 to 2012 resulting in patient exposure to potentially contaminated gastrointestinal endoscopes. RESULTS Lapses occurred in various types of facilities and involved errors in all major steps of reprocessing. Each lapse continued for several months or years until the problem was discovered except for one that was described as a single incident. There were significant implications for patients, including notification and testing, microbial transmission, and increased morbidity and mortality. Only 1 reprocessing lapse was found in a peer-reviewed journal article, and other incidents were reported in governmental reports, legal documents, conference abstracts, and media reports. CONCLUSION Reprocessing lapses are an ongoing and widespread problem despite the existence of guidelines. Lack of publication in peer-reviewed literature contributes to the perception that lapses are rare and inconsequential. Reporting requirements and epidemiologic investigations are needed to develop better evidence-based policies and practices.

The Use of Rapid Indicators for the Detection of Organic Residues on Clinically Used Gastrointestinal Endoscopes with and without Visually Apparent Debris

BACKGROUND Outbreaks of multidrug-resistant organisms have been linked to endoscope reprocessing lapses. Meticulous manual cleaning before high-level disinfection (HLD) is essential in reducing residual contamination that can interfere with HLD. Current reprocessing guidelines state that visual inspection is sufficient to confirm adequate cleaning. OBJECTIVE Our aim was to evaluate contamination of clinically used endoscopes, using visual inspection and rapid indicator tests before and after manual cleaning. A second objective was to determine which rapid indicator instruments and methods could be used for quality improvement initiatives in endoscope reprocessing. DESIGN Clinical use study of endoscope reprocessing effectiveness. SETTING Tertiary care teaching hospital with an inpatient endoscopy center. METHODS Researchers sampled endoscopes used for gastrointestinal procedures before and after manual cleaning. The external surfaces and 1 channel of each endoscope were visually inspected and tested with rapid indicators to measure protein, blood, and adenosine triphosphate (ATP) contamination levels. RESULTS Multiple components were sampled during 37 encounters with 12 unique endoscopes. All bedside-cleaned endoscopes had high levels of ATP and detectable blood or protein, whether or not any residue was visible. Although there was no visible residue on any endoscopes after manual cleaning, 82% had at least 1 positive rapid indicator test. CONCLUSIONS Relying solely on visual inspection of endoscopes prior to HLD is insufficient to ensure reprocessing effectiveness. For quality assurance initiatives, tests of different endoscope components using more than 1 indicator may be necessary. Additional research is needed to validate specific monitoring protocols.

Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: Results of visual inspections, biochemical markers, and microbial cultures

HighlightsEndoscopes accumulated contamination, visible damage, and debris over time.Examination of internal components detected damage or fluid inside every endoscope.Routine cleaning verification tests identified endoscopes requiring re‐reprocessing.Microbial culture incubation >48 hours fostered growth and pathogen identification.Microbial growth was found in samples from 60% of gastrointestinal endoscopes. Background: Flexible endoscopes are currently reused following cleaning and high‐level disinfection. Contamination has been found on endoscopes, and infections have been linked to gastrointestinal, respiratory, and urologic endoscopes. Methods: This longitudinal study involved visual inspections with a borescope, microbial cultures, and biochemical tests for protein and adenosine triphosphate to identify endoscopes in need of further cleaning or maintenance. Three assessments were conducted over a 7‐month period. Control group endoscopes reprocessed using customary practices were compared with intervention group endoscopes subjected to more rigorous reprocessing. Results: At final assessment, all endoscopes (N = 20) had visible irregularities. Researchers observed fluid (95%), discoloration, and debris in channels. Of 12 (60%) endoscopes with microbial growth, 4 had no growth until after 48 hours. There were no significant differences in culture results by study group, assessment period, or endoscope type. Similar proportions of control and intervention endoscopes (˜20%) exceeded postcleaning biochemical test benchmarks. Adenosine triphosphate levels were higher for gastroscopes than colonoscopes (P = .014). Eighty‐five percent of endoscopes required repair due to findings. Conclusions: More rigorous reprocessing was not consistently effective. Seven‐day incubation allowed identification of slow‐growing microbes. These findings bolster the need for routine visual inspection and cleaning verification tests recommended in new reprocessing guidelines.

Simethicone residue remains inside gastrointestinal endoscopes despite reprocessing

BACKGROUND During a study designed to assess endoscope reprocessing effectiveness, a borescope was used to examine lumens and ports. Cloudy, white, viscous fluid was observed inside fully reprocessed gastroscopes and colonoscopes. This fluid resembled simethicone, which is commonly administered to reduce foam and bubbles that impede visualization during gastrointestinal endoscopy. This article describes methods used to determine whether the observed fluid contained simethicone. METHODS Photographs of residual fluid were taken using a borescope. Sterile cotton-tipped swabs were used to collect samples of fluid observed in 3 endoscope ports. Samples were evaluated using Fourier transform infrared spectroscopy (FTIR)-attenuated total reflection analysis. RESULTS Residual fluid was observed inside 19 of 20 endoscopes. Fluid photographed in 8 endoscopes resembled simethicone solutions. FTIR analysis confirmed the presence of simethicone in 2 endoscopes. CONCLUSIONS Fluid containing simethicone remained inside endoscopes despite reprocessing. Simethicone is an inert, hydrophobic substance that may reduce reprocessing effectiveness. Simethicone solutions commonly contain sugars and thickeners, which may contribute to microbial growth and biofilm development. Studies are needed to assess the prevalence of residual moisture and simethicone in endoscopes and determine the impact on reprocessing effectiveness. We recommend minimizing the use of simethicone pending further research into its safety.

Effectiveness of worksite interventions to increase influenza vaccination rates among employees and families.

Objective: To increase influenza vaccination rates among industrial employees and their families through a campaign at a large corporation. Methods: This prospective, multisite study used employee surveys and claims data to evaluate an evidence-based worksite vaccination program. Results: Vaccination rates among insured employees and dependents (N = 13,520) increased significantly after the intervention (P < 0.001). More than 90% of vaccinated employees received vaccine at employer-sponsored events. There was a strong association between employee and family vaccination status. Primary reasons for receiving the vaccine were economic (free 84%; convenient 80%; avoid absenteeism 82%), rather than health-related. Knowledge was associated with vaccination, but customized education did not change beliefs. Conclusions: Worksite programs can demonstrably increase vaccination rates among industrial employees and families. Consideration should be given to repositioning vaccination from medical treatment to community initiatives offered with other worksite health promotion programs.

Re-evaluating endoscopy-associated infection risk estimates and their implications.

According to the Centers for Disease Control and Prevention (CDC), approximately 11 million gastrointestinal endoscopies are performed annually in the United States.1,2 The 2008 CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Disinfection and Sterilization in Healthcare Facilities states that contaminated endoscopes have been linked to more health care-associated infections than any other medical device.3 Paradoxically, several guideline-issuing organizations assert that the risk of endoscopy-associated infection (EAI) is only 1 in 1.8 million procedures.3-6 Recent audits have documented widespread lapses in infection control involving medical equipment.7-11 Inspections of multiple facilities determined that certain endoscopy equipment was not properly reprocessed for up to several years.8,11-15 Direct observation in a multisite study revealed that endoscopes were virtually never reprocessed in accordance with guidelines.7 The implications of these lapses are unknown because no epidemiologic studies have determined the risk of EAI associated with reprocessing quality. Research was conducted to evaluate the origins and accuracy of the risk estimates after a single outbreak involvedmore cases of EAI than would be expected in 1 year nationwide.15,16 This article describes the methodology used to estimate risk and discusses the patient safety implications of relying on the statistics appearing in guidelines.

Assessing residual contamination and damage inside flexible endoscopes over time

Researchers evaluated flexible endoscope damage and contamination levels at baseline and 2 months later. Postcleaning test results exceeded benchmarks for all gastroscopes and no colonoscopes. Microbial growth was found in samples from 47% of fully reprocessed endoscopes at baseline and 60% at follow-up. Borescope examinations identified scratches, discoloration, debris, and fluid inside endoscopes. Irregularities changed over time. Study evaluations allowed damaged and contaminated endoscopes to be identified and re-reprocessed or sent for repairs.