Risk Management of Transmission of CRE via ERCP Scopes: Utilization of Automated Electronic Monitoring Systems

Background: Duodenoscopes used to perform endoscopic retrograde cholangiopancreatography (ERCP) have been implicated in outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) despite validated adequate cleaning and high level disinfection.  Regulatory agencies issued advisories to review scope processing, staff training, competency, and supervision.  However, no guidelines exist regarding maintaining data to mitigate risk.

Methods: At MSK scheduling an ERCP for a CRE+ patient triggers an automated staff alert. Additionally, CRE surveillance rectal swabs are performed prior to ERCP.  Duodenoscopes used for CRE colonized patients are quarantined until culture testing results are negative.

 

Six electronic programs are used to track all essential steps in scope use and reprocessing including date, time, scope #, CRE status pre and post procedure, results of Adenosine Triphosphate (ATP) testing for residual bioburden and times for procedure, transport, and cleaning the scope.

Our endoscopy reporting software (ProVation®) links patients to scopes by serial number and automatically sends reports that form the backbone of the database.  A bar-coded instrument management system (Abacus®) records the arrival of scanned scopes at key stations in the cleaning cycle and times are entered.  Elapsed time ≥60 minutes from procedure end to cleaning requires increased cleaning, and elicits an investigation. ATP readings are added.

Our laboratory information system (Harvest®) identifies culture results hourly, and our institutional data mine reports post ERCP infections daily.   

Results: Substantial improvement in time to manual cleaning occurred after a surveillance system was implemented - from an average of 6 hours (range of 1.5 to 18 hours) per scope to ≤ 60 minutes. (Figure 1)  All ATP readings are < 200 (Figure 2). Among 31 patients screened by rectal swab, none were newly identified on pre-ERCP surveillance for CRE. All tested scopes used on known CRE + patients were culture negative.

Conclusion: Aggregating data aids in reducing risks of infection transmitted by duodenoscopes. Electronic surveillance of key process measures allowed us to recognize inferior practices, and make data driven interventions.