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NEWS FEATURES
Bronchoscopes
Handwashing
REGULATORY/LEGISLATIVE/QUESTION OF THE MONTH
Glutaraldehyde Use
NEWS AND ANNOUNCEMENTS
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
NEWS FEATURES
Bronchoscopes
Bronchoscopy is a generally safe and widely used medical procedure. It is estimated that approximately 500,000 bronchoscopies are performed each year. Although infectious complications are rare, multiple outbreaks and pseudo-outbreaks have resulted from the failure to properly clean and disinfect the bronchoscope.
The importance of proper cleaning and disinfection was recently highlighted in a report of 3 clusters of bronchoscopic-related infections and pseudoinfections which was published in Morbidity and Mortality Weekly Report (MMWR 1999;48:557-560). All three clusters resulted from the failure to properly connect the bronchoscope to the Steris System 1 in accordance with the Steris manufacturer's recommendations. This resulted in a failure to properly perfuse the channels with the disinfectant.
Bronchoscopic-related infections and pseudoinfections most commonly have resulted from the following: failure to properly clean the scope immediately after use, use of an ineffective disinfectant, inadequate contact time with the disinfectant, and terminal rinse with tap water. The key factors in proper disinfection of bronchoscopes include: immediately cleaning after use, complete immersion in an appropriate high-level disinfectant (e.g., 2% glutaraldehyde, 7.5% hydrogen peroxide) for at least 20 minutes or use of an approved low-temperature sterilization method, monitoring of disinfectant concentration, terminal rinse with sterile water or clean water and alcohol, and post-disinfection care to prevent recontamination (i.e., hang bronchoscopes in a clean environment). When new low-temperature disinfection methods are used one must rigidly adhere to the manufacturer's recommendations.
Handwashing
Handwashing is the single most effective infection control intervention to prevent cross-transmission of nosocomial pathogens. Multiple studies have documented that proper handwashing by medical personnel occurs in 30 to 50 percent of patient contacts.
A recent study published in the Annals of Internal Medicine (Pittet D, et al. AIM 1999;130;126) observed 2834 patient contacts for which handwashing was indicated. A multivariate analysis revealed that the noncompliance was higher among physicians (OR 2.8), nursing assistants (OR 1.3) than among nurses and was lowest on weekends (OR 0.6). Importantly, noncompliance was higher in intensive care than in internal medical units (OR 2.0), during procedures that carry a high risk for contamination (OR 1.8), and when intensity of patient care was high (OR 1.3-2.1).
This study demonstrated that handwashing compliance was lowest under the very circumstances it is most indicated such as ICU patients and during procedures that carry a high risk for contamination. Improving handwashing compliance is an important goal of infection control. Staff education, easy access to sinks, and easy access to waterless antiseptic agents may improve handwashing rates. In the future improved agents with antimicrobial persistence may become available. The introduction of such agents may aid in decreasing cross-transmission of nosocomial pathogens between patients.
REGULATORY/LEGISLATIVE/QUESTION OF THE MONTH
Glutaraldehyde Use
Q: What are the guidelines for glutaraldehyde in-use temperature, monitoring solution concentration, and employee exposure?
A: SPICE has received several calls from facilities being surveyed by JCAHO regarding practices associated with the use of glutaraldehyde for high-level disinfection of endoscopes and patient-care equipment. The issues that are being addressed by surveyors include glutaraldehyde in-use temperature, requirements for monitoring solution concentration, and employee exposure.
In 1995, the FDA approved a label for one liquid chemical germicide that required a 45-minute immersion at 25oC to support a high-level disinfection label claim. Scientific data reviewed in the Journal of Infection Control and Hospital Epidemiology (1995;16:231-235) by Drs. Rutala and Weber noted at least an 8-log reduction in Mycobacterium tuberculosis contamination with cleaning (4 logs) followed by chemical disinfection for 20 minutes (4 to 6 logs). Therefore, the APIC Guideline for Selection and Use of Disinfectants supports the position that the FDA should modify the label to state that if cleaning is accomplished using a standardized cleaning protocol, then a 20-minute immersion at 20oC will be sufficient to achieve high-level disinfection. The second issue is that of monitoring minimally effective concentration of 1.5% available glutaraldehyde. Currently test strips are constructed to indicate concentrations above 1.5%. Therefore, to ensure that the appropriate concentration is present, the solutions should be monitored periodically, with the exact frequency based on how often the solutions are used (e.g., if used daily, test daily). Testing should not be used to extend the use-life beyond the expiration date, and record keeping (e.g., log book) should be maintained. Finally, monitoring of glutaraldehyde exposure is typically accomplished by employee badges that indicate an exposure below the OSHA 0.2 ppm ceiling limit.
NEWS AND ANNOUNCEMENTS
The 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections will be held March 5-9, 2000 in Atlanta, Georgia, USA. The conference is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), with co-sponsors being the Association for Professionals in Infection Control and Epidemiology, Inc.(APIC), the National Foundation for Infectious Diseases (NFID), and the Society for Healthcare Epidemiology of America (SHEA).
Additional details are available at the following URL:
http://www.decennial.org/
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control Part II: The ICP as an Environmentalist" will be held September 27-October 1, 1999 at the Holiday Inn in Chapel Hill.
"Infection Control in Home Health and Hospice" will be held October 11, 1999 at The Friday Center in Chapel Hill.
Contributors to Report of the Month: Karen K.
Hoffmann, RN, MS, CIC; William A.
Rutala, PhD, MPH, Eva P. Clontz,
MEd.
To subscribe to the Report of the Month, send email to spice@unc.edu
Report of the Month is also available on the home page of the Statewide Program for Infection Control and Epidemiology at http://www.unc.edu/depts/spice/
The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by the General Assembly of North Carolina to serve the State. SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.
Copyright 1999 North Carolina Statewide Program for Infection Control and Epidemiology
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