With an ever-growing number of cases, novel coronavirus (COVID-19) is on everyone’s minds. While dedicated healthcare professionals work tirelessly on the frontlines, it’s equally important to minimize the spread of disease by preventing contamination of medical devices.

What We Know About COVID-19

COVID-19 is a zoonotic disease, meaning infected animals can give it to humans. Since COVID-19 is a new disease, people have no immunity to the virus. As of this writing, there is no vaccination or cure.

Most believe COVID-19 is spread when respiratory droplets (from a sneeze or cough) come in contact with another person through their mucous membranes (nose, eyes, mouth). Infection results in respiratory symptoms from mild to severe, and in rare cases, even death.

The potential for transmission by objects or surfaces is not currently known for COVID-19 nor is the potential for the fecal-oral route although these forms of transmission have been seen with other human coronaviruses, such as SARS and MERS.¹

The Role of Medical Device Reprocessing During a Disease Outbreak

During an outbreak it’s critical to treat reusable medical devices as potential sources of transmission. This presents its own set of concerns. How do we prevent the spread of COVID-19 in the healthcare setting? What happens when hospitals are overwhelmed? What’s the toll of high-volume reprocessing? When does human error become a factor?

Helping Prevent the Spread of COVID-19 in the Healthcare Setting

To do their job effectively, central sterile services departments (CSSD) must be given the resources and time needed to properly follow medical device manufacturer guidelines to decrease the risk of disease transmission from contaminated devices.

If standard infection prevention measures are not followed, the hospital setting can become an environment for disease transmission. Patients whose defenses are lowered because they’re fighting the outbreak pathogen are often vulnerable to other healthcare associated infections, such as Pseudomonas aeruginosa or E. coli.

In addition to infection prevention measures, CDC notes that task-specific training is essential during an outbreak, including implementing refresher training to reinforce procedures and manufacturers’ instructions for use.²

Hospitals Can Become Overwhelmed

In the course of a regional or multinational outbreak, the ill flock to emergency departments and other care facilities for treatment. This can overwhelm healthcare resources. During the H1N1 pandemic over a decade ago, U.S. hospitals were inundated with sick patients. Approximately 275,000 people were hospitalized, and health officials worried about running out of resources, such as beds, personal protective equipment, and other medical supplies.³ Without critical supplies it is difficult to prevent further pathogen spread, including protecting healthcare workers who must handle contaminated reusable medical devices.

The Toll of High-Volume Reprocessing During a Crisis

In the context of reprocessing there are two types of equipment: Reusable medical devices for patient care and equipment used to sterilize those devices.

During a disease epidemic, instruments used for patient care may see higher use rates per a given period. In a respiratory illness outbreak, for example, bronchoscopes and laryngoscopes could be in high demand with clinicians waiting on instruments to be decontaminated or sterilized between patients. In addition to a shortage of available devices, those devices in circulation may see increased wear rates yet not be taken out of circulation for service and repair. Worn or damaged devices may not perform as intended and could contain pathogens sequestered in cracks or fissures that can’t be reached with standard cleaning and decontamination methods.⁴

Pressure to quickly return a contaminated device to service may lead to rushing or totally bypassing important steps in reprocessing. This means a contaminated device could be sent back into service without being properly disinfected or sterilized with potentially hazardous consequences.

There may also be pressure to ration disinfection and sterilization supplies during a crisis. For example, single-use items, such as scrub brushes for flexible endoscope lumens, should not be reused since a worn brush can damage a lumen, leave bristles behind in the endoscope, or transmit disease between endoscopes.⁵ The CDC notes that more healthcare-associated disease transmission outbreaks have been linked to contaminated endoscopes than to any other medical device.⁶

In an epidemic, reprocessing equipment used to disinfect or sterilize may experience higher than normal cycles. For automated equipment this means that service intervals will come sooner and accessories and consumables, such as solutions, filters, chemical and biological indicators and sterilization packaging will be depleted faster. If supplies are not maintained to compensate for these higher volumes, equipment could become unusable or even hazardous.

Human Error in a Crisis

Another risk during an epidemic is human error. Staff may be asked to work extra shifts or have a higher work load than normal, understandably leading to exhaustion and burnout. When there’s a shortage of staff due to illness, untrained or less experienced workers might be asked to cover their shifts. Mandatory quarantines or closure of public places, such as schools, may also make staff coverage difficult due to transportation or childcare concerns. This means that the few remaining staff could be overworked and tired.

Fatigue, inexperience and other pressures on staff can lead to workarounds in efforts to reprocess medical devices, such as omitting steps in a procedure, inattention, incorrect data entry, improper use of personal protective equipment, or other practices that are not validated or do not conform to manufacturers’ instructions for use. Not following standard methods for sterilization puts patients, healthcare providers and reprocessing staff at risk of infection or injury.

What Can We Do?

During an outbreak, patient to patient transmission via medical devices is totally preventable with proper reprocessing and sterilization procedures. CSSD staff should be given the resources and time needed to properly clean, disinfect or sterilize reusable medical devices between patients. Careful planning and resource management are key to making sure there are enough supplies and experienced workers during an epidemic. Refresher training on how to properly follow hospital reprocessing guidelines as well as manufacturers’ instructions for use are also necessary to ensure pathogen-free devices. In the event of a crisis, leadership must help doctors and nurses understand that reprocessing requires time and skill to do correctly and that rushing the process may put patients and staff at risk.

As patients, we all expect to be kept safe in the hospital environment and to receive quality treatment, especially during an epidemic. Supporting our teams that provide disinfection and sterilization services is a critical part of keeping patients and healthcare workers safe.

References

1.  European Centre for Disease Prevention and Control. 2020. Factsheet for health professionals on Coronaviruses. January 30. Accessed February 19, 2020. https://www.ecdc.europa.eu/en/factsheet-health-professionals-coronaviruses.
2. Centers for Disease Control and Prevention. 2020. Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings. February 12. Accessed February 14, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html.
3. Thielking, M. for STAT. 2020. ‘We need everyone for this’: U.S. hospitals harnessing resources to brace for any spike in coronavirus cases. February 7. Accessed February 14, 2020. https://www.statnews.com/2020/02/07/hospitals-harnessing-resources-brace-spike-coronavirus-cases/.
4. Ofstead, CL. et al. 2019. “Challenges in achieving effective high-level disinfection in endoscope reprocessing.” Am J Infect Control.
5. Society of Gastroenterology Nurses and Associates, Inc. 2018. Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal. Standard Guideline, Chicago: SGNA.
6. Centers for Disease Control and Prevention. 2008. Disinfection of Healthcare Equipment. Accessed February 14, 2020. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html.