Bronchoscope Reprocessing: A Secure Procedure

• The FDA has issued communications regarding the secure reprocessing of bronchoscopes
• Precleaning at the point of use, leak testing, manual cleaning, high-level disinfection, rinsing, drying, and storage are critical components in reprocessing bronchoscopes
• Automated Endoscope Reprocessors (AERs) offer advantages over manual disinfection by limiting process variation opportunities
• Personnel involved in bronchoscope reprocessing should have appropriate education, hands-on training, and competency assessments initially and at designated intervals
• Training is needed when new equipment or disinfection technologies are introduced
• Strict adherence to bronchoscope, AER, and chemical manufacturers' instructions is essential, along with preventative maintenance

Bronchoscope Reprocessing: Problem

• If a bronchoscope fails a leak test, water may penetrate inside, leading to damage and inadequate cleaning/disinfection
• A bronchoscope failing a leak test should be removed from the water immediately, and the manufacturer should be contacted

Key Steps for Bronchoscope Sterilization/Disinfection

• Mechanically cleaning internal and external surfaces (brushing and flushing channels)
• Immerse the bronchoscope in high-level disinfectant or chemical sterilant, ensuring all channels are in contact, and expose for the time recommended by the product
• Rinse the bronchoscope and channels with sterile, filtered, or tap water
• Rinse insertion tube and inner channels with alcohol and dry with forced air
• Store the bronchoscope to prevent recontamination, such as hanging vertically in an enclosed cabinet

Disposable Equipment

• Single-patient-use disposable devices are an option for reprocessing equipment
• Disposable medical devices now include humidifiers, nebulizers, incentive spirometers, ventilator circuits, bag-valve-masks, laryngoscopes, bronchoscopes, and monitoring transducers
• Major issues with disposable devices include cost, quality, and reuse
• Evaluating costs associated with purchasing and processing reusable versus disposable devices requires dollar comparisons
• Recent findings support the cost-effectiveness of disposable devices in respiratory care
• Respiratory care managers should evaluate disposable devices being considered for purchase to evaluate physical testing of multiple units
• Before use, bedside clinicians should inspect and confirm the operation of any disposable device
• Reusing devices labeled for "single-use only" raises safety concerns and negligence issues
• The FDA provides stringent regulations for reprocessing and reusing single-use devices
• Reused single-use devices must meet the same regulatory requirements as the original manufactured device
• The Centers for Medicare and Medicaid Services (CMS) recommends single-use devices be reprocessed by an FDA-approved third-party reprocessor, not by hospitals

Fluid and Medication Precautions

• Unit dosing has not eliminated infection hazards of medication
• Simple procedures exist to prevent cross-contamination when using fluids and medications

Handling Contaminated Articles/Equipment

• Reusable contaminated items should be in biohazard-labeled bags or rigid containers prior to leaving a patient’s room to prevent accidental exposure
• Reusable patient-care equipment must be returned to the applicable processing area after containment
• Facility policy in compliance with OSHA should be followed when discarding contaminated single-use devices

Precautions for Fluids and Medications

• Sterile fluids should be used for tracheal suctioning and to fill nebulizers/humidifiers
• Sterile water should be used for rinsing equipment, following with an alcohol rinse or thorough air-drying if tap water is used
• Large stock bottles of sterile fluid that are reused must be discarded within 24 hours
• Multidose medication vials must be handled, dispensed, and stored according to the manufacturer's instructions and expiration dates

Handling Laboratory Specimens

• Extreme care is needed when gathering laboratory specimens (e.g., sputum) to prevent contamination of the external surface of the container
• Contaminated containers must be disinfected or placed in an impervious bag
• Specimens should be placed in a sturdy container with a secure lid to minimize leaks during transport
• Specimens from patients on isolation precautions must be placed in an appropriately labeled, impervious bag before removal
• Special handling procedures may be needed for specific clinical situations, like using a dual-vessel sputum trap for acid-fast bacilli (AFB)

Surveillance for Hospital-Acquired Infections (HAIs)

• Surveillance is an ongoing process that monitors patients and healthcare personnel for acquiring infection and/or colonization of pathogens
• Surveillance, investigation, prevention, control, and reporting are the components of an IP program
• Surveillance is a systematic process designed to review and analyze HAI data on patients to provide outcome measurements
• Outcome measurements may include interventions, identifying clusters or outbreaks, and identifying opportunities to intervene to prevent the transmission
• An IP committee generally establishes surveillance policies, and an infection preventionist/epidemiologist administers them
• Principles of an IP surveillance program:
• Use of standard HAI definitions
• Use of microbiology-based data (when available), including resistance patterns for pathogens of significance
• Establishment of risk stratification for infection risk when available
• Monitoring the results prospectively and identifying trends indicating unusual infection or transmission rates
• Providing feedback to stakeholders
• Hospitals surveil device-related infections like central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonias (VAPs) by applying the National Healthcare Safety Network (NHSN) definitions
• Tracking C. difficile and methicillin-resistant S. aureus (MRSA) infections is also common
• Regulatory mandates exist for public reporting of surveillance results
• VAP surveillance has changed to the ventilator-associated event (VAE) surveillance definition that is based on objective criteria that may identify several conditions or complications in mechanically ventilated adult patients that could contribute to VAP
• VAEs are broken down into three tiers: ventilator-associated condition (VACs), infection-related ventilator-associated complication (IVACs), and possible VAP (PVAP)
• Surveillance starts with VAC identification that is defined as increases in positive end-expiratory pressure (PEEP) and fraction of inspired oxygen for 2 calendar days or longer after a period of stability
• IVAC is present if a VAC has been identified and a patient has an elevated temperature or white blood cell count, and new antibiotics have been started and administered for 4 or more days
• PVAP is present if an IVAC has been identified in a patient with positive culture results meeting specific threshold values or purulent respiratory secretions and a positive culture result with sufficient growth to meet the threshold values
• VAE practice examines ventilator therapy’s overall safety rather than focusing only on infection-related outcomes through IP, critical care physicians, and RT partnerships
• Surveillance activities are enhanced when they generate actionable data in a timely way to the bedside caregiver, becoming the basis for continuous improvement in care delivery
• Infection preventionists must communicate surveillance data to bedside caregivers to improve care based on local data
• Healthcare workers must be willing to accept surveillance data in the original intention, not as a punitive approach, but as a tool to inform reflection for current care processes