柔性內窺鏡：干燥儲存的重要性以防止生物膜的形成.pdf

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1、Importance of Dry Storage to preventbiofilm formationName:Dr.Michelle Alfa Ph.D.Affiliation:AlfaMed Consulting LtdDisclosuresDisclosures:Consulting services:Consulting services:Olympus America,Nanosonics,AustraliaRoyalties:Royalties:University of Manitoba for patent license to HealthmarkSponsoredSpo

2、nsored EducationalEducational Speaker:Speaker:Olympus,3M All publications mentioned are listed at the end of the presentationThe information presented today is based on published data and my opinion and is independent of any company to whom I provide consulting services.OBJECTIVES:OBJECTIVES:n Ident

3、ify key weaknesses in current reprocessing protocolsn Focus on the impact of inadequate drying on endoscope contamination-Reprocessing is a SYSTEMwith sequential stages-Breaches in any one stage can result in persistence of microbes and organic matter in the patient-ready endoscopes Leading Biofilm

4、formationManual or flushing pump assisted;brush/flush+detergentDRYING;-StorageBedside Pre-cleanLeak TestingManual cleaningAER:cleaning,HLD,final rinseDrying for storageStorageFINAL RINSE WATER;-Bacteria-freeEndoscope Reprocessing SystemBedside channel flush&exterior wipeWHAT STAGES IN REPROCESSING A

5、RE DIFFICULT FOR STAFF?WHAT STAGES IN REPROCESSING ARE DIFFICULT FOR STAFF?“70%of survey respondents felt pressure to work quickly and 17%of the respondents routinely skipped endoscope IFU steps due to time pressure.”Sivek A et al Healthcare worker feedback on duodenoscope reprocessing workflow and

6、ergonomics.AJIC 2022 https:/doi.org/10.1016/j.ajic.2022.01.012Alfa MJ,Sitter DL.In-hospital evaluation of contamination of duodenoscopes:a quantitative assessment of the effects of drying.J Hosp Infect 1991;19:89-98Forced Air Drying for 10 mins:N=19No detectable microbes at 2,24 or 48 HrsEvidence of

7、 Evidence of MicrobialMicrobial ReplicationReplication duringduring Storage of Storage of ClinicallyClinically usedused,FullyFully ReprocessedReprocessed DuodenoscopesDuodenoscopesYassin M et al How effective are the alcohol flush and drying cycles of automated endoscope reprocessers?Stripped endosc

8、ope model.AJIC 2023;51:527-5323 min Air flush in AER:-Suction/Instrument Channel:Not OK-Air/Water channel:Not OK10 Min Air flush in AER plus 7 day storage:-Suction/Instrument Channel:OK-Air/Water channel:Not OK 10 min AER Dry 7 day hang3 min AER DryAir-water channelsAir-water channelsAir-water chann

9、elsInstrument channelHow Dry How Dry is is an AER Channel Flush?an AER Channel Flush?Biofilm:Rapid accumulation in Patient Biofilm:Rapid accumulation in Patient used Gastroscopesused GastroscopesPrimo MGB,et al.(2021).Biofilm accumulation in new flexible gastroscope channels in clinical use.Infectio

10、n Control&Hospital Epidemiology,https:/doi.org/10.1017/ice.2021.99Biofilm in Air/Water channels of clinically used gastroscopes:These narrow channels were replaced with new channels but they developed similar extensive biofilm within 30 days of clinical use that persisted for 60 days.Image:GESA GENC

11、A;Infection Prevention and Control in Endoscopy 2021.Gastroenterological Society of AustraliaOnly Distal Air/water channels replaced.Rapid recolonization from Umbilical portion of Air/Water channels Okamoto N,et al.A prospective,multicenter,clinical study of duodenoscope contamination after reproces

12、sing.ICHE 2022 https:/doi.org/10.1017/ice.2021.525ClassificationHigh Concern Organisms#of TJF-Q180V DuodenoscopesGastrointestinalKlebsiella spp.Enterococcus spp.Escherichia spp.Pantoea spp.Pluralibacter spp.42211Human-origin(other than GI)Staphylococcus aureusS.lugdenensisCandida spp.552Environmenta

13、lAcinetobacter spp.Candida spp.Erwinia bilingaePseudomonas spp.Ralstonia spp.Roseomonas spp.Sphingomonas mucosissema4111111Water-borneBrevundimonas spp.Massilia spp.Pseudomonas spp.322NON-OUTBREAK SETTING DUODENOSCOPESHigh ConcernOrganisms(35/859;4.1%)van der Ploeg K,et.al.Impact of Duodenoscope Rep

14、rocessing Factors on Duodenoscope Contamination:A Retrospective Observational Study,Journal of Hospital Infection,https:/doi.org/10.1016/j.jhin.2024.09.01843/307(14%)cultures grew Gut organismsDrying Cabinet for storage;90 mins drying considered adequateNON-OUTBREAK SETTING DUODENOSCOPESCobalt Chlor

15、ide test Cobalt Chloride test paperpaper:NEGATIVEWATER DETECTEDPerumpail et al.Endoscope reprocessing:Comparison of drying effectiveness and microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet Am J Infect Control 2019 https:/doi.org/1

16、0.1016/j.ajic.2019.02.016Bronchoscope:5 uL Suction/Biopsy channelDuodenoscope:250uL Air/water channel100uL Suction/Biopsy channelColonoscope:100 uL Air/water channel150 uL Suction/Biopsy channelLimit of Detection:SurfacesSurfacesSurfaces3 Hours12 Hours24 Hours48 Hours1.Low level of P.aeruginosa inoc

17、ulated into instrument channel of Colonoscope,Duodenoscope&Bronchoscope2.After 31 days storage;-0 CFU in Colonoscope&Bronchoscope-1 CFU in DuodenoscopeAUTOMATED AIR FLOW IN ALL CHANNELS VERSUS STANDARD:NO AIR FLOW IN CHANNELSPerumpail et al.Endoscope reprocessing:Comparison of drying effectiveness a

18、nd microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet Am J Infect Control 2019 https:/doi.org/10.1016/j.ajic.2019.02.016ColonoscopeDuodenoscopeBronchoscopeFig.1.Droplets observed after alcohol flush and 2 AER air purge cycles totalin

19、g 13 minutes forced air(photos collected during pre-study training session).AER,automated endoscope reprocessor.Ofstead et al Fluid retention in endoscopes a real world study.AJIC 2024 https:/doi.org/10.1016/j.ajic.2024.02.015Borescope of Instrument channelCOBALT CHLORIDE TESTINGOfstead et al Fluid

20、retention in endoscopes a real world study.AJIC 2024 https:/doi.org/10.1016/j.ajic.2024.02.015After AER 3 min air PurgeAfter 10 minute Forced Air Drying System(FADS)cycleGastroscopeColonoscopeGastroscopeColonoscopeCobalt Chloride testingDistal end22/22(100%)20/20(100%)0/22(0%)0/20(0%)Visual Inspecti

21、onDistal end9/17(52.9%)5/13(38.5%)0/17(0%)0/13(0%)Borescope exam Suction/instrument channelNot doneNot done0/4(0%)0/6(0%)Ofstead et al Fluid retention in endoscopes a real world study.AJIC 2024 https:/doi.org/10.1016/j.ajic.2024.02.015Ofstead et al Fluid retention in endoscopes a real world study.AJ

22、IC 2024 https:/doi.org/10.1016/j.ajic.2024.02.0151.Manual;Compressed air-gun:Not Practical 3.Automated;Channel-purge storage cabinetsHow to Dry flexible endoscope channels?2.Flushing Pump-assisted;&Endoscope dollyImage from STERIS websiteImages from OLYMPUS websiteHow Long to Adequately Dry Flexible

23、 Endoscope channels?1.Manual Air-gun(channels&endoscope exterior):Published data1-Staff must hold Air-gun and flush each channel for at least 10 mins:HIGH RISK that staff will be not comply as it very labour-intensive2.Pump assisted channel drying:Published Data1,2,3-Various pump systems for channel

24、 drying:allows staff to do other tasks10 mins shown effective3.Drying Cabinet(channels&endoscope exterior):Published Data 1,4,5-Various commercial cabinets:allows staff to do other tasks90 mins to several hours1.Bellenhoff Ulrike.Endoscope reprocessing:How to perform an adequate air drying?Endosc In

25、t Open 2023;11:E440-E442.2.Alfa MJ,Sitter DL.In-hospital evaluation of contamination of duodenoscopes:a quantitative assessment of the effects of drying.J Hosp Infect1991;19:89-983.Ofstead et al Fluid retention in endoscopes a real world study.AJIC 2024 https:/doi.org/10.1016/j.ajic.2024.02.0154.Per

26、umpail et al.Endoscope reprocessing:Comparison of drying effectiveness and microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet Am J Infect Control 2019 https:/doi.org/10.1016/j.ajic.2019.02.0165.Van der Ploeg K.et.al.Impact of duodeno

27、scope reprocessing factors on duodenoscope contamination:A retrospective observational study.J Hosp Infect https:/doi.org/10.1016/j.jhin.2024.0.018 WHAT DO THE GUIDELINES SAY?WHAT DO THE GUIDELINES SAY?Quality Parameter:AAMI ST91 2021ISO 15883-4 2019EN 16442:2015User Verification:Routine Testing:Dry

28、ing of scope channelsOptional:(Cobalt Chloride)No frequency indicatedYES:(Cobalt Chloride)No frequency indicatedANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities.EN 16442:2015 Controlled environment storage cabinet for processed thermolabile endoscopes.DIN EN

29、 ISO 15883-4 2019 Washer disinfectors Part 4 Requirements and tests for washer-disinfectors employing chemical disinfection for thermolabile endoscopes.(section 6.8.4 Channel drying)Question?Manual or flushing pump assisted;brush/flush+detergentDRYING;-StorageBedside Pre-cleanLeak TestingManual clea

30、ningAER:cleaning,HLD,final rinseDrying for storageStorageFINAL RINSE WATER;-Bacteria-freeEndoscope Reprocessing SystemBedside channel flush&exterior wipe-Reprocessing is a SYSTEMwith sequential stages-Breaches in any one stage can result in persistence of microbes and organic matter in the patient-r

31、eady endoscopes Leading Biofilm formationSUMMARYHow can we break the cycle of Biofilm formation?Ensure adequate drying for storage:-Cobalt chloride test to monitor residual moisture in channels-Compressor assisted drying(not manual air-gun drying)-Adopt Drying endoscope storage cabinets(i.e.all channels flushed)Ensure all other stages of endoscope reprocessing are optimalWithout monitoring;You dont know what you dont know!