The How's and Why's of Infection Prevention Principles in the GI/Endoscopy Unit

By Michelle Day, MSN, RN, CGRN, and Loralee Kelsey, BSN, RN, CGRN
 

Your patient arrives for her colonoscopy and is very nervous. What makes her nervous about the procedure?

The risk of infection should never be cause for concern, andas healthcare professionals we must maintain the public trust by providing safe, high-quality care through evidence-based infection prevention standards, processes and practice. Human error can be mitigated through education, ongoing training and meticulous attention to reprocessing standards. SGNA seeks to assist endoscopy units in providing and maintaining the highest infection prevention standards through training, resources and programs designed to enhance the knowledge and skills of the GI professional.

Why are infection prevention standards so vitally important? Adherence to infection prevention standards protects both the patient and healthcare worker from illness and disease. Standard Precautions are the minimum infection prevention practices that apply to all patient care, in any setting where healthcare is delivered (CDC, 2011). Standard Precautions should be followed without exception and infection prevention principles maintained throughout the facility through handwashing, isolation precautions, terminal cleaning practices and scope reprocessing. Staff in the GI/Endoscopy setting must adhere to infection control principles that will ensure a safe environment (SGNA, 2012).

Why is infection prevention so challenging? The rapid pace of endoscopy units, multiple role expectations of endoscopy staff, and constantly changing technology and product design can make it especially challenging to understand and adhere to infection control principles, which is why ongoing education and training are so vital. The complicated designs, interchangeable parts and post-market changes of flexible endoscopes, valves and accessories require strict adherence to accepted practice at any step of the reprocessing process.

For instance, disinfection of flexible gastrointestinal endoscopes and reusable accessories cannot occur if these items are not first properly cleaned. A breach occurs when any one of the steps of reprocessing is incomplete or incorrectly performed. Documented breaches have been linked to a lack of knowledge with endoscope and accessories design and non-compliance with specific reprocessing steps. Any breach can increase the risk of transmission of infections, and once a breach is detected it should be reported to the infection prevention personnel of your institution. ASGE (2007) and the FDA (2009) both have documents that address how to manage and report breaches.

How do we avoid breaches in infection control? The most important way to prevent breaches is strict adherence to accepted practice at every step of the reprocessing process. The steps of endoscope reprocessing are (SGNA, 2012):
1. pre-cleaning
2. leak testing
3. manual cleaning
4. rinse after cleaning
5. high-level disinfection (manual or automated)
6. rinse after high-level disinfection
7. drying and
8. storage

Another way to prevent breaches is to perform competency reviews and infection prevention updates at time of hire and at least annually thereafter for all personnel in the gastrointestinal endoscopy setting (SGNA, 2012). In addition to detailed reprocessing procedures for endoscopes and reusable accessories, other core components of the training program should include standard precautions, personal protective equipment, bloodborne pathogens, disease transmission, safe handling of chemicals and procedures for waste management (SGNA, 2012). Providing a training program designating an individual who is responsible for maintaining a quality assurance program that includes annual training is essential.

The entire environment must be considered when developing infection prevention processes. Manufacturers guidelines, unit policies, collaboration with infection preventionists, and maintenance of staff competency all play a role in infection prevention. Furthermore, guidelines and policies should reflect current accepted practices that are based on scientific evidence.

How can you stay up to date on infection prevention? A variety of infection prevention guidelines, resources and educational programs are available through SGNA and other organizations. Guidelines relating specifically to the endoscopy setting and reprocessing, including the above step-by-step outline of endoscope reprocessing (SGNA, 2012), can be found on the SGNA website free of charge. A multi-society guideline on reprocessing flexible gastrointestinal endoscopes was revised and published in 2011 and addresses infection prevention principles, challenges and best practices in the gastroenterology setting. Education is available through SGNA e-learning courses, webinars, Gastroenterology Nursing SGNAs official journal, and in-person training programs such as the Train the Trainer course as well as the Associates and Advanced Associates programs.

Recognizing just how crucial providing regularly updated infection prevention information and education is, SGNA will launch the SGNA Infection Prevention Champions program in June 2013. This program supports a unit-based champion to carry out the vision and mission of the program by educating self and staff on infection prevention topics, maintaining high quality control within the endoscopy arena and addressing performance improvement needs. The program just completed a six-month pilot with 20 endoscopy units participating and proved a great success in developing knowledge and skills of infection prevention at the unit level. 

Why? It all comes down to patients. Endoscopy patients have a right to expect a safe and clean environment from admission to discharge with infection prevention principles maintained throughout their stay. This can be assured by sufficient training of new staff, ongoing education, collaboration with an infection control preventionist, familiarity of manufacturers guidelines and rigorous adherence to endoscope reprocessing standards. Infection prevention is not a nice-to-have concept or the latest buzz word. Infection prevention is imperative to the delivery of safe patient care and is the responsibility of every heathcare professional practicing in the field of gastroenterology.

Michelle Day, MSN, RN, CGRN, is hepatology coordinator for the Comprehensive Liver Center at Hartford Hospital in Hartford, Conn. and chair of the SGNA Practice Committee.

Loralee Kelsey, BSN, RN, CGRN, is digestive health supervisor at Carle Foundation Hospital in Urbana, Ill. and chair of the SGNA Infection Prevention Task Force as well as board liaison for the SGNA Research Committee.