Reassessment of the risk of healthcare-acquired infection during rigid laryngoscopy.

Inadequate reprocessing of rigid laryngoscopes has been linked to nosocomial outbreaks with associated morbidity and mortality. Last year an outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit was responsible for multiple infections and colonisations, and at least two infant deaths. An investigation of this outbreak identified contaminated rigid laryngoscopes as its source, demonstrating that inadequate reprocessing of rigid laryngoscopes remains a current public health concern. This article revisits and reassesses the risk of healthcare-acquired infection during rigid laryngoscopy and establishes the minimum reprocessing requirements for blades and handles of rigid laryngoscopes. Several potential risk factors for microbial transmission are identified and discussed, including the publication of inconsistent reprocessing guidelines for rigid laryngoscopes. Concern about guidelines that recommend low-level or intermediate-level disinfection of rigid laryngoscopes is expressed. The use of a sterile disposable sheath to cover the rigid laryngoscope and minimise the risk of contamination is also discussed. Regardless of whether a sheath is used during the procedure, thorough cleaning followed by high-level disinfection and drying of the instrument is recommended to prevent microbial transmission.

Biopsy forceps: disposable or reusable?

Current debate surrounds the cost-effectiveness of disposable and reusable biopsy forceps. Although a complex and arduous task, performing a cost analysis may be necessary to determine which forcep type is more cost-effective. Costs associated with disposable biopsy forceps include their initial cost as well as storage and disposal costs. In addition to initial cost, costs associated with reusable biopsy forceps include reprocessing, maintenance, and repair costs. Estimating the number of times forceps are likely to be reused is also essential to evaluating the cost-effectiveness of reusable biopsy forceps. In general, once a reusable biopsy forcep performs a threshold number of procedures, it becomes more cost-effective than a disposable forcep. While reusable biopsy forceps may be more suitable and cost-effective for larger gastrointestinal endoscopy centers that perform many procedures per day, the convenience of disposable biopsy forceps may make them the more appropriate choice for centers that are smaller and perform only a few procedures each day. Due to significant decreases in the initial cost of disposable biopsy forceps, the cost-effectiveness of reusable biopsy forceps is waning. This article reviews the various issues associated with disposable versus reusable biopsy forceps and provides readers with guidelines for evaluating the appropriateness of both forcep designs in their unique practice setting.

Current instrument reprocessing practices. Results of a national survey.

In June 1998, a questionnaire was mailed to approximately 2,900 healthcare professionals to assess current instrument reprocessing and infection control practices and determine whether they have changed during the past decade. Surveys were returned from 146 respondents whose facilities performed gastrointestinal endoscopy. Most respondents were registered nurses and almost all worked in healthcare facilities located in the United States. More than 75% of the respondents reported that infection control practices in endoscopy have improved during the past 10 years. Most respondents used glutaraldehyde to reprocess flexible endoscopes. Immersing endoscopes for 20 minutes at room temperature was commonly practiced. Almost 75% of respondents used an automated device to reprocess flexible endoscopes. Most respondents terminally rinsed the endoscope's channels with 70% alcohol followed by forced-air drying. Few respondents outsourced instruments to a commercial reprocessing company and almost 50% reused disposable items. While some practices in endoscope reprocessing have changed during the past several years, others have not. In general, infection controls appear to have improved during the past decade, with the possible exception of a trend to reuse single-use items.

Automatic flexible endoscope reprocessors.

Reprocessing medical instruments is a complex and controversial discipline. If all instruments were constructed of materials not damaged by heat, pressure, and moisture, instrument reprocessing would be greatly simplified. As the number of novel and complex instruments entering the market continues to increase, periodic review of the health care facility's instrument reprocessing protocols to ensure their safety and effectiveness is important. This article reviews the advantages and the limitations of automatic flexible endoscope reprocessors.

Instrument design and cross-infection.

This article reviews recently reported patient-to-patient transmission of disease during endoscopic procedures and discusses several important instrument reprocessing issues. In addition, the author offers several infection control recommendations to minimize the risk of patient infection during endoscopic procedures.

Are all sterilization processes alike?

Automated processes designed to sterilize reusable medical instruments use heat and low-temperature chemicals. Several factors, including the physical properties of the sterilizing agents and whether all of the instruments' surfaces can be adequately cleaned, can cause significant variations in the reliability and effectiveness of the sterilization processes. Instruments exposed to heat-based sterilization processes pose the lowest probability of transmitting diseases between patients. Heat can conduct through many different types of materials and can destroy microorganisms embedded under layers of patient debris. Studies have demonstrated, however, that--unlike heat--low-temperature chemicals require direct contact with the microorganisms to be effective. Moreover, the complex designs of some instruments can adversely affect the low-temperature sterilization processes' outcomes by hindering cleaning and preventing the flow of low-temperature chemicals to all of the instruments' contaminated surfaces. This article will explore the differences between heat-based and low-temperature chemical processes to help health care providers minimize the risk of cross-infection.

Advantages and limitations of automatic flexible endoscope reprocessors.

The advantages and limitations of automatic flexible endoscope reprocessors (AFERs) are presented. These medical devices can increase patient safety and minimize personnel exposure to the liquid chemical germicide and its vapors. Some models feature a printer to document important reprocessing parameters, an in-line tap water filtration system to reduce the likelihood of endoscope (and patient) contamination, and a heater to satisfy the elevated temperature requirements of some liquid chemical germicide labels. Although they offer significant advantages compared with manual reprocessing, AFERs have their limitations. Current models do not automate every endoscope reprocessing step and are not typically designed to reprocess every endoscope channel. Some AFER models may have to be periodically decontaminated to ensure that their internal components do not support microbial colonization. Moreover, their cost per cycle can be considerably more than manual reprocessing without necessarily reducing overall reprocessing time. Its limitations notwithstanding, an AFER is likely to be an asset in a busy endoscopy center. In addition to comparing automated and manual reprocessing, this article addresses important reprocessing issues and purchasing concerns.

High-level disinfection or "sterilization" of endoscopes?

Controversy has surrounded the use of liquid chemical germicides to reprocess medical instruments that are damaged by heat sterilization. A review of the literature was performed to assess and compare the efficacy of disinfection and sterilization processes. The results of this review demonstrate that high-level disinfection of thoroughly cleaned endoscopes is not associated with a higher infection rate than is "sterilization". While there may be a theoretical distinction between the highest level of disinfection and sterilization, thorough cleaning eliminates clinical differences between the two. High-level disinfection is quick, effective, inexpensive, and recommended whenever heat sterilization is not feasible. A low-temperature sterilization process should be considered only if it is comparable in cost to disinfection or if it offers demonstrated advantages without damaging the instrument. Neither disinfection nor sterilization is likely to be effective if the instrument is not cleaned thoroughly after use.