Cleaning instruments properly so they don’t transmit infections to patients is clearly an important component in the practice of otolaryngology, but how this cleaning is done remains open to question. Oversights can lead to harm, but some measures can be pointless and wasteful. A panel of experts discussed instrument cleaning at the Triological Society Combined Sections Meeting in January 2017, bringing big-picture considerations into focus while discussing their own experiences.
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April 2017Moderator Natasha Mirza, MD, director of the University of Pennsylvania Penn Voice and Swallowing Center in Philadelphia, said that what she learned as she prepared for the panel was eye-opening. “Most of the data is more than 10 or 15 years old, and it’s been done in a very disparate way all over the country, whether we are trying to be in compliance with our hospital policies or in clinics,” she said. “Everything’s done in a very different way, which isn’t good for us, or for our patients.”
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In 2015, researchers at Mayo Clinic in Rochester, Minn., found that viable microbes were collected from 64% of flexible endoscopes after high-level disinfection, even though the researchers observed the cleaning process and saw that guidelines were followed (Am J Infect Control. 2015;43:794–801). Dr. Mirza said it was important to note that the study pertained to gastroscopes and colonoscopes, not non-channel scopes used in otolaryngology.
The following month, the Centers for Disease Control issued an advisory on an “immediate need” for healthcare facilities to review their procedures for cleaning, disinfecting, and sterilizing equipment.
Dr. Mirza said that the risk of infection from an endoscope is just one in 1.8 million, a number she calls “extremely, extremely low.” There is potential for an infection, she added, but noted that some measures, such as excessive use of peel packs, can be a significant waste of time and resources.
Biofilm
Julio Figueroa, MD, acting chief of infectious diseases at Louisiana State University in New Orleans, drew particular attention to biofilm, the glue organisms make to stick to instruments. “That’s one of the reasons it’s important to disinfect,” he said. “Even though they might look clean, you might have this biofilm to deal with.” The endoscope, with its hooks and joints, is full of “nooks and crannies and crevices” from which it can be difficult to remove biofilm.
When facilities are found to be noncompliant, commonly cited problems are a lack of knowledge of procedures, a process that is not well defined or is not followed, and a poor design of the sterilization space, which needs to include a “dirty” area and a “clean” area where instruments dry.
Overkill
Soly Baredes, MD, chair of otolaryngology-head and neck surgery at Rutgers New Jersey Medical School in Newark, N.J., said literature on the cleaning of instruments is sparse in otolaryngology, but one in vitro study suggests that general recommendations might be more aggressive than needed.