Departments: Interventional Pulmonology—Year in Review
Chest 2004;125:307–314. Srinivasan A, Wolfeenden LL, Song X, Perl TM, Haponik EF.
Study Summary: In this study, the investigators invited practicing bronchoscopists to complete a 22-question survey addressing infection control issues related to bronchoscopy. The survey was distributed to the participants in 2 bronchoscopy courses. Of 46 completed surveys included in the study, 12 (26%) were completed by medical directors of bronchoscopy suites and 34 (74%) were completed by attending bronchoscopists. On average, the participants performed 19 bronchoscopies per month. Overall, 65% of respondents were not aware of any national reprocessing guidelines. Medical directors of the bronchoscopy suites (45%) were no more aware of reprocessing guidelines than the attending bronchoscopists (31%). Eighteen (39%) participants were not aware of the reprocessing method in their own institution. Seventy-eight percent of respondents did not know local practices for at least 1 of the reprocessing questions. There were considerable variations in the local infection control practices. Only 46% of respondents reported keeping the record of using specific bronchoscope in an individual case. Thirty-two percent reported surveillance of bronchoscopy cultures, most commonly by infection control personnel. Thirty percent reported culturing bronchoscope as a routine infection control measure. Almost an equal proportion of respondents did know whether bronchoscopy culture surveillance is done in their institution. The authors concluded that experienced bronchoscopists are unfamiliar with national guidelines and local bronchoscope reprocessing practices.
Comments: A contaminated bronchoscope could act as a vector for infection with serious clinical implications (N Engl J Med 2003;348:214–220, N Engl J Med 2003;348:221–227). The exact magnitude of this problem is unknown, partly as a result of difficulties in establishing a cause-and-effect relation between bronchoscopy and transmission of infection and partly as a result of lack of surveillance mechanism in most bronchoscopy suites.
There are data to indicate that breaches from reprocessing guidelines are common (Am J Med 1992;92:257–261, Thorax 1997;52:709–713). The current study provides an important explanation for this problem; there is a general lack of awareness and familiarity with infection control recommendations, bronchoscope reprocessing guidelines, and local practices followed in individual bronchoscopy suites.
The study raises several important issues. If directors and experienced bronchoscopists know so little about the reprocessing practices and guidelines, how much do fellows in training and bronchoscopy assistants know about this topic! The survey highlights marked variations in local reprocessing and surveillance practices. Less than half of the respondents reported keeping records of the specific bronchoscope used in an individual case. This information is critical for a subsequent epidemiologic investigation in an outbreak situation. Less than one third of respondents reported surveillance of bronchoscopy culture results in their institution. This kind of surveillance provides an important opportunity for early detection of an outbreak. On the contrary, 30% of respondents reported routine culture of bronchoscope, which is unnecessary as environmental surveillance cultures, including those from bronchoscopes are not required on a routine basis.
The results from this study reinforce the need for all bronchoscopy personnel, including bronchoscopists, bronchoscopy assistants, nurses, and pulmonary fellows, to become familiar with the infection control issues surrounding bronchoscopy. Several publications, including a recent review, address this subject in considerable details (Am J Respir Crit Care Med 2003;167:1050–1056). The Association for Professionals in Infection control and Epidemiology Inc. (APIC) has published comprehensive guidelines for infection prevention and control in the endoscopy suite (AJIC Am J Infect Control 2000;28:138–155). These guidelines provide thorough and state-of-the-art information on recommended reprocessing procedures. Similar bronchoscopy-specific guidelines are needed in pulmonary literature.
Several limitations of this study should be noted. The sample size was very small. Several critical questions pertaining to reprocessing steps were not asked. Some questions were unclear and could be interpreted in more than 1 way. The survey did not inquire who trains the personnel in charge of reprocessing bronchoscopes and how often such training is reinforced.
Despite these limitations, the central message from this paper is absolutely critical to everyday practice of bronchoscopy and patient safety. It should serve as a wakeup call for all who are involved in organizing and implementing infection control policies and procedures in their bronchoscopy suites.