Time to Sterilize Scopes?

A pair of studies suggest that sterilizing GI endoscopes, rather than high-level disinfecting them, may be necessary to prevent the transmission of multi-drug resistant organisms which have been found to survive standard reprocessing practices.

One study, published last week in JAMA, recounts the discovery of an outbreak of a rare strain of Carbapenem-resistant Enterobacteriaceae (CRE) among patients at Advocate Lutheran General Hospital in Park Ridge, Ill.

An investigation assisted by epidemiologists at the Centers for Disease Control and Prevention in Atlanta as well as the Illinois, Cook County and Chicago public health departments linked the outbreak to a duodenoscope used in endoscopic retrograde cholangiopancreatography (ERCP) procedures. The scopes cross-contaminated patients despite a disinfection process that fully complied with their manufacturers' recommendations. After they were sterilized with ethylene oxide, however, no additional infections were observed.

"The complicated design of duodenoscopes makes cleaning difficult," the researchers note. In addition to switching to sterilization, they advise routine testing for residual contamination.

The other study, presented this weekend at ID Week, the annual meeting for infectious disease professionals, reports similar findings from UPMC Presbyterian Hospital in Pittsburgh, Pa. There, researchers tracked an increase in antibiotic-resistant infections among ERCP patients before determining that standard disinfection failed to entirely eliminate bacteria from the flexible scopes' channels. Sterilization with ethylene oxide likewise halted the infectious spread.

"We are confident that the change from disinfection to sterilization of GI scopes is necessary in preventing serious infections and we are glad to share our findings with hospitals nationwide," says lead author Carlene Muto, MD, MS, UPMC Presbyterian's director of infection prevention.

In an editorial accompanying the JAMA study, epidemiologists William A. Rutala, PhD, MPH, and David J. Weber, MD, MPH, of the University of North Carolina, urge healthcare workers to keep an eye out for outbreaks.

"Clinicians should be encouraged to report and publish cases of infectious diseases related to endoscopy, especially if current reprocessing methods were adhered to," they write, "so it can be determined if the [study] is the tip of the iceberg or an isolated occurrence. If the former, then revision of the endoscope reprocessing guidelines will be necessary to ensure patient safety."

David Bernard

Anesthesia Complications on the Decline

Anesthesia-related complications fell by half between 2010 and 2013, according to findings presented last week in New Orleans at the annual conference of the American Society of Anesthesiologists.

Authors of the large-scale study accessed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry to assess outcomes of more than 3.2 million procedures, which accounted for a quarter of anesthesia practices nationwide. The findings show mortality rates remained constant during the study period, but anesthesia-related complications dropped from 11.8% to 4.8%. PONV, the most commonly reported minor complication, occurred in approximately one-third of the cases. Medication errors, the most frequent major complication, occurred in nearly 12% of cases.

Study lead author Adrian Liau, PhD, senior research associate at the Anesthesia Quality Institute in Schaumburg, Ill., says additional research years are needed to confirm the promising results.

"As large as our databases are, we only have 4 years of information so there hasn't been enough time to definitively gauge the trends we're seeing," he says, adding that the growing database of anesthesia outcomes will help guide future quality improvement efforts.

Daniel Cook

The Benefits of "Prehabilitation"

Physical therapy before total hip or total knee replacement surgery may help reduce the need for post-operative care by nearly 30%, saving an average of $1,215 per patient, suggests a study appearing in the Journal of Bone & Joint Surgery.

The study used Medicare data to examine the cases of 4,700 joint replacement surgery patients who had received pre-operative physical therapy and post-operative care. The average cost of pre-operative physical therapy was about $100 per patient, and was usually limited to 1 or 2 sessions. Researchers defined post-op care as the use of a skilled nursing facility, home health agency or inpatient rehabilitation center within 90 days of discharge.

Approximately 77% of the patients who had physical therapy before surgery used these care services post-operatively, the study found. After adjusting for demographic characteristics and comorbidities, patients receiving pre-operative physical therapy showed a 29% reduction in post-operative care use.

Kendal Gapinski

InstaPoll: Should Upper GI Endoscopes Be Sterilized Instead of High-Level Disinfected?

Because the complex channels in duodenoscopes may be more difficult to disinfect completely, some infection preventionists are suggesting that they be sterilized instead of high-level disinfected. Tell us where you stand in this week's InstaPoll, then check back next week for the results.

Last week we asked if going green is as important an initiative in your ORs now as it was a few years ago. Nearly one-third (31%) of the 213 respondents say recycling, reusing and reprocessing has lost a little steam. The results:

Is going green still a big deal?

  • It's much more important. 22%
  • It's somewhat more important. 16%
  • It's as important. 31%
  • It's somewhat less important. 22%
  • It's much less important. 9%

Dan O'Connor

News & Notes
  • Is minimally invasive surgery available to all? Patients' access to minimally invasive colon cancer surgery varies widely throughout the country, University of Michigan researchers report in the Journal of Clinical Oncology. Their review of more than 90,000 colectomies performed at nearly 3,500 hospitals nationwide revealed that one-third of the cases were laparoscopic, but at individual facilities the rates of keyhole surgery ranged from 67% to 0%. Since the researchers say the required laparoscopic equipment was available at most hospitals, access likely depends largely on surgeons' experience and comfort with the technique.
  • Sound satisfies after surgery Smooth jazz music slowed the heart rates of post-op elective hysterectomy patients, while patients who wore noise-cancelling headphones also experienced less post-op pain, according to researchers from Penn State University's Milton S. Hershey Medical Center in Hershey, Pa. Presenting their findings at the American Society of Anesthesiologists' annual meeting, they suggested that making PACU a pleasant aural environment could improve patient recovery, lessen the need for post-op medication and boost patient satisfaction.
  • Robots add costs, complications Robotic-assisted surgery for certain procedures may be more expensive and cause more complications than conventional laparoscopic surgery, according to a study by Columbia University Medical Center researchers. They found that robotic-assisted gynecologic surgery increased by more than 10% during a 3-year period. During that time, there was also a small increase in intraoperative complications for women undergoing robotic procedures for benign gynecologic conditions. The study also showed that the average cost for these robotic surgeries was around $3,000 more expensive than conventional laparoscopic procedures.