Traceability: Challenges IPs Face Keeping an Instrument Decontaminated

La’Titia Houston MPH, BSN, RN, CIC: “We work not only with the bedside nurses and the sterile processors, but even with our clinicians, our physicians. They want a timeout before the procedure is even performed because they want to ensure that the scope did pass during the high-level disinfection procedure.”

The move toward stronger ties between infection preventionists (IPs) and sterile processors was well on the way before COVID-19 struck. Now, with the COVID-19 vaccines adding to the growing hope that the disease will stop being a pandemic and become endemic, the focus on IPs taking a more active role in the sterile processing continues. La’Titia Houston MPH, BSN, RN, CIC, is a senior IP at a large hospital in Dallas. Houston was one of the presenters at the Cleaning, Disinfection, and Sterilization Conference hosted by the Association for Professionals in Infection Control and Epidemiology—APIC—earlier this month. Her presentation was titled Traceability: High Level Disinfection Challenges Met by Using Available Resources. The main hurdle to providing better traceability, as Houston sees it, is that the technology has not kept up with the demand for traceability pushed by the Joint Commission, the Centers for Medicare and Medicaid Services, and the Association for the Advancement of Medical Instrumentation. Still, IPs and sterile processors can follow the guidelines anyway. “Think outside the box,” Houston tells Infection Control Today®. “There are processes that we can easily use in order to become compliant with whatever it is that they’re requesting from us.”

Infection Control Today®: What’s the main thing that you want your fellow infection preventionists to take away from your presentation?

La’Titia Houston, MPH, BSN, RN, CIC: One of the things that we want to make sure that everyone understands is that it’s not the time for us to just get so nervous due to the fact that technology has not kept up with the demands or the requirements that the Joint Commission or CMS [Centers for Medicare and Medicaid Services] is requiring when it comes to our sterile processing. One of the things that they are requiring is the traceability of instruments and those instruments are the ones that are high-level disinfected. With that being stated, right now, the majority of all of our sterile instruments are traced and we can see where each instrument

actually has touched a patient. And once the procedure is completed, those instruments go to sterilization. And there’s already a program that is available for those particular instruments. But for our high-level disinfection instruments, it’s totally different. There are a lot of hands that are interchanging with these particular instruments. It is the patient with the physician, and then once it leaves that area, it goes to a decontamination area which is owned by sterile processing. And then once sterile processing does that particular decontamination of the instrument or the scope or the device that is high-level disinfected, then it has to go into another machine, which actually does the high-level disinfection if you are doing the automated reprocessing. Or you can also do the manual reprocessing whenever it is that if you’re going to do that. [But neither] the automated nor the manual are able to capture that last bit where it’s like, “OK. We’re no longer in the electronic mode anymore.” One of the things that we at our facility had to come up with was a process that was able to capture all the information that is required when it comes to sterile processing, when it comes to high-level disinfection and traceability.

ICT®: A two-part question. When you talk about some complicated instruments, we here at Infection Control Today® have published a number of articles about endoscopes and duodenoscopes. Are those examples of the instruments that you’re talking about? And we here at Infection Control Today® have also published a number of articles about how important it is for the infection prevention department and the sterile processing department to work together. Is that what you’re talking about as well?

Houston: Yes, it is. So, for the endoscope process. Yes. This was one of the things that AAMI, which is the Association for the Advancement of Medical Instrumentation; they are more or less stating that all of the high-level disinfection instruments—and I’m pretty sure it was due to an outbreak of Carbapenem-resistant Enterobacterales back in the day, which is CRE…. I’m pretty sure this is the reason why they are now wanting that traceability but not only just for that reason, but also for chemicals. It’s more or less [about] quality assurance. If the chemicals actually are no longer effective as far as when it comes to the high-level disinfection of those instruments, we now have a log of that particular lock number for that chemical that was used on this particular endoscope. And if the endoscope did get used on a patient, then we’re also able to select what patient that endoscope was used on. Now as far as us working hand-in-hand with sterile processing—the department that I work with, our sterile processing department, they are awesome. We work, again, just like they are in my office, and I’m usually in their office. That’s what happened on the ground.

ICT®: What facilitates such cooperation?

Houston: Initially, what I would do is I would just make up a scenario … and I would tell them, “Hey, you know, there’s a recall on a chemical and it was two weeks ago.” And I could actually pull this lot number up of that particular chemical due to the fact that we are in automated reprocessing of the machine itself. I could actually go to them and say, “Hey. I want to see all the patients that were run on this particular lot.” And they would have access in the automated property processor to be able to pull all the information. And they will also be able to go inside of the electronic medical record program that we use and actually pull the patient procedures that were performed, who the clinician was, what date it was performed on, did this patient have a biopsy? That way we can also see if there were any other invasive procedures when they had that particular procedure.

ICT®: Was this system upgrade begun before COVID-19? Did COVID-19 cause it to stall? Or did it make it accelerate? And where is it now?

Houston: The traceability actually was implemented right before COVID-19. We had our Joint Commission survey back in 2016, 2017. And we implemented the traceability program at that time. Because, again, this was one of the recommendations or the requirements based upon AAMI and also CMS and the Joint Commission, which are the ones that will actually come out and do these audits. But when COVID-19 came, it was somewhat of a delay due to the fact that we were still trying to understand: Is COVID in the stool? And do we need to hollow disinfect the endoscopes at least two times versus one? And when science proved that it was not a concern, we more or less just did it once. And we continued with our program then moving forward. But initially, during COVID-19 it was: “OK. We are not going to use these scopes that were reprocessing twice on someone that is not COVID positive so that way we can actually do a traceability on those that are COVID versus those who are not COVID?”

ICT®: Could you tell us a more about who you might cooperate with?

Houston:We collaborate not only with sterile processing, but also the areas that actually are performing these procedures. And so, in our organization sterile processors are not the ones who are actually at the bedside. We do work with the nursing staff. They are also doing all of the precleaning that’s required at the bedside once the procedure is complete. And the transporting of those instruments to sterile processing department at that time. And the endoscopes only have a certain amount of time that they can actually sit without being decontaminated. We work not only with the bedside nurses and the sterile processors, but even with our clinicians, our physicians. They want a timeout before the procedure is even performed because they want to ensure that the scope did pass during the high-level disinfection procedure. This was just another quality check that they wanted. So, it’s not just sterile processing. It’s all of us at one. One big happy family.

ICT®: And God bless us, everyone, hopefully. Do you ever come across health care professionals who are a little bit wary of this sort of cooperation and how do you win them over?

Houston: No. No. Actually, once we implemented the traceability, they were all on board with this. Especially the chief gastroenterologist. He was like “Oh, this would be great.” Due to the fact that we not only implemented the traceability, but we also had started ATP [adenosine triphosphate] testing at that same time. His concerns as far as any of his patients being infected or being contaminated by another patient previous that was using this particular scope, anything that we as infection prevention recommended, and the GI department was receptive to it, he was very much on board with it.

ICT®: When I first contacted you via email to ask you to do this interview, one of my possible questions began with “Now that COVID-19 is dying, where do we go from here?” And of course, within that short time, there’s talk now of a fifth wave. Hopefully, the fifth wave won’t cause as many deaths because of the vaccines. But I guess I’ll ask this question now: When COVID-19 finally becomes endemic, and not a pandemic, where does your program go from there?

Houston: Currently, we are purchasing some more automated processes. Not only just endoscopes will have hollow disinfection. The other items that are hollow disinfected in our organization are also the endocavity probes, proctoscopes, or cystoscopes. With that being stated, we are going to implement those same automated processes which were already working in with that particular area, which is our sonography department. And they’re rating, because they have been doing a lot of manual rating as far as when it comes to traceability. But as far as our endoscopes, we will continue with that process, and just start our automated process with our endocavity probes.

ICT®: Is there something that I neglected to ask you that you think is pertinent that you want your fellow professional infection preventionists to know about your presentation at the conference or this subject in general?

Houston: I would just like to just restate that although the technology is not there, that sometimes we choose not to even go forward with a lot of the things that are required or recommended by AAMI or the Joint Commission. Think outside the box. There are processes that we can easily use in order to become compliant with whatever it is that they’re requesting from us.

ICT®: One quick follow-up question. When you said that the technology’s not there what do you mean? What technology do you see on the horizon that you’d like to see implemented quickly?

Houston: OK, so what the Joint Commission and AAMI would like for us to be able to have all of this information in one thing. So, the decontamination: There are some items that are in place where you can scan the scope. But then at the same token, there are a lot of things where the organizations as far as when it comes to patients’ information…. Some of these programs are not secure for them to be able to have access to the patient’s demographics. It’s still a lot of information where you’re having to piecemeal just so that you can get that patient’s information available whenever it’s required when it comes to that traceability. So that you can have the patient information to connect it to that particular item that you’re using on the patient. And there’s no technology that is out there at this moment where it can actually securely be implemented into your electronic medical records.

This interview has been edited for clarity and length.