Becker's Hospital Review

42 Executive Briefing Sponsored by: T he COVID-19 pandemic is ushering in a more infection- conscious era, with terms such as "personal protective equipment," "virus" and "infection" entering the common vernacular. Pre-crisis, health systems were already striving for excellent outcomes. Fifty-three percent of hospital executives surveyed by Advisory Board in 2019 cited minimizing unwarranted clinical variation as an area of interest, making it the second- most cited area of interest in the survey. Improving ambulatory access, population health strategies and expense reduction rounded out the top five interests identified in the survey. Now, these goals have taken on new importance. For some organizations, they may mean the difference between folding and staying afloat amid pandemic-related financial challenges. Infection control and sterilization processes are under heightened scrutiny, and the resulting long-term changes to healthcare delivery are in question. Despite this uncertainty, one thing remains clear: physicians' obligation to do no harm. The question moving forward will be how, exactly, providers can fulfill that obligation — especially for patients who are already vulnerable. A pressing safety concern COVID-19 makes this question all-too pressing for pulmonary specialists such as D. Kyle Hogarth, MD, because the coronavirus specifically causes damage to the lungs — even leading to acute respiratory distress syndrome in the most severe cases. For Dr. Hogarth, a specialist with UChicago Medicine, continuing to do no harm means selecting bronchoscopes that won't increase a patient's infection risk. The rate of cross-contamination with reusable bronchoscopes concerns him. "It's not zero — and it should be zero," he said in an interview with Becker's Hospital Review. "That should be filed as a never event." Dr. Hogarth isn't alone in his concern. Researchers have evaluated contamination rates for reprocessed bronchoscopes. While some may find the results surprising, most should find them "disturbing," according to Cori Ofstead, an epidemiologist who spoke to Becker's about what she's learned in 25 years of studying hospital-based infections and outbreaks. In 2018, an Ofstead & Associates study published in CHEST found that 58 percent of "patient-ready" reusable bronchoscopes in three major U.S. hospitals tested positive for bacteria or mold. The researchers observed major breaches of infection control standards in two of the institutions, even though all three of them were accredited by The Joint Commission. This suggests that more rigorous quality management strategies should be implemented to ensure patient safety. Patients should always be able to expect that any device being used in their body is clean, whether a pandemic is ongoing or not, Dr. Hogarth said. But with new studies suggesting that COVID-19 coinfections are linked to "significantly higher mortality rates," bronchoscope reprocessing issues cannot be ignored. Reprocessing is arduous and resource-intensive To get to the root of the issue, it's important to understand why Ms. Ofstead's team has been seeing high rates of improperly cleaned reusable bronchoscopes for years. To properly reprocess bronchoscopes for reuse, clinicians must follow a series of complex steps to a tee, she said. Each step is critical to getting a bronchoscope fully disinfected, in part because it's impossible to see the inside of a bronchoscope with the naked eye — and therefore difficult to ensure it's been adequately cleaned. After procedural use, bronchoscopes must first be checked for leaks. Reprocessing staff also need to conduct a visual inspection of the fragile devices. Every time a bronchoscope is used, there's a risk of scraping the inside, Dr. Hogarth explained. Putting instruments inside bronchoscopes to take biopsies or diagnose bleeding, for example, can cause scratching. In most hospitals, Ms. Ofstead found, the reusable bronchoscopes are riddled with microfractures, cuts and grooves where biofilms, proteins and bacteria can easily escape cleansers. "We see a lot of damage to these scopes after not that many uses," she said. "Whenever you have a damaged surface on a fragile device like a bronchoscope, bugs can go into the cracks and crevices, and you can't know if the scope is harboring soil and biofilm." That's why guidelines advise technicians to swab and test bronchoscopes in addition to conducting leak checks and visual inspections. Reprocessing and related quality checks must be done using valuable personal protective equipment, which is in short supply as healthcare professionals scramble to protect themselves and patients from COVID-19. This intricate high-level disinfection process is far from ideal, especially considering each arduous step must be repeated if the cleaning verification test comes out positive for organic soil residue. It is possible to do the kind of high-end cleaning needed to get bronchoscopes properly cleaned, but Ms. Ofstead's research shows that critical steps are being missed far too often. Moreover, according to Dr. Hogarth, getting reusable bronchoscopes fully reprocessed after each and every procedure drives up costs and inefficiencies. "Neither is very acceptable," Dr. Hogarth said. "That brings in — from an operational perspective — [the case for] single-use" bronchoscopes. Cost and waste misconceptions When Dr. Hogarth first heard about disposable bronchoscopes, How COVID-19 is making the case for single-use bronchoscopes

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