Continuous Quality Improvement

30/30 Education Session - 30 minutes

3205 - Enterobacter cloacae Found in an Endobronchial Ultrasound Scope (EBUS): Now What Do We Do?

Friday, June 16
10:00 AM - 10:30 AM
Location: Oregon Convention Center, A 105-106

Transmission- and procedure-related infections associated with endoscopy procedures are not well understood. The challenges associated with endoscope reprocessing have been well documented in the literature and generally associated with breaches in reprocessing. More recently, transmission of infections has been documented with duodenoscopes and linear echoendoscopes despite adherence to reprocessing. In response, we embarked on implementation of a systemwide culturing and double high-level disinfection (HLD) protocol for duodenoscopes and linear echoendoscopes. Locally, we added endobronchial ultrasound (EBUS) scopes to the protocol due to a similar working channel as echoendoscopes but without an elevator channel. On culture findings, one EBUS scope intermittently tested positive for Enterobacter cloacae during a 10-week period. All reprocessing steps were adhered to, including double HLD, and validated by external agencies. During this time, the scope was repaired by the manufacturer and later passed quality control and was found to operate properly by a third party vendor. On retrospective case investigation, two patients had EBUS samples positive for Enterobacter cloacae within 4 days of each other and on deep dive represented probable transmission. Despite working properly and adhering to reprocessing steps, it appears that bacterial contamination and transmission may exist in endoscopes without elevator channels. No literature findings specific to EBUS scopes and transmission have been found to date. Our findings raise additional questions that need to be considered in relation to reprocessing of EBUS scopes and possibly all types of endoscopes. Lastly, further steps are needed to mitigate risk of transmission from all types of endoscopes, not just duodenoscopes and linear echoendoscopes. The presentation will describe the protocol, investigation findings, and process for reporting product problems. Implications, lessons learned, and potential next steps to mitigate risk will be discussed. The target audience includes, but is not limited to, infection preventionists, manufacturers, and those working in infectious disease, endoscopy, and risk.

Learning Objectives:


Angela Dickson

Manager, Infection Prevention
Providence Southwest Region
Centralia, Washington

Angela Dickson is currently the regional infection prevention manager for the Providence Southwest Washington Region. She has an extensive background in prehospital, critical care, and dialysis nursing. Angela transitioned from the bedside as a quality improvement consultant for critical care in 2001. It was during this time that she worked on fun  things like implementation of sedation vacation and learning the NNIS HAI definitions, which took her down the cool  path of infection prevention. Angela started working part time in infection prevention in 2005, transitioned to full time in 2006, and became CIC certified in 2007. During her undergrad, she developed a passion for community health and went on to obtain her master’s degree in nursing in community health from the University of Washington. Angela enjoys spending time with her husband and two teenagers, riding her Harley-Davidson motorcycle, and practicing yoga. One day she hopes to serve abroad in medical missions.

Presentation(s):

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Carol McLay

CEO
Infection Control International
Louisville, Kentucky

Dr. Carol M. McLay, DrPH., MPH, RN, FAPIC, CIC is the CEO of Infection Control International and is a consultant in the fields of healthcare epidemiology, infection prevention and control, and public health. Carol received her BSN from the University of Ottawa in Canada, an MPH from Emory University, and a DrPH in epidemiology at the University of Kentucky.

Dr. McLay serves as the Lead Nurse Planner with the Association for Professionals in Infection Control and Epidemiology (APIC), where she has responsibility for the management of their continuing educational programs.

She is a member of the Board of Directors for the Healthcare Laundry Accreditation Council (HLAC). She currently serves as a member of the Society for Healthcare Epidemiology of America (SHEA)‘s External Affairs Committee. She is the author of The Infection Prevention Competency Review Guide, 4th edition, and APIC’s Certification Study Guide, 5th and 6th edition.

Presentation(s):

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Assets

3205 - Enterobacter cloacae Found in an Endobronchial Ultrasound Scope (EBUS): Now What Do We Do?

MP3 Audio Slides Presentation + Audio

Attendees who have favorited this

  • YASH AGARWAL
    R&d Manager
    CIVCO MEDICAL SOLUTIONS
  • KATIE ALBERT
    RN
    NEW YORK PRESBYTERIAN
  • Mirza Ali
    Infection Control Manager
    Franciscan Health
  • SHOSHANNAH ANDERSON
    INFECTION PREVENTIONIST
    HUNTSVILLE HOSPITAL
  • CHRISTI ARCHER
    MANAGER, INFECTION PREVENTION
    SHAWNEE MISSION MEDICAL CENTER
  • MARCIA BARALDI
    HOSP. ALEMÃO OSWALDO CRUZ
  • STUART BARNARD
    NATIONAL SALES MANAGER
    WHITELEY CORPORATION
  • REBECCA BARTLES
    SYSTEM DIRECTOR, INFECTION PREVENTION
    PROVIDENCE HEALTH & SERVICES
  • KRISTY BENTON
    FEDERAL/STATE LICENSING TEAM LEADER
    AZ DEPT OF HEALTH SERVICES
  • AMANDA BEVERLY
    INFECTION CONTROL PRACTITIONER
    UNIVERSITY OF ALABAMA AT BIRMINGHAM
  • ELIZABETH BOWEN
    INFECTION PREVENTIONIST
    PROVIDENCE ST MARY MEDICAL CENTER
  • KELSI CANAVAN
    INFECTION PREVENTIONIST
    MEMORIAL HOSPITAL MIRAMAR
  • IRENE CARRILLO
    INFECTION CONTROL PRACTITIONER
    HOUSTON METHODIST HOSPITAL TMC
  • ASHLEY CONLEY
    INFECTION PREVENTIONIST
    ST. JOSEPH HOSPITAL
  • REGINA COX
    DIRECTOR CLINICAL SERVICES
    DAVITA
  • JODI DESPAIN
    INFECTION PREVENTIONIST
    PEACEHEALTH
  • KARA DOWNING
    INFECTION PREVENTION COORDINATOR
    CAPITOL MEDICAL CENTER
  • DENNIS DRAPIZA
    REGIONAL MANAGER, INFECTION PREVENTION & CONTROL
    KAISER PERMANENTE NORTHWEST
  • JOHN ESTEBAN
    INFECTION PREVENTION PRACTITIONER
    SAN JOAQUIN COMMUNITY HOAPITAL
  • JENNIFER FOSTER
    MANAGER, INFECTION CONTROL AND ACCREDITATION & REGULATORY SE
    HOLY CROSS GERMANTOWN HOSPITAL
  • ASHLEY FRYE
    RN-INFECTION PREVENTIONIST
    MINDEN MEDICAL CENTER
  • PAUL GENTILE
    INFECTION PREVENTIONIST
    CHARLOTTE HUNGERFORD HOSPITAL
  • RACHEL GURAN
    COORDINATOR, EPIDEMIOLOGY
    BROWARD HEALTH NORTH
  • ALYSON HIGHT
    INFECTION PREVENTION DIRECTOR
    VALLEY BAPTIST MEDICAL CENTER-HARLINGEN
  • Mary Horkay
    Infection Preventionist
    UCLA - Santa Monica Medical Center
  • MARY HORKAY
    Infection Preventionist
    UCLA-SANTA MONICA
  • KATHLEEN JHARIE
    Infection Preventionist
    ACADEMIC HOSPITAL
  • MABEL KELLEY
    Infection Preventionist
    VHA
  • PATRICIA KOPP
    INFECTION PREVENTIONIST
    SC DHEC
  • Joseph Kurland
    Vaccine Specialist / Infection Preventionist
    Children's Minnesota
  • TARA LONGVAL
    INFECTION PREVENTION COORDINATOR
    EAST COOPER MEDICAL CENTER
  • KATHERINE LUCHT
    INFECTION PREVENTIONIST
    ABBOTT NORTHWESTERN HOSPITAL
  • ALEXANDRA MADISON
    DIRECTOR INFECTION PREVENTION & CONTROL
    STANFORD HEALTH CARE
  • NORMA MARTINEZ
    MRS.
    HOSPICARE S.A.
  • ARMANDA MASON
    ICP
    PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL
  • SHEILA MCCULLOUGH CULVER
    INFECTION PREVENTION
    TEXAS HEALTH RESOURCES - HARRIS SOUTHWEST
  • KELLY MULHOLLAND
    INFECTION CONTROL NURSE
    MERCY MEDICAL CENTER
  • CATHERINE NOVAK
    INFECTION PREVENTIONIST
    FRANKLIN SQUARE HOSP. CENTER
  • THERESA NOYCE
    INFECTION CONTROL SPECIALIST
    ST. ALPHONSUS MEDICAL CENTER
  • MASASHI OKUNO
    3M JAPAN
  • Susan Oppenheimer
    IP/EH nurse, CIC
    PeaceHealth/ Peace Harbor Medical Center
  • SUSAN OPPENHEIMER
    IP / EH NURSE
    PEACEHEALTH
  • SUSANNE PAULSON
    Infection Preventionist
    RENOWN HEALTH
  • PAULA RAMSAMMY
    INFECTION PREVENTIONIST
    JACKSON HEALTH SYSTEM
  • BALINDA RHINEHART
    CLINICAL HEALTH FACILITY SURVEYOR IV
    OSDH
  • DANIELLE RICHARDS
    INFECTION CONTROL PRACTITIONER
    PROVIDENCE HEALTH CARE
  • KAY SAMS
    INFECTION PREVENTIONIST
    MOFFITT CANCER CENTER
  • PAULETTE SEBASTIAN
    INFECTION PREVENTIONIST II
    GEISINGER WYOMING VALLEY MEDICAL CENTER
  • JESSICA STRAUCH
    INFECTION PREVENTION SPECIALIST
    LUTHERAN MEDICAL CENTER
  • DEBRA SUMMERS
    SENIOR DIR, CLINICAL RISK, IP
    IASIS HEALTHCARE
  • JESSICA SYMANK
    DIRECTOR QUALITY IMPROVEMENT
    WASHINGTON STATE HOSPITAL ASSOCIATION
  • LIN TANG
    INFECTION PREVENTIONIST
    ST. MICHAEL'S HOSPITAL
  • ALICIA TELLES
    INFECTION PREVENTION MANAGER
    METHODIST HOSPITAL SOUTHERN CA
  • DAWN TOMAC
    DIRECTOR OF QUALITY AND SAFETY
    AVERA HEALTH
  • THORDIS TOMASDOTTIR
    Nurse
    UNIVERSITY HOSPITAL OF ICELAND
  • ROSEMARY TUCKER
    INFECTION PREVENTIONIST
    ELMENDORF AFB HOSPITAL
  • KATHLEEN USURIELLO
    ST. VINCENT HEALTHCARE
  • ANGELA VASSALLO
    DIRECTOR, INFECTION PREVENTION
    PROV. SAINT JOHN'S HEALTH CENTER
  • JULIE WARNER
    COORDINATOR, INFECTION PREVENTION
    COXHEALTH
  • MARY WHEATON
    ICN
    WILCOX HEALTH
  • AMBER WOOD
    Sr. Perioperative Practice Specialist
    AORN
  • SHANNON YNFANTE
    MANAGER INFECTION PREVENTION/EMP HEALTH
    VICTOR VALLEY GLOBAL MEDICAL CENTER

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