WIth the FDA recently warning healthcare facilities about multiple reported failures in the effectiveness of reprocessing procedures used on certain endoscopes that had become contaminated with the "nightmare superbug" CRE (carbapenem-resistant Enterobacteriaceae), we are reminded of the predictablity of generating and coming in contact with infectious GI pathogens during these commonly performed procedures.  CRE represents but one of a growing number of bacteria originating from the GI tract that have developed an increasing resistance to even the most powerful of antibiotics.  Publicized reports confirm that more than 100 infections and 28 deaths have been linked to the cross-transmission of CRE in endoscopic settings from unsuspected bacteria that had eluded standard cleaning and disinfection.  A sentinel event like this serves as a stark reminder that the GI tract serves as the ultimate origin of many of the most prevalent and infectious bacteria known today (including C. difficile, VRE, and CRE), and there is no place within a hospital or healthcare facility where encountering these same GI-borne bacteria and pathogens is as predictable, and their spread therefore preventable, as within an endoscopy setting.  Given the very nature and course of the procedures performed, there exists a dangerous disconnect between the inherent risks of generating infectious bacteria and the continuity of infection control processes employed to contain these during procedures. All too often these risks have been minimized, flying under the radar of infection control processes as they have been historically (and misleadingly) written off as "dirty" or "non-sterile" procedures. 

Eliminating "Gaps" in Endoscopy Infection Control

     The thorough reprocessing and safe handling of flexible endoscopes is, without question, the most important (and common sense) component of ensuring the hygiene of equipment and supplies used in GI endoscopy.  However, it is also critical to assure that the infection control and prevention processes implemented throughout the sequence of events that comprise these procedures sufficiently recognize and address the predictable risks of contamination and cross-transmission from the bacteria, bloodborne pathogens, secretions, and OPIM (other potentially infectious materials) generated through direct contact with the mucosal linings and fluids of the GI tract.

     In accordance with these risks, the ASGE "Guidelines for safety in the gastrointestinal endoscopy unit," (American Society for Gastrointestinal Endoscopy, 2014) highlight the need for the identification and elimination of any infection control "gaps" along the continuum of endoscopy care, recognizing that such gaps or failures jeopardize patient safety.  Expanding well beyond standard scope reprocessing and hand hygiene recommendations, these guidelines call for the development and implementation of a comprehensive infection prevention plan to address the risks of contact and cross-transmission of infectious GI pathogens throughout the course of an endoscopy procedure.  This includes a thorough evaluation of the complex activities and interactions that take place from the initial pre-op stage, contact with surfaces and equipment touched or contaminated during the procedure, and movement patterns that can facilitate cross-transmission extending all the way through recovery and discharge.

Unique Infection Control Needs in GI Endoscopy

When evaluating infection prevention processes along the continuum of care in GI endoscopy, one of the most commonly overlooked (and preventable) risks of introducing infectious bacteria and pathogens into the hospital or patient care environment is inherent to the traffic patterns and procedure flow within an endoscopy department.  To illustrate, consider that in an aseptic (sterile) O.R. surgical environment, a patient is transferred to a fixed surgical table and a defined "field" established to differentiate "clean" from potentially contaminated surfaces and equipment.  Any tool or supply entering the field is sterile, and significant attention is paid to activities within the operating room to avoid infections that can be caused from pathogens being transmitted from the environment to the patient.

In contrast, GI endoscopy procedures are, by definition and practice, non-sterile procedures as they are performed on existing anatomic portals.  However, this designation does not accurately reflect that these also involve extensive contact with mucous membranes already known to be heavily colonized with a persons microflora, or naturally existing bacteria.  During an endoscopic GI procedure, exposed linens, handrails, stretcher frames, mattresses  and even the patient's skin are readily subjected to contamination with bacteria and pathogens through incidental contact with the exterior scope surface, frequent contact with gloved hands, and the secretions and droplets generated.  Movement patterns within the environment of an endoscopy suite are also not as standardized, with biopsy snares and supplies, for instance, often being moved in and out of the immediate procedure area between uses. 

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     Endoscopic GI procedures provide a valuable, life-saving screening tool for the prevention of a wide array of diseases and disorders.  However, as simplistic and routine as these may seem on the surface, having comprehensive infection prevention processes in place during GI procedures is a critical and often overlooked step in preventing exposure of your patients, staff, and entire facility to the easily avoidable risks associated with infectious GI pathogens.

     In any given hospital or ambulatory care setting, there is no department or patient care area where encountering potentially infectious enteric (GI) bacteria is a more certain and predictable occurrence than during the course of an endoscopic GI procedure.  In these procedures, a long flexible endoscope is intended to extensively explore the tissues of the GI tract, which is the ultimate origin of many of the most notorious bacterial pathogens, including C. difficile, Enterobacteriaceae (think CRE), Enterococci (including VRE), and a host of other bloodborne pathogens and viruses frequently implicated in hospital infection.  Hospital and other healthcare facility infection control processes are often plagued by patients who develop infections from these GI borne pathogens, most of which are known to be extensively transmitted from environmental surfaces.   GI endoscopy is often a tool used for the differential diagnosis of many enteric infections, and has long been among the CDC's top risk factors for the development and transmission of C. difficile.  Even so, the critical need to implement common sense strategies to contain these types of pathogens during endoscopic procedures is all too often minimized.   Often these are regarded as "dirty, non-sterile procedures," almost as if this somehow implies that reasonable controls and hygiene measures and are not even necessary to prevent the introduction of bacteria and pathogens into the rest of a facility.

     When it comes to infection control and safety during endoscopic GI procedures, discussions have generally focused on scope reprocessing and injection safety.  Add in the required reviews of hand hygiene compliance and PPE use to meet OSHA requirements and the bases are all covered, right?  Maybe not so fast.

     In issuing its "Guidelines for safety in the gastrointestinal endoscopy unit," the ASGE (American Society for Gastrointestinal Endoscopy, 2014) calls for the elimination of "gaps" along the continuum of care that can negatively impact patient safety.  In recognition of these risks, the ASGE guidelines necessitate the development and implementation of a specific infection prevention plan to prevent the transmission of pathogens in GI endoscopy units.  This includes a thorough evaluation of the activities that take place from the pre-procedure through discharge in order to protect the health and safety of both patients and care providers.

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