By Chelsea Huffman, AGTS, CRCST
As healthcare professionals we often wonder how much difference we truly make in the lives of our patients. I often wonder if I am doing everything that I possibly can to create a safe environment for every person around me — not just patients but my team as well. Maybe you are a nurse or tech who has wondered the same. Having worked in healthcare for the last nine years and endoscopy for the last four, I have met a variety of people each with their own story to tell. There are certainly moments that bring to light just how much impact we truly have in someone’s life. Errors often occur due to a lack of education or what I would refer to as follow-the-leader. Someone performs a task incorrectly and it continues until someone questions the process. That is where we come in. I want to encourage all of you to take that step forward and be the advocate that our patients so desperately need. Let me explain why I am so passionate about infection control and what we can do to continue creating a safer environment for all of our patients.
In 2005, my mother complained of epigastric pain. She was referred to a GI physician and among other testing an EKG was performed. The physician felt that there may be an underlying cardiac issue so he suggested that a cardiac catheterization be performed. Post-procedure she was in extreme pain and after some time had passed, she returned to have it checked out. It turns out that the angio seal used during the procedure had leaked into the artery and caused a clot to form. At that point she underwent a thrombectomy.
Over the next few days numerous people came in and out of her room and there were multiple dressing changes and examinations of the surgical site. My mom noticed how some of these people didn’t wear gloves or really wash their hands all that often. She told herself surely they had just washed their hands and she missed it. They know what they are doing, right? They must know the proper way to handle an incision like that, right? She was eventually discharged. After being home for a short time, she developed a fever and felt as if something was wrong. She contacted her physician and he assured her that it was not an urgent matter. A couple of days later, she saw one of the vascular surgeons in the office. At this point not only did she have a fever but also had a decent amount of fluid draining from the surgical site which was now a wound. She was again admitted and spent a few more days in the hospital on antibiotics. She was scheduled to be discharged but noticed there was a small amount of bleeding. She expressed her concern and was told it was nothing to worry about. She was again discharged. The next morning, she awoke to a large amount of blood underneath her. Obviously at this point there was a much deeper concern. She made her way to the emergency room where she waited for a few hours. When she finally arrived on the vascular floor, the team decided they should take her to the OR and see what was going on. She was scheduled for later that day.
In the short amount of time since her arrival, she had gotten a brief biography of the nurse caring for her. She had previously worked in the emergency room and was now working with vascular patients because she had become a traveling nurse. She seemed like a very efficient nurse who was very involved in her role and truly loved what she did. As my mother prepared for surgery, my step father left to pick up my brother from school, as he was only 5 at this time. They were told it would be awhile before she would go to surgery and he felt that there was a good plan in place. Shortly after he left, my mother decided to use the bathroom prior to her impending surgery. As she stood up, nurse at her side, they began to see a large amount of blood coming from her previous surgical site. The nurse quickly told her to lie back down in the bed as she could tell this was not a small bleed. This was something very serious. She proceeded to hold pressure on my mother’s leg and yell for help, as the door to the room was closed. As help arrived, the team realized that this was now an emergency and she needed to go to the OR right away. At this point, the resident who had previously seen my mother stepped in to hold pressure on her leg. She was rolled down the hall to another area while the resident continued to hold pressure. Poor communication between the OR and the team ready to start the case led to an hour lapse in time. The entire time the resident sat on her bed and held pressure on her leg.
Each time someone came by to check if she needed a break her response was always the same, “I am fine, go check and see if the OR is ready.” My mother lost a lot of blood overall and was eventually taken to the operating room. What they found was beyond belief. MRSA had eroded 12 inches of her femoral artery and therefore caused this nearly catastrophic bleed. The surgeon noted how the artery simply fell apart in his hands as he tried to repair it. My mother was awake during a portion of the surgery and recalls the extreme amount of pain and confusion about what was happening. They placed an artificial graft and she would go on to have complication after complication including neurological issues, intubations, chronic pain, loss of mobility, multiple angiograms, stent placements to keep the graft open, surgery to completely redo the graft, a number of hospital stays, near amputation, and most importantly, a loss of quality of life.
She was 44 years old when all of this occurred. Who saved her life, you might ask? I believe the nurse with her quick response and the resident who refused to give up undoubtedly saved her life that day. I know without them my mother would not have survived. In the hour it took for the surgical intervention to occur, I am certain that she would have lost such a high volume of blood that it would be almost impossible to recover from given the circumstances. What if this had happened at home knowing that help would never arrive in time? I can tell you I would be writing a much different story.
Why am I telling you all of this? Let me explain. You see, these healthcare professionals saved a life retroactively after an infection, and I am forever grateful for them, but let’s think about this for a second. What if we could turn back the clock? What if we could proactively prevent infection before it occurs? I think we can. There were multiple breakdowns in this scenario and a lot of scenarios regarding infection control. There are too many lives at stake for this to not be in the forefront of our minds. Our patients rely on us to be their advocates and to keep them as safe as possible. You have heard the saying time and time again, “What if it was your loved one on the table? What if it was your mother or father?” Well, it was mine and I am forever changed because of it. I was a state away when all of this occurred and as hard as it is to be there for those moments, it is even harder not to be. What was happening? Was I ever going to see her again? Did she know how much I loved her? So many things run through your mind and in those moments you are left waiting for answers. Fear takes over and you are truly lost, at least I was. The thought of having to bury my mother at the age of 18 and share memories with my brother, who would most likely not remember her, made my heart sink deeper than I ever thought possible. Who anticipated all of this because of a preventable infection? I hope this seems as outrageous to you as it does to me.
So let’s talk about what we can do and where we have come up short. When we discuss the complication of infection in endoscopy, we explain how low of a risk it is — hovering in the neighborhood of 4 percent. All reported cases of transmission of infection resulted from defective equipment and/or failure to adhere to reprocessing guidelines (such as those from ASGE).
Keep in mind this is strictly from the actual endoscopy performed, not including environmental components. What about those patients with C. diff or MRSA or another MDRO? The number of deaths each year from C. diff alone is upwards of 29,000 according to the CDC. The bigger picture shows that half a million people are infected with C. diff each year. The fact that C. diff can live on inanimate objects for long periods of time is part of the struggle. This should remind us just how important a thorough disinfection of the room and all equipment used for a procedure truly is. It is very likely working in endoscopy that you will see a number of patients in isolation for a variety of different reasons. Ask questions and dive a little deeper if you are unsure. Don’t proceed in the face of uncertainty. Knowing how to care properly for each patient and their unique circumstances will help create a safer environment for all patients as well as staff.
There has been a lot of talk about CRE lately. When was there a realization that there may be a link between patients contracting CRE and history of ERCP using a duodenoscope? We know that this concern traces back to at least 2011. So the question is, why did we not have this information until 2015? We have a responsibility to our patients to acknowledge all risks that they may encounter. Not to mention that we as healthcare workers should be in the know about what is going on around us and whether or not we should be doing more to ensure patient safety. There has been a trend of contaminated duodenoscopes as well as other scopes used in endoscopy. In 2013, APIC conducted a study in five hospitals across the country. They found that 3 out of 20 of the scopes tested harbored higher than acceptable levels of bacteria. Who was the biggest offender? Not surprisingly (since USA Today informed us that there was a problem) the duodenoscope with a failure rate of 30 percent. Following right behind was the gastroscope with a failure rate of 23 percent. Surprisingly, the colonoscope had a significantly lower failure rate at 3 percent. Why do we think this is the trend? We are all much more enlightened as to the cleaning difficulties when it comes to the duodenoscope, but what about the gastroscope? Could it be that we pay more attention to scopes that are grossly contaminated (i.e., colonoscopes) because we can see what we are getting? It is truly something to think about. Do we use more caution when we know all of the facts about what patients carry (i.e. HIV, hepatitis) because it is our nature?
I can tell you that I have seen this time and time again over the last nine years. As much as we talk about universal precautions, there is still an underlying human component that we can’t seem to resolve. I think the APIC study and others like it really drive home the message that we have some clearly defined areas of concern. What can we do to create a safer environment? Be more aware of infection control practices in your institution and if there is a break down speak up. One of the biggest infection control breaches involving endoscopy in recent history happened in Las Vegas. Why did no one speak up when items were being reused to lower costs? After the state of Nevada conducted an investigation, they learned that a large percentage of nurses did not report patient safety concerns out of fear of retaliation. Since then Nevada passed a good faith law that will ensure negligent parties are held accountable. I think the more this occurs, the more confident healthcare professionals will be in reporting negligence. That being said, we have a responsibility to all of our patients and they have entrusted us to keep them safe. It should be less about personal comfort and more about doing what is right. How awful to see someone suffer from something that was preventable, and even worse to know that you had a hand in it, directly or indirectly. I also find the more that we can make personal connections with each of our patients, the more in tune we are to caring for them. Remind yourself every day that the patient in front of you could be your family member. In fact, just pretend that they are. Find that one thing about them that reminds you of your sister or your uncle. How would you care for them? I guarantee it will change your point of view.
It seems that time and time again lack of education is our downfall. I cannot stress enough how important following manufacturer recommendations really is. Not just that, but also knowing the difference between cleaning, disinfection, and sterilization. Cleaning is truly just the removal of debris using an agent such as a detergent or soap. For us, this means that before a contaminated item can be safely handled, disinfection must occur. A simple cleaning is not adequate. Cleaning merely removes items such as lipids and proteins, but does not protect you from any bacteria left behind. Anything that you touch that has not been properly disinfected, has now recruited you as a vehicle for an indirect infection of someone or something else. The type of disinfectant you will use (low, intermediate, high) depends on the classification of the item you wish to disinfect (critical, semi-critical or non-critical). As I was reading about the CRE outbreaks, I stumbled upon an article that mentioned that they had properly “sterilized” the scope.
What is the problem here? They meant to say that they had performed a high-level disinfection. Had this facility been referring to ethylene oxide (ETO), the term “sterilization” would have been correct. Unfortunately, the whole world read this article and they were misinformed. The difference between these two methods is substantial. Sterilization is the only method that kills spores. Spores are encapsulated bacteria that are extremely difficult to kill because they are so protected. Disinfection, at any level, will not kill spores. High level disinfection is appropriate for endoscopes because they are classified as a semi-critical device, meaning they come into contact with mucous membranes but do not enter sterile tissue or the vascular system. Sterilization is however a preferred method whenever possible. Unfortunately, there has been little advancement in the realm of endoscope sterilization. To date, ETO is the only low-temperature sterilant that is validated for GI endoscopes. There are known health risks associated with the use of ETO, and for this reason a large number of facilities have removed these sterilizers all together. Also because of the length of the ETO cycle, a lot of facilities would find it hard to maintain patient volumes with the limited number of scopes available at any given time. It is also important to mention that regardless of the method chosen, disinfection or sterilization, if the item has not been properly cleaned the next step is impeded. I can recall the first manager I ever worked for in healthcare and her epic statement “you can’t sterilize dirt.” How right she was. Not only is there bioburden that you can see, but there is also bioburden that you can’t see. For this reason, diligent cleaning and following of manufacturer recommendations remain key factors in the reprocessing of endoscopes and other reusable items.
I hope my mother’s story and all of the other information that I have shared with you is enough to put into perspective just how important it is to be an active participant in infection prevention and control. Care for every patient the way you would care for a family member or even how you would want to be cared for yourself because at some point we all become the patient. Ask questions, challenge old habits and explore new and safer methods. We have the power to change the future of healthcare. Right here, right now. Who’s with me?
As a result of the life-changing events surrounding her mother’s MRSA infection, Chelsea Huffman began her healthcare career in sterile processing. Over the course of seven years, she became well-versed in infection control and instrument reprocessing, spending three of those years in leadership roles that allowed her to serve on committees and participate in projects that would improve patient outcomes. She became an instructor for the CRCST program to assist others in becoming certified, then became an endoscopy technician in pediatrics and most recently, spent two years in adult endoscopy at Mayo Clinic Arizona. Huffman became an Infection Prevention Champion through SGNA and served on the board for the regional society, presenting locally and nationally on infection control. She now serves as a clinical endotherapy specialist for Olympus America Inc.