Mycobacteria and glutaraldehyde: is high-level disinfection of endoscopes possible?

BACKGROUND: High-level disinfection of endoscopes has traditionally been undertaken by manual or automatic scope cleaning plus a 10 to 20 minute soak in 2% alkaline glutaraldehyde. Mycobacteria species are less sensitive to glutaraldehyde, and a 45-minute instrument soak has recently been recommended by the manufacturer. Because of concerns over endoscope damage, need for more endoscopes, and perception that the current cleaning method is adequate, we prospectively studied mycobacteria-contaminated endoscopes at various stages of the cleaning process. METHODS: All work was done under a laminar flow hood in a microbiology laboratory. Five gastrointestinal scopes were contaminated with 10(8) colony forming units per milliliter (CFU/mL) of Mycobacterium chelonei, an atypical mycobacterium similar in chemical resistance to Mycobacterium tuberculosis but with less infectious potential. Cultures of the sheath, biopsy channel, and elevator channel were taken at baseline, after manual cleaning, and after 10, 20, and 45 minutes to glutaraldehyde soak both before and after alcohol rinse. RESULTS: Manual cleaning resulted in a mean of 4.7 log10 reduction in viable mycobacterial colonies. Qualitative studies of the external endoscope surface as well as the air-water valve showed no detectable organisms after a 10-minute exposure to alkaline glutaraldehyde. Conventional quantitative culture techniques of the channels demonstrated one endoscope out of five with consistent growth after a 10-minute exposure to glutaraldehyde. Following alcohol treatment, there was no significant colony growth. In contrast, a quantitative membrane filter system showed the presence of at least one mycobacterial colony in four out of five scopes after a 45-minute glutaraldehyde exposure. CONCLUSIONS: Additional studies utilizing a standardized mycobacterial species, inoculum size, and suspension characteristics are recommended to delineate adequate duration of disinfectant exposure time.

Reusable biopsy forceps: a cost-effective measure for the endoscopy suite.

Some healthcare practitioners have recommended the use of disposable medical accessories as standard practice. Advantages of using disposable medical equipment include the potential for infection prevention, convenience, and decreased reprocessing and storage costs. Disadvantages of reusable accessories include the initial cost, "down time" required for repair and, most importantly, the potential for spreading infection. In this study, the investigators provide a cost analysis of reusable biopsy forceps for a 12-month period from April 1993 through March 1994. This prospective, descriptive study evaluated purchase price, number of uses, repair history, and cleaning costs for reusable biopsy forceps used in the endoscopy unit of a large multi-specialty clinic. Results of the study revealed that the reusable biopsy forceps became cost-effective after seven uses.

The impact of OSHA regulations on nursing care cost and compliance.

The Occupational Safety and Health Administration (OSHA) requires health care facilities to protect employees from bloodborne pathogens. One of the mandates is to provide personal protective equipment (PPE) to employees at no cost to the employee. In this article, the authors explore the cost and compliance of implementing the new OSHA regulations for nursing staff assisting with colonoscopies over a 6-month period. The data were collected on a total of 461 procedures. The cost of implementing PPE for the nursing staff was $2.98 per procedure. The PPE available for the nursing staff included goggles, splash-proof gown, face mask, shoe covers, and latex gloves. The total cost of implementing the new regulations for the nursing staff assisting with colonoscopies was $2,747.56 and was projected to cost approximately $50,000 yearly if implemented for all GI procedures in the institution. Staff compliance rates for the five pieces of PPE ranged from 6.5 to 97.8%.

The impact of disposable equipment on room fee reimbursement for endoscopic retrograde cholangiopancreatography.

Disposable equipment is widely used in many gastroenterologic procedures. Such equipment decreases risks of cross contamination, is convenient, and decreases the processing, storage, and cost of reusable equipment. However, disposable equipment has a far-reaching environmental impact. Most disposable equipment must be handled as infectious waste. Moreover, cumulative costs associated with disposable equipment may be quite high. In this study, the authors attempted to delineate the percentage of room fee reimbursement spent on disposable equipment. The procedure selected for the study was Endoscopic Retrograde Cholangiopancreatography (ERCP). Two hundred forty-eight procedures were surveyed over a 6-month period between September 1992 and February 1993, and the total cost of each procedure was calculated. Reimbursement figures for diagnostic and therapeutic ERCPs were obtained for Medicare, contracted providers, and private payors. The percentage of room fee reimbursement monies used for disposable equipment for diagnostic ERCPs ranged from 5.8 to 12.8%. For disposable equipment in therapeutic ERCPs the percentage of room fee reimbursement monies ranged from 40.5 to 59.7%. Combining both diagnostic and therapeutic ERCPs, the percentage of room fee reimbursement to defray the cost of disposable equipment was 42.4%. Disposable equipment costs are a large portion of the room fee reimbursement. leaving potentially inadequate revenues for salaries, general upkeep of equipment, and capital to buy new or replace aging equipment.

Beyond the basics of endoscopy suite design.

For unit managers facing their first (or next) suite design, these beyond-the-basics points of advice may be helpful: 1. Allow ample time; 2 years from planning to ribbon-cutting is the minimum. 2. Start with the program, not the space. 3. Look ahead 5 to 7 years. 4. Choose an architectural firm with experience in designing endoscopy suites. 5. Work with staff and physicians to assess their needs and benefit from timely feedback on key decisions. 6. Be prepared to be flexible, especially when converting or remodeling space not fully described in existing drawings. 7. Build a client-architect relationship based on mutual respect that will remain in place through the first few months of operation.

Coaching for success and improved performance.

As a supervisor it is important to realize that coaching will not only help the deficient employee but also inspire the good worker to become outstanding. This article will discuss the techniques and skills necessary in the coaching process. How can managers help their employees grow and be successful? Tom Peters in A Passion for Excellence defines coaching as "the process of enabling others to act, of building on their strengths." Managers must do more than motivate, they must show people how to grow.

Effects of dietary wheat bran fiber on rectal epithelial cell proliferation in patients with resection for colorectal cancers.

A preponderance of carcinogenesis studies in rodents and epidemiologic studies in humans suggests a potential role of dietary fiber in the prevention of colorectal cancer. Recently, wheat bran fiber used as a dietary supplement has been shown to decrease the growth of rectal adenomatous polyps in patients with familial polyposis; however, few studies of high-risk human populations have been attempted to determine the effects of dietary fiber supplementation on markers of carcinogenesis in the colon or rectum. We have designed a one-arm study to evaluate the effects of dietary supplementation with wheat bran fiber [i.e., 13.5 g/day for 8 wk; after 1 mo, 2 g/day (compliance evaluation period)] on [3H]thymidine rectal mucosa cell labeling (i.e., percent of epithelial cells incorporating [3H]thymidine into DNA in intact rectal crypt cells over a 90-min exposure as well as in minced rectal biopsy tissue over a 24-hr exposure) in rectal biopsy specimens. The biopsy specimens were obtained at sigmoidoscopy in 17 compliant patients with a history of resected colon or rectal cancer. We categorized patients as having initially low or initially high [3H]thymidine-labeling indices (i.e., percent of mucosa cells that incorporate [3H]thymidine into DNA during 1.5- or 24-hour in vitro incubations) by using the median baseline labeling index as a cutoff between high and low values. On the basis of a chi-square test used to identify patients with a statistically significant (P less than .001) change, six of the eight patients who initially had high 24-hour outgrowth labeling indices showed a significant decrease in the rectal mucosa biopsy specimens obtained after treatment. An overall 22% decrease was observed in rectal mucosa cell biopsy specimens obtained at study termination (P less than .001). Of the eight patients with initially high total [3H]thymidine-labeling indices in crypt organ culture, four had a significant (P less than .001) decrease from baseline values, one had a significant increase, and three showed no change following the fiber intervention. The wheat bran fiber dietary supplement of 13.5 g/day was well tolerated by this group of older (54-70 yr) patients. Although the [3H]-thymidine labeling index data suggest that the wheat bran fiber supplement can inhibit DNA synthesis and rectal mucosa cell proliferation in high-risk patients, the results of this small pilot study should not be overinterpreted vis à vis the potential role of wheat bran fiber as a chemopreventive agent for colorectal cancer.(ABSTRACT TRUNCATED AT 400 WORDS)